People in Western societies today clash profoundly on two levels: on the level of their cultural beliefs, within which people define the goals of life and the meaning of death; and on their hierarchies of value against which people decide which values may be sacrificed and which values must be maintained at all costs. In this context, ethics requires a shift from a divergent to a convergent method and mode of thought. The required shift is from the task of constructing arguments in support of diverse value systems to the work of constructing practical judgments about what must be done, what should be prohibited, and what can be tolerated in the care of very sick people. The shift from theoretical to practical reasoning in ethics is needed to reach the decisions that often have to be made quite rapidly at the bedside of the sick and the dying. This is the shift required to extricate clinical ethics and the ethics of palliative medicine from the deadlock of interminable discourse about matters upon which people are likely never to agree.

The starting point of clinical ethics, as also of clinical practice, is the consideration of patients in their full particularity, what Charles Fried has called the principle of personal care. The complete palliative physician holds together two seemingly incompatible excellences: sensitivity to signals of the patient’s body and receptivity to the messages of a life in crisis at the crossroads or at the terminus of a personal history.

The clinical goals to be pursued for each patient, and the requirements of clinical care, inevitably change along the continuum of disease. While diseases vary considerably both as to rate and as to continuity of evolution, the evolution of disease is also always unique to each individual patient. It is the nature of a patient’s response to treatment plans that indicates when the times arrive to down-regulate intensive life-prolonging care and up-regulate palliative care. The shift is rarely abrupt or of the on-off, binary kind of change. Moreover, certain interventions, such as radiotherapy or surgery, may serve curative clinical goals for some patients and palliative goals for others. Along this continuum of evolving disease and correspondingly changing clinical goals, moments are reached when it is clinically, ethically, and legally justifiable to withhold or to discontinue clinical treatments, such as resuscitation procedures, respiratory support, dialysis, antibiotics, chemotherapy, surgery, and assisted hydration and nutrition; the discontinuance of this last-mentioned intervention being still very controversial.

The kinds of decisions that have to be taken for and with gravely ill and dying persons are not purely technical. These decisions become an intrinsic component of the event of dying. Depending on the content of these decisions, and on the way they are made, some people will have the chance to die well, masters of their dying, not alone and not lonely. Others may die before their time, without a chance to live their dying through. Others may die too late, reduced to biological systems that have to be tended. Some may die uninformed and unenlightened, caught trying to play ’scene two’ when life’s drama is in fact about to close. Still others may die, who could have lived.

Decisions having such consequences demand that comprehensive attention be given to patients in their full particularity; that attention is focused on the unique biology, clinical condition, needs, desires, life plans, hopes, sufferings, strengths, vulnerabilities, and limitations of this particular person now. Decisions of this kind, and they are the primary outcome of clinical ethics in palliative medicine, cannot be deduced from any one principle or set of principles. These decisions result rather from a process of highly practical reasoning. The method of clinical ethics in palliative medicine is inductive. It works by passing the existing principles of the philosophical and religious moral traditions through the grid of particular personal and clinical histories to learn gradually what these principles command, prohibit, or tolerate. This knowledge is not all worked out in advance, completed, and awaiting to be applied. The clinical ethical order within these principles is, to use an expression of David Bohm, an implicate order. An implicate order cannot be made explicit as a whole. It is manifested slowly and only partially as it is worked out in the case-by-case practical judgments reached at the bedsides of utterly unique persons as their disease advances and their biographies come to a close.

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