The Clinical Guide to Supportive and Palliative Care for HIV/AIDS

A Clinical Guide to Supportive and Palliative Care for HIV/AIDS • Chapter 17: Ethical Issuescians who treat patients living with HIV/AIDS at the end of life should not rely on a simpleformulation of the proportionality principle if they are to diagnose and treat their patients’suffering appropriately.26 picasA reformulation of the principle of proportionality that takes these issues into account follows:A physician’s therapeutic response to terminal suffering is justified, even if itforeseeably hastens the patient’s death, if and only if (1) the measures implementedproperly correspond to the intensity of the patient’s suffering; (2) the measuresimplemented are appropriate for the type of suffering the patient is experiencing;and (3) the patient understands and accepts the risks associated with the measures. 14Clearly, the word “appropriate” in the second clause of this principle is crucial. It should beunderstood in light of the interest the patient may have in being restored (as much as theircondition permits) to a state of psychosocial well-being. As has been suggested, one importantway in which this interest can be ignored is when physicians prescribe high-dose narcotics totreat psychosocial suffering. Such interventions are effective in the sense that they alleviatesuffering, but they are inappropriate in that the restorative interests of patients are ignored orset back.The requirement that the therapeutic measure be appropriate to the kind of suffering the patientis experiencing calls for discrimination on the part of the physician in diagnosing suffering.In particular, it enjoins the physician to attempt to distinguish between the pain and sufferingthat is caused by the underlying physiological condition of the patient and psychosocial5, 14, 27, 28forms of suffering.Additionally this modified principle of proportionality requires physicians to recognize the limitsof their medical authority. Physicians can fulfill their duty to relieve certain types of sufferingby relying solely on pharmacological measures, but these measures are inappropriate responsesto other forms of terminal suffering that are likely to be experienced by patients livingwith HIV/AIDS. With respect to psychosocial suffering, patients may need other measures suchas counseling or spiritual support. 5, 14, 28, 29 Some physicians are skilled in providing these interventions,but many are not. For those who are not, they best fulfill their obligation to relieve thiskind of terminal suffering by involving other members of the palliative care team in the care ofthe patient.The modified principle of proportionality therefore differs significantly from the simple formulationof the principle of proportionality introduced at the beginning of this section. It providesa more precise response to the specific types of ethical dilemmas surrounding pain and sufferingthat clinicians are likely to encounter in the palliative care context. These include dilemmassurrounding the use of terminal sedation and other measures that go beyond routine clinicalinterventions. Different types of suffering at the end of life may call for different therapeuticinterventions. Thus, to comply with this reformulated principle of proportionality, physicianstreating patients living with HIV/AIDS must develop skill in working as a member of an interdisciplinaryteam as well as in diagnosing, and appropriately attending to, the different types ofsuffering present at the end of life. The training clinicians should receive to develop these clinicalskills is addressed in detail in other chapters of this guide.XVIIU.S. Department of Health and Human Services • Health Resources and Services Administration • HIV/AIDS Bureau 357