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Why is a chapter on end-of-life ethics included in a textbook of pain treatment? After all, this topic was not included in the previous edition. There are at least two major reasons: first, pain is common at end of life; second, many have contended that most suffering at end of life is due to pain, and that most requests for assistance in dying or hastening death would disappear if adequate pain relief were provided. Both these reasons raise many ethical issues. The emerging field of biomedical ethics is influencing the approach to pain treatment and to dying. This brief essay will be confined to familiarizing the reader with specific, limited ethical aspects regarding the present status of pain treatment and some ethical considerations having an impact on end-of-life care.

With the expansion of the concept of autonomy to patients and the erosion of the authority of physicians over the past generation, dramatic changes have occurred in the way the public (and part of the medical profession) view the process of dying.1,2 At the end of the 20th century (or at the threshold of the 21st) we are the recipients of more than a century of scientific and biomedical progress. This has changed the expectations of physicians and the public alike. Only a few decades ago the ability of medical practitioners to diagnose and cure was exceedingly scant. When illness struck, physicians would attempt to reduce fever and relieve pain. A large proportion of their practice was to comfort patients and families. The famous portrait of “The Doctor” by Fildes accurately portrays the impotence of the physician to cure (Fig. 86-1). It depicts the physician in the home, providing a bedside vigil of a sick, perhaps dying, child with the parents present in the background. In the past half century, as “cure” became the norm, specific diagnosis the expectation, specialization accepted, and hospitalization the standard, a progressive distancing of the physician from the patient-family unit occurred.

Figure 86-1

“The Doctor” by Fildes portrays a physician keeping a bedside vigil with his young patient’s parents.

Nowhere has this distancing been more dramatic than at the end of life. Whether from a feeling of failure, a belief that further expenditure of effort would be wasteful, or simply the discomfort of the physician with death, patients who could not be cured often became ignored or abandoned. At the same time, until the conclusion was reached that further effort was futile, no measure was overlooked. This sometimes led to prolongation of dying and increased suffering.

One of the consequences of these changes has been the growth of the right-to-die movement. The tenets of this are that when an individual rationally decides that his or her suffering outweighs the benefits of living, that decision should be honored.3,4 Only the person who experiences suffering ...

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