Concepts of personhood and autonomy as they apply to end-of-life decisions in intensive care
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Amongst traditionally-available frameworks within which end-of-life decisions in Intensive Care Units (ICU) are situated, we favour Ordinary versus Extra-ordinary care distinctions as the most helpful. Predicated on this framework, we revisit the concepts of personhood and autonomy. We argue that a full account of personhood locates its foundation in relationships with others, rather than merely in “rationality”. A full account of autonomy also recognises relationships with others, as well as the actual reality of the patient’s situation-in-the-world. The fact that, when critically ill, the patient may no longer be able to take an active role in decision-making does not bring about the end of their personhood, or of their autonomy. Because the patient’s autonomy is intimately linked to their relationships with others, once critical illness supervenes, respect for their autonomy devolves to those others with whom the patient is in relationship. In practical application, this means that there must be a dialogue, as the end-of-life of the critically-ill patient in ICU comes into view. Such dialogue should be grounded on this understanding in order to conform best to moral philosophical principles. Ideally the dialogue will involve all those with whom the patient is in relationship and, practical difficulties within an ICU notwithstanding, will aim to be inclusive, non-coercive and reflective as it seeks to maximise the good of the patient in their unique context.
KeywordsAutonomy End-of-life Intensive care unit Moral decision-making Ordinary versus Extra-ordinary care Personhood
We acknowledge the insights of the anonymous reviewers in clarifying our thoughts.
- Aggarwal, A., J. Davies, and R. Sullivan. 2014. “Nudge” in the clinical consultation—an acceptable form of medical paternalism? BMC Medical Ethics 15(31): 1–6.Google Scholar
- Beauchamp, T. 2009. Moral foundations. In Ethics and epidemiology, eds. S. Coughlin, T. Beauchamp, and D. Weed, 39–41. Oxford: Oxford University Press.Google Scholar
- Beauvoir, S. 2011. Biological data. In The second sex. New York: Random House.Google Scholar
- Bishop, J.P. 2011. Embracing death. In The anticipatory corpse: Medicine, power, and the care of the dying. Notre Dame: Indiana, University of Notre Dame.Google Scholar
- Campbell, Alastair V. 2012. The body: Property, commodity, or gift. In Reconceiving medical ethics: Bloomsbury studies in philosophy, ed. Cowley, Christopher, 1st ed., Chap. 1, 15–29. London: Bloomsbury Academic.Google Scholar
- Catholic Health Australia. 2001. Code of ethical standards for catholic health and aged care services in Australia, 1st ed., 44. Red Hill, ACT: Catholic Health Australia Inc. http://www.cha.org.au/images/resources/Code%20of%20ethics-full%20copy.pdf.
- Childress, J. 2001. Christian ethics, medicine, and genetics. In The Cambridge companion to Christian ethics, ed. R. Gill. Cambridge: Cambridge University Press.Google Scholar
- DeGrazia, D. 2006. On the question of personhood beyond homo sapiens. In In defence of animals: The second wave, ed. P. Singer, 42. Malden, MA: Blackwell Publishing.Google Scholar
- Deligiorgi, Katerina. 2012. The many faces of kantian autonomy. In The scope of autonomy: Kant and the morality of freedom, Chap. 1.2, 18. Oxford: Oxford university Press.Google Scholar
- Descartes, Rene. 2011. Of the principles of human knowledge. In The principles of philosophy (trans: Veitch, John). Chap. 10. Whitefish, Montana: Kessinger Publishing LLC.Google Scholar
- Engelhardt, H.T. 1996. The context of health care: Persons, possessions and states. In The foundations of bioethics. New York: Oxford University Press.Google Scholar
- Fletcher, J.F. 1998. Four indicators of humanhood—the enquiry matures. In On moral medicine: Theological perspectives in medical ethics, ed. S.E. Lammers, and A. Verhey. Grand Rapids: William B Eerdmans Publishing.Google Scholar
- Flyvbjerg, B. 2000. Ideal theory, real rationality: Habermas versus Foucault and Nietzsche. Political studies association’s 50th annual conference. London School of Economics and Political Science.Google Scholar
- Gert, B. 2004. Features of the moral system. In Common morality: Deciding what to do. Oxford: Oxford University Press.Google Scholar
- Gillett, G., and Clair Amos. 2014. Words are not just things. The New Zealand bioethics conference. Jan 26 2014, in Dunedin, Otago, NZ.Google Scholar
- Griffioen S. Woudenberg, R. 1990. We must not forget those who are absent: Interview with Karl-Otto Apel on the universality of ethics. In What right does ethics have?: Public philosophy in a pluralistic culture. Amsterdam: VU University Press.Google Scholar
- John Paul II, Pope. 1995. In Evangelium Vitae, Vatican City: Libreria Editrice Vaticana. http://www.vatican.va/holy_father/john_paul_ii/encyclicals/documents/hf_jpii_enc_25031995_evangelium-vitae_en.html.
- Janssens, L. 1979. Ontic evil and moral evil. In Readings in moral theology: moral norms in the Catholic tradition, vol. 1, ed. C. Curran, and R.A. McCormick, 40–93. New York: Paulist Press.Google Scholar
- Kitwood, T. 2001. On being a person. In Dementia Reconsidered, 8. Buckingham, UK: Open University Press.Google Scholar
- Kerridge, I, Lowe, M, and Stewart, C. 2013. Problem solving in clinical ethics and law. In Ethics and law for the health professions. Sydney: The Federation Press.Google Scholar
- Larmore, C. 2008. The problem with morality. In The autonomy of morality, 88. Cambridge: Cambridge University Press.Google Scholar
- Mackenzie, C. 2000. Introduction: Autonomy refigured. In Relational autonomy: Feminist perspectives on autonomy, agency, and the social self, ed. N. Stoljar, C. Mackenzie, and N. Stoljar, 3–31. New York: Oxford University Press.Google Scholar
- Mathews, Eric. 2012. Old age and dependency. In Reconceiving medical ethics: Bloomsbury studies in philosophy, ed. Cowley, Christopher, 1st ed., Chap. 4, 59–71. London: Bloomsbury Academic.Google Scholar
- McCarthy, T. 1981. Moral consciousness and communicative action. Cambridge: Polity Press.Google Scholar
- McMahan, J. 2003. Endings. In The ethics of killing. Oxford: Oxford University Press.Google Scholar
- Mill, J.S. 1859, 2002. Introductory. In On liberty. New York: Dover Publications.Google Scholar
- O’Donovan, O. 1998. Again: Who is a person. In On moral medicine: Theological perspectives in medical ethics, ed. Stephen E. Lammers and A. Verhey. Grand Rapids, Michigan: William B Eerdmans Publishing.Google Scholar
- Pellegrino, E. 1985. Moral choice, the good of the patient, and the patient’s good. In Ethics and critical care medicine, ed. John C. Moskop and L. Kopelman. Dordrecht: D Reidel Publishing.Google Scholar
- Radha Krishna, L.K. 2013. Accounting for personhood in palliative sedation: the Ring Theory of personhood. Medical humanities. Sep 26. doi: 10.1136/medhum-2013-010368.
- Scambler, G. 2001. Introduction: Unfolding themes of an incomplete project. In Habermas, critical theory, and health. London: Routledge.Google Scholar
- Scanlon, T.M. 1998. Wrongness and reasons. In What we owe to each other. Cambridge, Mass: Belknap Press of Harvard University Press.Google Scholar
- Svenaeus, F. 2014. Phenomenology as a method within the realm of bioethics. The New Zealand bioethics conference, Jan 24 2014, Dunedin, Otago, NZ.Google Scholar
- Walter, J. 2004. Life, quality of. In Encyclopedia of bioethics, ed. Stephen G. Post. New York: MacMillan.Google Scholar
- Warren, M.A. 1973. On the moral and legal status of abortion. In Ethical issues in modern medicine, ed. B. Steinbock, and J.D. Arras. Mayfield Publishing Co: Mountain View.Google Scholar