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.
“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 ...