Principles of medical ethics in supportive care: a reflection.

The possibility of medical-moral controversy in contemporary health care delivery is occasioned by the interfacing of expanding technology with both professional and personal value systems, frequent and significant knowledge deficits on the part of health care consumers, and increased circumspection of and economic constraints experienced by health care providers. Particularly in an era of increasing regulatory mandates and the frequent and lamentable decrease in the availability of human, natural, and institutional resources, an understanding of the function of ethical analysis is indigenous to care, which is simultaneously medically appropriate and morally indicated. But while a familiarity with and an appreciation of the potential contribution of ethical reasoning is essential in all health care delivery, it assumes critical importance in supportive care. In that venue, where the rigors and demands of aggressively therapeutic interventions have ceased and the goal and the demeanor of care have shifted to the palliative mode, heightened attention to the principles of medical ethics is necessary for the balancing of rights and responsibilities for health care consumers and providers alike. This issue ultimately can be singularly salient in providing care that is patient centered and directed. Individuals acting as moral agents, suggesting what "ought" to be done in a given situation, either for themselves or as they are involved in rendering or supporting decisions proffered for or by other moral agents, particularly those in extremis, those in the throes of terminal illness following the collapse of the curative mode, need recourse to principles to facilitate their reasoning. Although the employment of each principle of medical ethics offers guidelines for reflection on the most comprehensive and appropriate care, it is attention to autonomy, informed consent, and beneficence that promotes the most effective supportive care. For even as the question of medical viability is settled in favor of palliation over aggression, there remain the entanglements of psychological stability, conflicting value systems, and the impact of the social milieu as well as the issues of economic responsibility and resource accountability. It is in the attention to the medical ethical principles of autonomy and informed consent, especially as amplified by the creation of and respect for advance directives, that the most holistic and productive supportive care can be offered. It is also in this posture that appeal to the principle of beneficence is made. Just as the progress of disease and, therefore, the realistic goals of care change, so too can an individual's considered opinion with regard to end-of-life decisions. Preserving the integrity of patients and caregivers alike and engaging in fruitful and informative dialog prior to seeking volitional authorization or operationalizing a supportive approach demonstrates renewed concern for both patient autonomy and professional accountability in the provision of a comprehensive end-of-life care plan. Discussions will not be avoided until they can no longer effectively take place, salient questions will not go unanswered, and decisions around end-of-life questions, in the mode of supportive care, will not be absent where care was exercised to engage patients in significant dialog earlier rather than later in their disease processes.