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It has been identified that nurses as a profession find ethical dilemmas particularly stressful; however one of the most frequently occurring stressors surrounding ethical issues are concerned with end of life decision making (Ulrich et al, 2010).
One particular study (Levi et al, 2004), observed that registered nurses, more frequently than their medical practitioner colleagues, felt that ethical issues surrounding the end of life are not thoroughly discussed with the care team, patient or their family. This essay intends to explore the underpinning principles of the Doctrine of Double Effect (DDE), explore its relevance in legal and ethical issues and critically analyse the DDEs’application to modern nursing practice.
DDE is a legal principle that is concerned with the balance of good versus any harmful effects which may arise from a specific act (Foster et al, 2011). According to DDE, it is ethically permissible to cause harm in the pursuit of an intended good effect with respect to four basic requirements; the act will have a good or at least neutral effect, only the good effect is intended, the good effect is not achieved by way of the bad effect and that the good result prevails the bad.
In medicine, DDE is used in many areas such as the separation of conjoined twins, termination of pregnancy and the breaching of confidentiality; this essay however, will focus on the use of DDE within the domain of the administration of analgesia within end of life care (EOLC) (Fry and Veatch, 2006).
Often considered two similar fundamental bases of nursing care, differentiation between palliative care and EOLC is required when considering issues around the topic of death and dying.
Suggested by Macpherson (2004), palliative care is concerned with mitigating atient suffering with no aim to cure; this may be the final treatment option for a patient suffering with a long term and possibly debilitating condition. Identified by the National Institute for Health and Care Excellence (2011), any palliative care that is given within the final 12 months is regarded as EOLC. Clarification of the distinction between these two realms of care is required to consider cases in context, and to give a better understanding of when and how the DDE may and can be used.
Recognised by the World Health Organisation (2013), morphine is an opiate which is frequently used in EOLC, and for that reason the principles of the DDE will be illustrated using it as an example. Morphine is readily available and despite its proven efficacy in palliative and EOLC, adverse side effects associated with the opioid such as respiratory depression may, inadvertently expedite death (Pattison, 2008). Under the first principle of DDE, the goodness of the action needs to be decided, for this we may ask ourselves ‘Was the pain relief good?’, and in the vast majority of cases the answer would be yes. Identified by Gao et al. (2014), effective pain relief during EOLC must be a clear priority. In addition, it must be affirmed that the hastened death was not intended and also that the intention of pain relief was not achieved by death. When considering the final principle of the doctrine, quality and quantity of remaining life must be examined in order to identify if the effect of pain relief outweighs a hastened death. If without the morphine, the patient would have lived for an additional five years, many would argue that the good did in no way, outweigh the bad.
However in a polar opposite, if the patient’s death was merely hastened by minutes, however excruciating pain was controlled, the bad effect may be considered to be worth it. (Wilkinson, 2003)
With respect to EOLC, there are many options that could be considered in order to ensure a good death. These options are of course diverse and differ between individuals; however, often considered the most pertinent is the administration of effective analgesia during end of life care and the dying process (World Health Organisation, 2009). Bradbury (2003) describes bad deaths as those which are uncontrolled and suggested that good deaths to have an aspect of control; an element of this could consist of the easing or total freedom of
pain. Ascertation of intent is a core element to DDE, and providing that doses of analgesia which have been prescribed and administered, that outside of EOLC or palliative care may be considered excessive, are done so primarily to relieve pain and suffering and not to cause
death, the health care professional is legally blameless (Grace, 2009).
Arguments against DDE are often concerned with a perceived likeness of the principle to euthanasia, the intentional termination of life to relieve suffering. It has been argued that confusion over the ethical difference between indirect killing, which by way of the DDE is permitted, against direct killing, forbidden by it (Shaw, 2002). Dependant on case specifics, euthanasia is viewed as either murder or manslaughter, carrying a maximum penalty of life imprisonment (NHS, 2014).
In the of R v Dr Bodkins Adams ( Crim LR 365) (the Adams case), a doctor was acquitted of murder following the administration of increasing doses of opiate analgesics to a terminally ill patient. This was a landmark case in regards of the use of DDE within British law, with the presiding judge ruling that Dr Bodkin Adams was in fact innocent. The jury was told that in medicine when a doctor can do no more in order to recover a patient to a state of good health, that a doctor is permitted to do what is necessary to relieve pain and ease a patients suffering, even if these measures may incidentally shorten life.
In the more recent case of Tony Bland, a 21 year old, who had been left permanently unconscious and in a persistent vegetative state (Airedale NHS Trust v Bland, 1993), the NHS trust applied for a ruling in order to discontinue Blands’ artificial nutrition and hydration. It was ruled by the House of Lords that it is ethically and legally permissible for a doctor, when caring for a dying patient, to administer analgesia despite the possessing the knowledge that the administration may shorten their life. The ruling judge asserted the requirement of this decision being made with the patients best interests at the forefront of the decision making process, with the input of the patient himself, or their family if possible.
Considering the aforementioned Bland case, it is especially pertinenent to ascertain intent and alongside this, if the doctor was honestly and truthfully acting in the best interest of the patient. Arising from the case of Bolam v Friern Hospital Management Committee (1957), a case where the claimant, Mr Bolam, was proposing a breached duty of care by his doctor. The House of Lords judged that the accused doctor had not breached his duty of care, as when asked the practice that he had engaged in was deemed correct by a body of individuals of skilled in the same discipline. This process of comparing practice is still used within law and the Bolam test can be used to see if a body of reasonable healthcare professionals agree with a certain aspect of practice which for one reason or another is questionable. However this test of negligence has been criticised for it’s over simplicity, disregard for actual working practices as opposed to preferred standards of practice and can only be used as one stage of proving or disproving negligence and liability (Jones, 2000).
When applying the DDE, it is first necessary to ensure that the level of prescribing is consistent within the reasonable practice of a competent healthcare professional. Nurses who may be unsure or concerned regarding the levels of analgesia a patient is receiving are advised to check the prescription with another medical practitioner or seek guidance from a pharmacist (Dimond, 2008). According to the Nursing and idwifery Council (2008), in instances where medication has been prescribed in a range of increasing doses, nurses may titrate the doses of medication in accordance to a patient’s response and level of symptom control and the continue to administer accordingly within the prescribed range.
When considering ethics within in the field of healthcare, there are many frameworks and ethical principles that can be examined and applied. However, there are two overarching ethical ideologies that can be considered, deontology and utilitarianism. Deontology is an ethical principle rooted in philosophy, is based on obligation, or a duty of care. According to deontological theory, acts are based on selflessness and carried out due to obligation and duty. Utilitarianism is a theory which is concerned with ensuring the greatest good for the greatest number of people. Consequentialism, a branch of utilitarianism, focuses on utility of acts and therefore is affiliated with analysing cost versus benefits (Fry and Johnstone, 2008).
Beauchamp and Childress (2001) proposed 4 principles of biomedical ethics, and although they are guides, there is room for subjective judgement and decision making within them (Clinical Ethics Network, 2011). Respecting autonomy is by and large concerned with providing information and enabling and accepting the decision making process of an autonomous individual, whilst ensuring that patients in similar positions are treated similarly establishes justice. Beneficence, the way in which healthcare professionals should only act in a way that would benefit the patient and non malefience, avoiding the causation of harm, are both themes that are deeply rooted within the Nursing and Midwifery Councils (2015) The Code. This highlights that although it may be the medical practitioner prescribing a high dose of opiate analgesia; it is very likely that a nurse will administer it. Therefore when applying beneficence and non-maleficence to practice, especially surrounding the administration of high dose opiates, the application of the DDE must be considered in order to prevent a nurse from effectively breaching his/her code of professional conduct.
A grievous criticism of the DDE is the lack of certainty when ascertaining intention.
There is no objective test, no intention exam that a practitioner can take to determine the intention only to relieve pain and suffering and not to kill. Critics of the DDE have suggested that overuse of the DDE may illicit an alternate form of euthanasia, opening up the potential for the rinciples abuse (Williams, 2001). Others have proposed the argument that by the nature of the DDE, exclusive rights are given to people dependent on their professional stature, allowing them the opportunity to accelerate death without punishment (Quinn, 1989).
Clearly apparent is the popularity of the DDE, regardless of the DDE begging questioning over the potential side effects and consequences of the prescription and administration of high dose opiates during EOLC versus the perceived benefits. Nursing is a professional role that is rich in compassion, empathy and care. It could be argued that no one, irrelevant of occupation or moral stance would like to witness the suffering of another human being, possibly at the end of a terminal illness or such during their last hours or minutes on this earth. With the use modern medicine it is possible to ease the pain, relieve the suffering and of course ensure what is commonly perceived as a good death, not only for the patient, but also their family; the ones that too often are left in the dark during EOLC, with questions that begged to be asked but will not be answered. Previously discussed has been the reluctance of nurses to involve themselves in the ethical issues that they are faced with daily, with decisions surrounding EOLC proving particularly stressful. Nurses as a profession are accountable for of their actions; and although it may have been a medical practitioner who has prescribed a large dose of analgesia to a patient receiving EOLC, it will ultimately be the nurse who’s accountability may be questioned and consequentially their registration to the nursing and midwifery council register being placed at risk.
“Nursing is primarily assisting the individual in the performance of those activities contributing to health and its recovery, or to a peaceful death.”
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