This thesis - in the area of clinical ethics - addresses some of the ethical dilemmas which arise in the practice of adult intensive care. These problems are dealt with from the perspective of a practising physician in the setting of a busy intensive care unit. Narrative, usually in the form of detailed case histories, is used to paint word-pictures of various patients. All of the clinical details, with the exception of the patients' names, are factual.
As no single ethical theory provides total practical guidance in the unique and complex milieu of clinical intensive care, a number of ethical theories and approaches, including principlism, casuistry, narrative, case and virtue ethics are seen to be drawn upon when deciding the "right" course of action in any particular circumstance.
The thesis comprises four sections.
SECTION ONE: Intensive Care and its Setting
The evolution of the specialty is traced from its origins before World War II to its current position as an integral part of acute hospital practice. Since intensive care is shaped by the medical and social culture in which it is embedded, it has evolved differently, in different countries. To illustrate these differences the UK, the USA and Australia are used as examples of contrasting systems of practice.
A synoptic description is given of a day in the life of a director of intensive care. Insights are provided into the human dramas, which unfold at the bedside, the type of ethical problems that arise and which usually demand immediate resolution, as well as the time pressures, the fatigue of clinical practice and the multiplicity of roles that the intensivist must fulfill.
SECTION TWO: Intensive Care, Economic Constraints and Distributive Justice
The interplay of clinical intensive care with economics and distributive justice is investigated. Modem intensive care is extremely expensive and challenges the health budget. Given limited health care resources, even in the richest countries, the specialty must demonstrate that its costs and clinical outcomes justify the expense. Without a favourable interplay of cost and effectiveness, it will become increasingly difficult to continue to support this type of high technology medicine.
Rationing, in one form or another, is therefore, inevitable. Some of the clinical and ethical issues facing the intensivist when rationing intensive care are examined.
Actual clinical outcomes and costs are described and evaluated from a study undertaken at the intensive care unit of Princess Alexandra Hospital.
SECTION THREE: Ethical Dilemmas at the Bedside
Two major ethical problems in clinical practice, the dying patient and the doctor-patient relationship during critical illness, are considered. In particular, ethical issues, which arise when the intensivist is confronted with the care of a dying patient, are illustrated by case histories involving decisions about the withholding or withdrawal of life-sustaining treatment.
Patients undergoing intensive care are uniquely vulnerable and many are totally at the mercy of those caring for them. The doctor-patient relationship is examined, particularly from the aspects of autonomy and surrogate decision-making in the case of helpless, critically ill patients.
SECTION FOUR: Always to Care
The various roles of the intensivist are seen to be complex, interacting and occasionally in conflict. An attempt is made to identify within these roles, the ethical and clinical attributes of a “good intensivist” and from this to sketch a picture of the role of the intensivist as a good and wise healer and carer. In particular, the usefulness of virtue ethics in this context is discussed.