Brendan Leier

The Case of Samuel Golubchuk and the Right to be Spared an Excruciating Death

The right to life has been raised as the central issue in a wide variety of health care debates. However, the assertions advanced by Jotkowitz and colleagues (2010) have little to do with such a right. Instead, Jotkowitz and colleagues present several arguments about the supposed right of patients or family members to demand health care, insisting that said right be upheld regardless of the effects on the patient, or the ethical obligations of and potential burdens born by the clinicians at the center of these cases. The case of Mr. Golubchuk has as much to do with the right to be spared an excruciating death as it does with a right to life. This case also cries out for a discussion of the factors that should be taken into account when making decisions for others at the end of life. Although the altar of autonomy is put forth by the author as the holy grail for such decision making, our discussion asserts that this is but one of many essential factors to consider on the way to reaching an ethically justifiable decision, and that no appeal to a single principle can result in a reasoned and proportionate decision. We also argue that while ethical decision making must be sensitive to cultural and/or religious considerations, these factors cannot be considered a trump card to be played and regarded as the highest suit. Jotkowitz and colleagues reference the Manitoba Guidelines (2008) and the physicians involved in Mr. Golubchuk’s care, and state that they contradict the universally adopted principles of ethics in the Western world: autonomy and informed consent. It is true that the principle of autonomy has become a leading principle that has formed the basis of many ethical and legal decisions in the last few decades. It would be fair to say that this principle has dominated other ethical considerations in many areas. However, we have not gone so far as to exclude from serious ethical consideration other important and relevant principles such as beneficence and non-maleficence, or such protections as fundamental justice or fair processes subject to review. Important to consider is the context in which autonomy typically plays its strongest role: the situation when a patient must consider a treatment or modality of care offered by the health care team. The individual has a right to accept or refuse care in the role of a “privileged interpreter” of his or her own best interest. This, however, does not equate to

Brokering trust: estimating the cost of physician-assisted death

In this issue of the Journal, Mottiar et al. provide an excellent summary of the current legal environment pertaining to physician-assisted death (PAD) and the possible implications for anesthesiologists in our country. What concerns us, from the perspective of front-line clinicians, is the lack of a real national dialogue on how this issue fundamentally challenges the goals of medicine and the relationship we have at the bedside with many of our most vulnerable patients. Physician-assisted death is not end-of-life care in the traditional sense of the term. This is evident in the practical implementation of physicianassisted suicide and euthanasia in other countries. Existential suffering and fears of losing control, being a burden, experiencing pain, and grappling with the unknown are real fears that cause tangible suffering, but we need to ask if there are better ways for physicians and communities to address this suffering. Several questions need answering. Do we practice medicine in a system that provides sufficient access to social and mental health supports as well as the proper resources for palliative care? Do our patients and their families feel isolated and abandoned as they try to deal with the challenges of a complex chronic condition? Do they feel unable to cope and become exhausted trying to meet the needs of their loved ones? Do our workers in the areas of social welfare, mental health, and palliative care consider they have the resources to meet the needs of our patients and their families? When patients do come to us with unremitting somatic and existential suffering, do we have the resources to help them? As physicians, perhaps we should imagine better ways to deal with these issues. Instead of advocating for physician-assisted suicide and euthanasia, we should be advocating for a solution to the root causes of these requests. The Hippocratic tradition is not immutable, but any evolution of the goals or ethos of medicine that grounds the trust between physicians and their patients ought to be undertaken very seriously. Artificial timelines set by others are forcing us to truncate what ought to be a reflective dialogue among physicians and between physicians and their entire community of patients. The current legal and political climate of our nation and the interests of isolated advocacy groups cannot dictate a change that may have a serious impact on what it means to be a physician and provide care for our patients. This matter is not merely about one subset of patients; rather, we need to consider what impact a change in practice might have on all our patients. Our most vulnerable patients, in particular, need us to advocate for their lives in a very different way from what is being asked of us in PAD. We need to ensure that we advocate for a system that protects their interests and finds value in their lives. While physicians did not advocate for or facilitate the recent Supreme Court decision, Carter v. Canada, physicians will bear a disproportionate responsibility and burden as a result. Setting predetermined, non-medical C. Mack, MD (&) Divisions of Adult Cardiothoracic and Pediatric Anesthesiology, Department of Anesthesiology and Pain Medicine, Division of Pediatric Palliative Care, and Department of Pediatrics, University of Alberta/Stollery Children’s Hospitals and Mazankowski Heart Institute, John Dossetor Health Ethics Centre, 5-16 University Terrace, Edmonton, AB T6G 2T4, Canada e-mail: cheryl.mack@shaw.ca

Managing Ethically Complex Issues in Critically Ill Patients—A Neonatal Perspective

Ethically complex issues are commonly encountered in critically ill patients in intensive care units and usually relate to disagreements about care in such high risk situations. Because the clinical course is often uncertain and unpredictable, serious disagreements about the plan and priorities of care occur. This is presented simplistically as a conflict between the (surrogate) autonomy of the family members and the physician (health care professional) authority, in promoting the patient’s best interests. The ethical issues emerge only when discussion includes broader concerns about morbidity, mortality, and meaning to family and the hospital staff. We review the theoretical ethical basis of decision-making in such situations in the context of neonatal intensive care units and recommend that the physician focuses on the professional role of advocate for the infant’s best interests. Reflective conversations with family, including openness about uncertainty and willingness to re-evaluate care plans, are essential to maintain trust. This mediation approach supports different moral views in an atmosphere of mutual respect. Expert ethics assistance early on in high risk cases is recommended. We suggest that this be provided by an ethics consulting service readily available to the staff for optimizing care and preventing the development of crises.