Introduction
One of the factors that leads to high levels of health professional burnout is moral distress. Moral distress can occur when doctors and nurses feel unable to do what they perceive to be the right thing or when faced with ethical uncertainty. It is therefore of no surprise that moral distress occurs frequently in critical care. The continuing capacity of technology and medical advances to improve our ability to maintain life, leads to the question of whether critical care is prolonging life or merely prolonging existence.Historically medical decisions made by doctors went unchallenged. Recent professional guidance, legislation and societal expectations demand a greater role be played by patients, families, courts and society. As a result, the emotional stress on staff has never been greater. Making defensible, time-critical decisions is therefore a core competency for critical care clinicians and all doctors who work in acute specialties. Surprisingly ethical decision making, and the theory that underpins it, is covered only sparingly in many medical curricula.
This website reflects a growing effort in intensive care medicine education and discourse to consider how ethical decision-making can be improved. Clinicians, like most members of society, often respond to ethical challenges by relying on well-rehearsed patterns of behaviour. This approach is undoubtedly quick and frequently offers outcomes that are aligned with preconceived ideas. However, the problem with such approaches is that they are unreactive to changing or new information, and risk prejudicial and biased decision-making. While care should be individualised, it can appear to be individualised to the clinician rather than the patient and family, especially to outsiders.
We have developed an ethical decision making framework based on Beachamp and Childress’s Principles of Medical Ethics, and highly recommend their book which is in its 7th edition.
Why do we need a framework?
Why not just do what seems to feel like the right thing to do? In such circumstances if there is a difference of opinion between doctor and patient, family or other members of the clinical team then controversy and conflict often results. It can be difficult to prevent this, as arguments will be presented as “intrinsically right or wrong”. We think that an ethical framework can facilitate a structured analysis of ethical problems, which exposes bias and heuristics within the decisions, suggests compromise or alternative resolutions and aids communication. Whilst disagreement may persist, the exact nature of the disagreement will be clear.
It is increasingly important that the process and mechanism through which we make decisions is clear and transparent. When these decisions are later challenged by patients, families or external authorities we will be able to defend the process that led us to a conclusion.