Ethics Introduction

End of life care raises many and challenging ethical issues. One example is the question of when to withhold or withdraw potentially life-prolonging treatment in the terminally ill. Another is the issue of euthanasia and palliative care, (see "Euthanasia and physician-assisted suicide: a view from an EAPC Ethics Task Force" and "Palliative care on the 'slippery slope' towards euthanasia?").

Then what is the meaning of “ethics”? The concepts “ethics” and “morality” are used interchangeably in everyday language. Etymologically, this is appropriate since ethical is a word stemming from the Greek ethos, whereas moral is from the Latin mos, both of which mean “custom”, “habit”.

However, pointing this out brings up the topic of ethical relativism. A relativist holds the view that since customs vary very much across the world, accordingly right and wrong are relative to:

• culture (e.g. Western vs. Muslim)
• society/country (laws on ethically substantial matters differ from country to country, even within one single cultural sphere)
• social group (within one particular society)
• the individual (“it is correct for me, although it may not be so for you”; also called subjectivism)

End of life care is indeed a field in which different and sometimes even conflicting ethical views abound. A much debated, key question, though, is whether "it is all relative” or if there are at least some shared ethical standards globally.

One thing is ethics; another is professional ethics. With regard to the former, we are all ethicists in the sense that everyone has some ethical worldview or other. But few are ethicists in the latter sense of the word. Those who do ethics for a living are often philosophers by training. We may distinguish between theoretical ethics on the one hand, and practical or applied ethics on the other.

Theoretical ethics consists of a reservoir of ethical theories and concepts that may be used to analyse and construe certain ethical issues; these theories and concepts are thus “applied” to these “practical” issues – hence the very notion of applied or practical ethics. To illustrate, the ethics of euthanasia is going to look very different when dealt with within a framework of Utilitarian ethics as opposed to one of a Kantian ethics. These and other ethical theories thus make up the “tool box” carried, as it were, by philosophers who are ethicists.

Practical/applied ethics has several sub categories, such as environmental ethics, military ethics, and animal rights. The sub category that directly addresses ethical issues within end of life care is that of medical ethics or, more broadly, health care ethics.

Within The International Observatory on End of Life Care (IOELC) we have chosen a particular framework/template for global, ethical analysis. This is the so-called Four Principles approach to health care ethics. The principles are:

• Beneficence - (the obligation to provide benefits and balance benefits against risks)
• Non-maleficence - (the obligation to avoid the causation of harm)
• Respect for autonomy - (the obligation to respect the decision-making capacities of autonomous persons)
• Justice - (obligations of fairness in the distribution of benefits and risks)

An example of the employment of this template, as well as an attempt at justification for its use, may be found in the IOELC’s Uganda Country Report - which has also been published in Michael Wright and David Clark: Hospice and Palliative Care in Africa. A review of developments and challenges (2006) - and in a forthcoming Observatory Publications book due to be published in 2007. Otherwise, there is a huge collection of articles that either use or discuss the four principles approach. Also, a special issue of the Journal of Medical Ethics contains many different viewpoints as to the usefulness of the approach.