Rethinking ‘Westernised’ medical ethics in end-of-life care

In early 2021, a High Court judge ruled that a 32-year-old woman with COVID-19 in a coma and on VV-ECMO should be allowed to die ¹ . This was counter to clearly expressed and sincere wishes of her husband and sister. Many will have encountered similar scenarios, where there is a moral feeling amongst treating clinicians of when it is correct and appropriate to stop. The recent qualitative study from Reader et al. brings out several themes around end-of-life care in ICU that we believe have not yet been addressed sufficiently. ² Whilst ‘good communication’ with families is often described as important, defining exactly what this involves is problematic, and getting these discussions right is an art that we all labour at for a lifetime.

Conflict probably begins when the medical decision has been made and clinicians have formed their own consensus about withdrawing life sustaining therapies, which then makes the issue about justifying this decision and communicating it. Navigating a path between religion, science and ethics at the end-of-life is a difficult and delicate process, and we rightly fall back on our four pillars of medical ethics: autonomy, beneficence, non-maleficence and justice. These govern how we do right by our patient, but they might also lack the finesse required to incorporate religion, faith and conflict. The work by Reader et al. reminds us of the need not to discount the overarching influence of spirituality and religion, ² and we believe there is a need for us all to be more informed in this regard. Sometimes, these principles can even feel too Westernised and of less relevance to the relatives and loved ones of our patients. They might simply not work, and the result is that best interests are decided ultimately by a judge in court. Whether or not escalation to legal proceedings is inevitable or avoidable for certain cases, or results directly from poor communication, is unclear.

During critical illness, we should open channels of communication with family members and spiritual leaders, which must be maintained. The point at which prolongation of life crosses into harm receives little attention in the acute medical literature and it is time for that to change. Reader et al. should be congratulated for getting ‘under the skin’ of an area of clinical practice that is well suited to a qualitative approach. There is arguably much more to do now to increase our understanding and hopefully reflect on whether traditional teachings in medical ethics remain applicable to 21st-century practice.