Ethics of Critical Care Patient Management and Interactions
Medical personnel involved with the transport of critically ill or injured children regularly encounter situations that require ethical consideration. A basic understanding of ethical precepts assists in forming a structured approach to responding to such situations.
Applicable ethical precepts for consideration in the transport process include: obligations, consequences, rights (which includes the respect for autonomy), virtue, justice, and general moral constraints.Obligations include those of a fiduciary nature to the patient and those of professional integrity. The term fiduciary refers to one who acts on behalf of another to promote their well-being. In medical settings, fiduciary obligations encompass the need to protect and promote the best health interest of the patient. This duty is expressed in the principles of beneficence and nonmaleficence. Beneficence refers to the principle of “doing good.” Nonmaleficence involves the tenet of “first, do no harm.” In any clinical setting, it is incumbent on the medical team to seek a balance of clinical good over clinical harm in the care of the patient. This can be a particularly important consideration in the transport of a critically ill/injured child, as the team weighs the benefit of more specialized care with the inherent dangers of transporting critical patients.
Consideration of the consequences of decisions made regarding transport is vital. Consequences surrounding decisions may be either long or short term, will involve all parties (eg, a particular patient, other patients, family, health care professionals, and health care organizations), and should be evaluated in regard to the seriousness of the individual action or nonaction:
• Irreversible
• Serious and far-reaching
• Probable—what is the likelihood of a consequence occurring?
The strongest of any consequence should govern actions to promote the best possible outcome and anticipate course of action, should they occur.
Rights can be described as justified claims against individuals or institutions to act or not act in a specific manner. Perhaps the most venerated right in clinical medicine is respect for autonomy. Personal autonomy describes the moral right of people to choose and pursue their own plan for life. This is a particular challenge in pediatrics, because children are generally reliant on a surrogate in the decision-making process. Ethically, these surrogate decision makers should make choices on the basis of 2 things: (1) reliable information about the patient's own beliefs, values, and preferences; and (2) the patient's best interest. The latter standard implies that decisions will be made by the surrogate on the basis of the protection and promotion of the patient's health-related interests and that patient's autonomy. Also included in a discussion of rights are confidentiality and the virtues of honesty and respect.Virtues are characteristics of an individual that focus on the interests of others and promote those interests by fulfilling our obligations to them. They include, but are not necessarily limited to, compassion, courage, integrity, and self-sacrifice as well as those noted previously.
Justice is the intention to be fair in the administration of both risks and benefits. Justice involves how competing needs are addressed in a setting of limited resources. Ethical obligations involving the concept of justice are sometimes difficult, because there is no single consensus concerning which of the 3 major interpretations of justice should be primary:
• Libertarian: health benefits are dispensed on the basis of what the patient can pay.
• Egalitarian: all should receive health care benefits in proportion to what the individual’s actual medical needs require, without regard to cost.
• Basic decent minimum: medical benefits are provided in proportion to the individual’s basic medical needs but not beyond. Any medical needs above the basic provision are in proportion to what the patient can pay.
Limited resources may affect the principle of justice, and other factors, such as need, possible benefit, and access, must be taken into account.
Moral constraints also limit what is ethically permissible in medical practice, independent of other ethical precepts. Moral constraints may be religious or secular in origin and may be cultural. Moral constraints may vary from one religion or culture compared with another. Although they should be treated as important factors weighed against other ethical considerations, these moral constraints should not necessarily hold sway, because they are not constant, whereas the other precepts enumerated previously are.
Finally, one must balance our obligations to patients against legitimate interests of our own. Self-interests of a health care professional include preserving the ability to provide appropriate care well and faithfulness to one’s own personal values, beliefs, and moral convictions (ie, personal integrity) in spite of outside circumstances and demands.
This chapter addresses several ethical issues: those related to the patient, research, consent/assent, ethical dilemmas that may occur during the transport process, and perceived or real malpractice.