The Philosophy of Palliative Care Critique and Reconstruction

by Randall, Fiona; Downie, R. S.

• ISBN13: 9780198567363
• ISBN10: 0198567367
• Format: Paperback
• Copyright: 2006-04-13
• Publisher: Oxford University Press

Summary

The idea of a philosophy of palliative care emerged with Cicely Saunders' vision for 'a good death', and was developed further with the WHO definition of palliative care. It is now being applied not only to cancer patients, but to all patients in end of life situations. As this 'palliativecare approach' advances, it is important to pause and comment on its effectiveness. It is a philosophy of patient care, and is therefore open to critique and evaluation. Using the Oxford Textbook of Palliative Medicine, 3rd edition as their basic reference, Randall and Downie present their argument that the palliative care approach has become too busy and over-professionalised, and that it therefore has significant weaknesses. They examine the framework of thespecialty - quality of life, autonomy, dignity, patient-centredness, and the priority assigned to relatives in the remit of care - and the moral problems associated with implementing such a philosophy. The resource implications of various health care policies are also discussed in relation to theWHO definition. Whilst the authors defend the achievements of palliative care and those who work in the profession, they present suggestions for an alternative philosophy. Their philosophy prompts many ethical and philosophical questions about the future of palliative care.

Author Biography

Fiona Randall is a consultant in palliative medicine, with a background in health care ethics and philosophy. She has served on BMA ethics committees, the Association of Palliative Medicine ethics working party, and has been recently involved in drafting the UK law on decision making for patients lacking capacity. She is also on the editorial board of the Journal of Palliative Care. Robin Downie has been a member of various government and professional committees and working parties dealing with issues of medical ethics. He is now an Honorary Professorial Research Fellow and Emeritus Professor of Moral Philosophy at the University of Glasgow.

Table of Contents

List of abbreviations	xv
Part 1: Framework and concepts
Roots, traditions, and philosophy	3	(22)
Introduction and aims	3	(2)
Roots and traditions	5	(2)
Two traditions of health care	7	(2)
Consumerism in health care	9	(1)
Critique	10	(1)
A `philosophy' of palliative care	10	(2)
The normative function of a philosophy of palliative care	12	(1)
Theoretical questions	13	(1)
Practical questions: ethics	14	(5)
Paradoxes in palliative care	19	(2)
Conclusions	21	(4)
References	22	(3)
Quality of life	25	(28)
Introduction	25	(2)
The use of the term `quality of life'	27	(8)
Qualities, evaluations, and definability	27	(2)
The global sense of quality of life	29	(2)
Health-related quality of life	31	(4)
Assessment and measurement of quality of life	35	(9)
Theory of measurement and quality of life	35	(5)
Weighting and summing scale items	40	(2)
Utility rating scales	42	(1)
Should quality of life be represented as numerical data?	43	(1)
Decision-making for individual patients	44	(4)
Quality of life as the goal of palliative care?	48	(1)
Conclusions	49	(4)
References	50	(3)
Autonomy, dignity, respect, and the patient-centred approach	53	(22)
Introduction	53	(1)
Autonomy, dignity, and respect in Kant	53	(2)
Developing Kant's ideas: a bad way and a good way	55	(1)
Truth-telling, information giving, dignity, and autonomy	56	(3)
Consent, autonomy, and dignity	59	(2)
Professionalism, and consent as patient self-determination	61	(1)
Consumerism, patient self-determination, and consent	62	(2)
Human Rights, consent, and patient self-determination	64	(1)
Patient-centredness, consent, and self-determination	65	(2)
Dignity and self-determination	67	(2)
The analysis of dignity	69	(3)
Conclusions	72	(3)
References	73	(2)
Relatives	75	(22)
Introduction	75	(3)
Patient, family, and conflict of interest	78	(6)
Conflicts over confidentiality	80	(1)
Conflicts over place of care and death	80	(2)
Conflicts over time of death	82	(2)
Bereavement care: benefit or harm?	84	(4)
Cost effectiveness of benefit to relatives	88	(2)
The nature and extent of obligations to relatives	90	(2)
Conclusions	92	(5)
References	92	(5)
Part 2: Interventions, effectiveness, and cost
Control of symptoms and prolongation of life	97	(28)
Introduction	97	(1)
Relief of physical symptoms and improvement of function	98	(2)
Treatments which may prolong life	100	(6)
Prolonging death or prolonging life?	100	(4)
Withholding and withdrawing life-prolonging treatment	104	(2)
Treatments which may hasten death	106	(11)
Not hastening death or not intending to hasten death?	107	(1)
Killing versus letting die: the issue of causation	108	(3)
Intending versus foreseeing death	111	(1)
Double effect	112	(3)
Euthanasia and letting die	115	(2)
The roles and responsibilities of patients and professionals	117	(5)
Conclusions	122	(3)
References	123	(2)
Resuscitation and advance statements	125	(24)
Introduction	125	(1)
CPR: a life-prolonging treatment	126	(2)
CPR compared with other life-prolonging treatments	128	(5)
The `nothing to lose' argument	129	(2)
The `symbolic value' argument	131	(1)
The `low cost' argument	132	(1)
CPR decisions and competent patients	133	(3)
CPR decisions and incompetent patients	136	(1)
Positive recommendations for CPR decision-making	136	(2)
Advance statements	138	(1)
Arguments in favour of advance statements	138	(3)
Giving patients what they want	138	(1)
Facilitating best interests judgements	139	(1)
Making life easier for the family	140	(1)
Avoiding waste of resources	140	(1)
Arguments against advance statements	141	(5)
Difficulties of interpretation and enactment	141	(1)
Best interests and the duties of doctors	142	(3)
Advance statements and family problems	145	(1)
Advance statements and resources	145	(1)
Additional problems	146	(1)
Advance statements and the philosophy of palliative care	146	(1)
Conclusions	147	(2)
References	147	(2)
Assessment and treatment of psychosocial and spiritual problems	149	(34)
Introduction	149	(1)
Psychosocial and spiritual problems as health care responsibility	149	(26)
The patient-professional relationship	151	(3)
Effect of the recommended relationship on the patient	154	(6)
The effect of the recommended relationship on the professional	160	(2)
Benefits versus harms of the relationship	162	(3)
An alternative: the client-counsellor relationship	165	(4)
Empathy	169	(3)
Respect	172	(1)
Genuineness	173	(2)
Psychosocial and spiritual care: an alternative approach	175	(4)
Conclusions	179	(4)
References	179	(4)
Resource allocation	183	(16)
Introduction	183	(1)
Needs assessment	184	(5)
Efficiency	189	(5)
Conclusions	194	(5)
References	194	(5)
Part 3: Critique and reconstruction: some suggestions for a better way
Critique and reconstruction: some suggestions for a better way	199	(28)
Introduction	199	(1)
Palliative care as a specialty	199	(2)
The Asklepian model of holistic care	201	(4)
Asklepian attention	201	(2)
Asklepian attention and Hippocratic observation	203	(2)
Asklepian acceptance and spirituality	205	(4)
Honest hope	209	(4)
Personal and professional development	213	(5)
Teams	218	(1)
The desirability of a philosophy of palliative care	219	(1)
Towards a new philosophy	220	(4)
A new philosophy statement	224	(3)
References	225	(2)
Index	227