Basic ethical principles in critical care

Background

Since the inception of the practice of medicine, there have been ethical challenges for doctors and other health care professionals. Many of the challenges, such as who has the authority to make key decisions (autonomy vs. paternalism) and what the boundaries of life are at the beginning and the end, have existed for a long time. However, the ever-changing landscape of modern technology has presented new and unforeseen questions surrounding when new technologies should be applied and when they exceed ethical boundaries—technologies such as life support and genetic manipulation. Finally, changes in society and its values have led to new ethical challenges. Ethics exist as a perceived set of rules that are formed and judged by the culture in which they exist. Different cultures can have very different ethical systems. In many countries, not only are there very diverse cultures but these cultures continue to change and evolve. The net result of these forces is that modern ethics can change as well. Things once thought unethical may become ethical or vice versa.

The practice of medicine in intensive care units (ICUs) has been the source of many ethical challenges. These are often driven by conflicts surrounding death, a common occurrence in ICUs. Our ability to keep human beings alive has increased steadily, and thus rules and beliefs surrounding when not to continue life support have been tested on a regular basis. Once firmly fixed concepts, such as death or “brain death,” are now coming under increasing attack. In other areas, the concept of patient autonomy has been used to request life-prolonging therapies once thought “futile.” Finally, ICU physicians are increasingly finding themselves caring for patients who are unable to express their wishes and must rely on some kind of surrogate decision maker, which can add further ethical challenges.

Goals of care and medical decision making