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 IssuesCONCLUSION■ Determining when physicians should violate their patient’s interest in confidentiality or whenphysicians26 picascan and should administer high doses of sedating medication to dying patients arechallenging and complex matters that require sound clinical comprehension of the patient’scondition, good ethical judgment, and an understanding of the ideals and principles that havebeen discussed. Although certainly not definitive, the discussion of these cases has shown howthe theoretical ideals of palliative medicine inform certain fundamental ethical principles, whichin turn provide guidance in clinical cases.These cases and the principles they illustrate are not the only ones relevant to the ethics ofpalliative medicine. We have not discussed a number of issues that raise important ethical problemsfor palliative care physicians, such as issues that surround decisions to withdraw or withholdmedical interventions. To be sure, the principles that we have discussed in this chapter arerelevant to these issues. For example, according to the rule of double effect, a physician shouldnot withhold food and fluids from his patient as a means to hasten the patient’s death. Nonetheless,she could withhold or withdraw feeding tube treatment from a patient whose medical conditionhad made him unable to eat if the treatment were disproportionately burdensome, even ifthis would forseeably (but unintentionally) shorten the lifespan of the patient. We have notattempted to provide a full discussion of these issues here.The cases that we have discussed in detail, however, are particularly important for several reasons.Studies indicate that ineffective communication between physicians and their dying patientsis a major cause of inappropriate care for dying patients. 6 Likewise, uncertainty over therule of double effect has been cited as a key factor in the inadequate control of distressingsymptoms in terminally ill patients. 23 And—for HIV and AIDS patients in particular—the issueof patient confidentiality remains a vital one as physicians struggle to honor the dignity andpromote the well-being of their patients as they approach death. 38, 39 With respect to each ofthese pressing issues, a good understanding of the considerations discussed in this chapter isessential if health care providers are to respond adequately to the difficult ethical challengesthey now confront, and will continue to confront, in treating AIDS patients.362U.S. Department of Health and Human Services • Health Resources and Services Administration • HIV/AIDS Bureau