CORRESPONDENCE
Intensive care units and ethical
issues
Nagraj G Huilgol
The October-December 2003
issue of IME carried two interesting articles (1,2) that raise some
interesting questions. Prolonging life at any cost in the terminal state is
definitely not justified. Medical practitioners have subtly practised this art
of palliation where prolongation of life is abrogated, with or without legal
sanctions. Withholding any supportive treatment, for example, a gastrostomy in
oesophageal cancer, needs an explicit consent from the patient. Withholding
nourishment in a patient with an obstructed oesophagus due to cancer and who may
live for few months even without treatment, is tantamount to starvation and is
bound to be construed as cruel, unethical and illegal.
Barreto (1) correctly states, 'It is ethical to
withdraw life-sustaining treatments from those unable to decide for themselves,
only when the treatment can no longer achieve its intended clinical purpose and
cannot provide any benefit.' Indeed it is laudable to help patients live with
dignity till the last breath. But does the law of the land permit anyone to be
take off the life-supporting system even before the patient is dead? Similarly,
in the article, 'The friend', one gets an impression that the patient's
relatives took the decision to switch the ventilator off without having the
power of attorney to do so (2). The pertinent question is also about switching
off the ventilator without any objective evidence of brain death. I wonder what
the legal stand is on this issue of switching off ventilators at will. I hope
the future issues of the journal will discuss these matters.
References
1. Baretto Z. Ethical issues
in palliative care. Issues in Medical Ethics. 2003;11:118-19.
2. Shah
K. The friend. Issues in Medical Ethics 2003;11:120-1.
Nagraj G Huilgol, Chief, Division of Radiation Oncology, Nanavati
Hospital, Mumbai 400056, India, e-mail:
nagrajh@vsnl.net
Informed consent-a view from the trenches
Arun Sheth
I read with interest the
deliberations of two MBBS students on informed consent (1). They state
that for a consent to be legally valid, it must be both,
informed and intelligent. They further point out many fallacies and
loopholes that exist in the process of making the patient understand the
implications of a proposed clinical manoeuvre. They state that lack of
intelligence, communication barriers, unpredictable course of the illness or
'motivated' interests, all hamper the true spirit of 'informed
consent'.
A recent report (2) on the study of patient factors
affecting the process of informed consent in a proposed clinical trial reported
some interesting results. Only 30% of the subjects gave consent for the trial,
irrespective of the quantum of information given (complete or partial). Of those
who gave consent, the understanding of the elements of consent was poor,
irrespective of the subjects' educational status. Such poor understanding of the
information given to subjects of a clinical trial before they consent to
participate has been reported in other countries as well (2).
In my
own clinical practice, I find that most patients are unable to understand
completely, the 'fine print' about a proposed clinical manoeuvre. Indeed, they
cannot be expected to do so, as they are completely uninitiated to medical
jargon. Why, even doctors when they come as patients, fail to comprehend
completely the nuances of their proposed treatment. Hence, often, patients
refuse to listen to a detailed description of their planned treatment and prefer
to leave the decisions to the physician in good faith. It is, indeed, ultimately
a matter of trust and integrity. Patients prefer to be treated by the physicians
they trust and it is incumbent upon the physician to prove this faith. As
physicians we must be ready to make decisions for patients. Actually, this is
something that all of us do every time. For example, we decide which
investigation modalities are necessary for a particular patient. We decide on
the drugs to give to a particular patient. Several medication alternatives often
exist for a given illness but, it is the physician who chooses the drug and not
the patient. It would be ridiculous to discuss every drug with the patient and
leave him to choose his own medicines. Why, in principle, it would indeed be a
breach of the trust the patient has in his doctor.
I agree with the
medical students when they say that consent must be individualised in every
case. The idea is to make the patient a participant in his treatment and not
thrust the treatment upon him. But, the spirit of consent must prevail at all
times. The 'fine print' in writing is important in a court of law. But in the
court of human mind, it is the benevolent intention that is important. Such
intentions must precede and preside over all technicalities.
References
1. Dangayach N, Joshi N. Informed consent:
consent with a view. Issues in Medical Ethics 2003;11:86.
2. Gitanjali
B, Raveendran R, Pandian DG, Sujindra S. Recruitment of subjects for clinical
trials after informed consent: Does gender and educational status make a
difference? J Postgrad Med 2003;49:110-13.
Arun Sheth, Plastic and reconstructive surgeon, 1/7, Ellora, Daftary road,
Malad East, Mumbai 400097 India, e-mail:
arunsheth@hotmail.com
