Since the last generation medical ethics has seen a remarkable shift from benign medical paternalism to patient rights and autonomy. Whereas once it might have been acceptable for doctors to decide, largely on their own, what was in the best interests of their patients, today senior health professionals are expected to make decisions jointly both with patients or their carers and with other health professionals. Patient autonomy and justice, and not simply beneficence, are usually thought to be crucial to medical (...) ethics today.Although I strongly support this shift in medical ethics, I believe it is important to recognise that it has some cost to medical professionals, to patients and even at times to the National Health Service . Medical paternalism, when it was genuinely benign, did have some benefits both for doctors and for their patients. Yet precisely because most of us are no longer prepared to be at the receiving end of such paternalism, these particular benefits are now largely lost to us.The new joint statement, Decisions Relating to Cardiopulmonary Resuscitation,1 illustrates this point well. At the outset it admits that “health professionals are aware that decisions about attempting resuscitation raise very sensitive and potentially distressing issues for the patient and people emotionally close to the patient”. It was because of these sensitive and potentially distressing issues that it was once thought acceptable to make do not attempt resuscitation orders without consulting either patients or their families and with the knowledge that the latter would probably never discover that such orders had ever been made. Now, however, health workers are warned frankly that they “should remember …. (shrink)

In March of this year the British Medical Association , the Resuscitation Council and the Royal College of Nursing published guidelines outlining the legal and ethical standards for decision making in relation to cardiopulmonary resuscitation .1 The guidance follows a year of increasing public awareness and concern about the issue and builds upon joint guidance issued by these institutions in June 1999.In April 2000 Age Concern issued a press release stating that “some doctors are ignoring national guidelines on the resuscitation (...) of older people” and indicating that they had information on cases that had come to light in their campaign against age discrimination. Age Concern went on to say that older people have found “not for resuscitation” recorded in their medical notes without their agreement or knowledge.During the same month Professor Shah Ebrahim wrote a leader in the British Medical Journal stating that doctors regularly issue “do not resuscitate” orders for patients without their knowledge.2 He claimed that black people, alcohol mis-users, non-English speakers and those with HIV are more likely to get a “do not resuscitate” order, suggesting that prejudice is influencing medical decisions.This combination of events was followed by intense press and media interest in the way in which decisions were being made about cardiopulmonary resuscitation. Such was the level of concern that a health service circular was issued to all National Health Service trust chief executives in September 2000 asking that appropriate resuscitation policies be in place which respect patients' rights, are understood by …. (shrink)

The guidelines on Decisions Relating to Cardiopulmonary Resuscitation begin with a reassuringly objective view of medicine: its “primary goal” is to benefit patients by “restoring or maintaining their health as far as possible, thereby maximising benefit and minimising harm”. Some might want to add that medicine has several goals, not all of which relate to promoting health; however, those who see the aim of the profession as more than consumer satisfaction will welcome the suggestion here that not just any choice (...) counts as medicine. In the same way, the statement which heads the next paragraph would be rejected by very few readers if “quality of life” were suitably defined. If all we mean by “quality of life” is the patient's level of wellbeing, with no suggestion that the value of his or her “being” can fall to zero or below, it is uncontroversial that “it is not an appropriate goal of medicine to prolong life at all costs with no regard to its quality or the burdens of treatment on the patient”. This is, however, an overly benign interpretation of “quality of life” observations as they appear in the guidelines. (shrink)

The theme of the XVIth International Congress of the European Society for Philosophy of Medicine and Healthcare ….