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The Philosophy of Palliative Care: Critique and Reconstruction
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 'palliative care 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 the specialty - 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 the WHO 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.
256 pages, Paperback
First published April 13, 2006
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June 25, 2011
A bulwark against modern airy-fairy ideas of how doctors and patients should interact. Primarily about Palliative Care but most of the conclusions can be applied to medicine in general. Read this during a four week rotation in palliative care.
The structure of the the extended essays is a systematic critique of current assumptions and precedents concerning the patient-doctor relationship, especially those found in WHO guidelines, the oxford textbook of palliative care and other current relevant texts. It is a critique that we never got in medical school.
Anyway, the major conclusions I believe are (note I'll just list some conclusions, in no way can I expand on the reasoning in a review. The ones applicable to medicine in general are 2, 3, 4, 6, 7):
1. There is a fundamental difference between the Asklepian (mystical) and Hippocratic (rational) traditions of care. The interaction of these traditions can cause paradoxes especially in palliative care.
2. Quantitative quality of life scales are meaningless; they are a qualitative measure.
3. The concepts of autonomy, respect, dignity originate in Kantian moral philosophy, and these concepts have been horribly distorted. E.g. dignity and self-determination - although often acting in parallel - are fundamentally different principles: e.g. treatments need a net benefit, so you shouldn't provide a treatment just because the patient self-determines it. Also self-determination and autonomy are different from the original Kantian view.
4. Patients>Relatives. QoL of relatives is not a value of palliative care.
5. The commonly used phrase from WHO: palliative care 'intends to neither hasten nor prolong death' is ambiguous and should be abandonded. Both are often appropriate in palliative care contexts. (e.g. for hastening, forseen but not intended consequence)
6. CPR is no different from other treatments. You need a net benefit. I am much more clear on the ethics of 'Do Not Resuscitate' orders now.
7. It is not the doctors role to manage psychosocial and spiritual aspects of a patient's care unless it is consented for (there are numerous ways that non-consented care in this way can be harmful, and numerous reasons that it is unethical) - this goal should be abandoned. I particularly found this section of the book intriguing - a counter point to the holistic models of care that are in fashion. Current models seem to jump from the correct premise that health is multifactorial, to the conclusion that this means that it is the doctor's role to manage the different non-physical areas.
The structure of the the extended essays is a systematic critique of current assumptions and precedents concerning the patient-doctor relationship, especially those found in WHO guidelines, the oxford textbook of palliative care and other current relevant texts. It is a critique that we never got in medical school.
Anyway, the major conclusions I believe are (note I'll just list some conclusions, in no way can I expand on the reasoning in a review. The ones applicable to medicine in general are 2, 3, 4, 6, 7):
1. There is a fundamental difference between the Asklepian (mystical) and Hippocratic (rational) traditions of care. The interaction of these traditions can cause paradoxes especially in palliative care.
2. Quantitative quality of life scales are meaningless; they are a qualitative measure.
3. The concepts of autonomy, respect, dignity originate in Kantian moral philosophy, and these concepts have been horribly distorted. E.g. dignity and self-determination - although often acting in parallel - are fundamentally different principles: e.g. treatments need a net benefit, so you shouldn't provide a treatment just because the patient self-determines it. Also self-determination and autonomy are different from the original Kantian view.
4. Patients>Relatives. QoL of relatives is not a value of palliative care.
5. The commonly used phrase from WHO: palliative care 'intends to neither hasten nor prolong death' is ambiguous and should be abandonded. Both are often appropriate in palliative care contexts. (e.g. for hastening, forseen but not intended consequence)
6. CPR is no different from other treatments. You need a net benefit. I am much more clear on the ethics of 'Do Not Resuscitate' orders now.
7. It is not the doctors role to manage psychosocial and spiritual aspects of a patient's care unless it is consented for (there are numerous ways that non-consented care in this way can be harmful, and numerous reasons that it is unethical) - this goal should be abandoned. I particularly found this section of the book intriguing - a counter point to the holistic models of care that are in fashion. Current models seem to jump from the correct premise that health is multifactorial, to the conclusion that this means that it is the doctor's role to manage the different non-physical areas.
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