an indication for palliative sedation is rare,
there is mostly a cluster of different kinds of
suffering, and physical symptoms also have a
psychological and even existential
dimension.
Suffering in itself is an affliction of persons,
not bodies. (22) Cassell and Rich have
strongly advocated for the discontinuation of
the ancient and long-discredited distinction
in medicine between mind and body:
"Suffering is personal, individual, lonely, and
marked by self-conflict. When a source of
distress, like pain, produces suffering, it is
the suffering that becomes the central
distress, not the pain. It is not valid to make
a distinction between suffering whose
source may be physical, such as pain, and
suffering coming from the threat to the
integrity of the person from the very nature
of the person's existence." (23)
participation." (25) With the 4-principles
model, medico-ethical reasoning about
decisions on treatment and care should work
differently: What could be (theoretically and
under consideration of best practice)
justified as an indication in the patient's
situation in question, should only be done
considering patient autonomy.
For any medical procedure, an indication is
needed. Cassell's holistic approach to
suffering goes well beyond the limited
medical approaches of assessment. (20) The
revised framework states, that indication
should be a joint decision between the
physician (and/or the multi-professional
team) and the patient or their legal
representative/significant other(s); "the
former determining the treatable or
untreatable nature of the suffering, the
latter the intolerable nature of their
intensity" (statement 3). Consultation with a
specialist palliative care team or other
healthcare experts is strongly recommended
to determine the untreatable nature of the
suffering.
However, the principles represent general
ethical orientations for individual cases,
which allow considerable scope for judgment
in their application.
The four biomedical principles, as introduced
by Beauchamp and Childress in the late
1970s, have largely influenced the bioethical
discourse and the practice of medicine. (24)
Whereas the principles of non-maleficence
(first do no harm), beneficence (a moral
obligation to act for the others' benefit) and
the principle of justice (comprising a huge
variety of theories of justice in health care)
refer to a long-established ethical codex in
medical practice, the emphasis on the newly
introduced principle of autonomy reflects a
shift from paternalism (more inclusively
termed parentalism) to patient autonomy.
The emphasis on parentalism had assumed
"that there are shared objective criteria for
determining what is best. Hence the
physician can discern what is in the patient's
best interest with limited patient
Significant other(s)
Decision-making and
patient autonomy
26 The term significant other has been used to
replace the term family. This reflects the ethical
imperative to understand the "unit of care"(26)
as the patient and the persons with a very close
and special relationship to them, with or
without family ties. It should also be understood
as a consideration of diversity and gender
equity.