Four Ethical Principles in End-of-Life Care

Case Presentation and Clinical Background

Mr. B is a 75-year-old man who suffered cardiorespiratory arrest and was immediately admitted to the intensive care unit (ICU). On admission, he presented with a Glasgow Coma Scale (GCS) of 3, indicating severe neurological compromise. By the seventh day of hospitalization, his neurologic status had not improved. He remained intubated on assisted control ventilation and was dependent on multiple vasopressor medications, including Levophed and Dobutamine intravenously, as well as renal-dose Dopamine. Despite maximum medical support, he remained hemodynamically unstable, with systolic blood pressure maintained at only 90 mm Hg. His urine output progressively decreased, and he was diagnosed with acute renal failure, for which he was started on slow continuous renal replacement therapy (CRRT). Hemodialysis was not pursued due to his continued hemodynamic instability. Nutritional support was provided via Dobhoff tube insertion, and bowel function remained intact.

The clinical team and family faced a profound ethical conflict. Mr. B's son, Dr. B, is a physician employed at the same institution and demanded continuation of full aggressive treatment and full code status. In stark contrast, Mr. B's wife, Dr. B's mother, wished to discontinue aggressive therapy because she no longer wanted to witness her husband's suffering. The ICU medical team, upon reassessment, agreed that continued aggressive intervention would not be beneficial. The patient was already on maximum doses of pressors yet remained hemodynamically unstable. His Glasgow Coma Scale showed no improvement over seven days. He could not be weaned from ventilator support and was completely dependent on CRRT. The medical consensus was that continuing aggressive therapy would only delay an inevitable outcome. This disagreement among the son, the wife, and the medical team created a complex ethical dilemma requiring careful application of established ethical principles.

The principle of beneficence means that every action is performed for the benefit of others. Beneficence encompasses actions that prevent or remove harm, or that improve the condition of others. In nursing, beneficence is supported by values emphasizing health promotion, well-being, and helping patients reach the best possible quality of life (Canadian Nurses Association, 2002). The principle assumes that health care providers have full knowledge and mastered skills in delivering care, ensuring that patients receive the utmost quality that will benefit improvement of their health condition.

Beneficence and the Limits of Treatment

Beneficence is distinguished between obligatory and ideal forms. Obligatory beneficence refers to doing good as required by one's profession. Ideal beneficence comprises acts of extreme generosity or attempts to benefit others on all possible occasions (Pantilat, 2006). Health care professionals are required not only to prevent or remove harm but to weigh and balance possible benefits against possible risks of any action.

In Mr. B's case, the principle of beneficence initially supports continued aggressive treatment. Every possible action was undertaken to maintain his life. However, after seven days, the medical team began questioning whether their actions had become extraordinary rather than beneficial. At what point does providing every possible treatment fail to benefit the patient? Prolonged artificial ventilation carries serious risks. Patients on mechanical ventilation may develop pneumonia and acute respiratory distress syndrome. Other severe complications include cardiovascular complications, gastrointestinal bleeding, and multiorgan failure (Lawrence et al., 2002). The central question becomes: how extensive should treatment be? When does doing well become unnecessary or even harmful measures?

Withdrawing aggressive therapy would likely lead to Mr. B's death, which appears to contradict beneficence. If this principle alone were used to resolve the dilemma, continuing all aggressive treatment would be ethically required to maintain life. Yet beneficence, when applied with wisdom, also asks whether prolonging a dying process without realistic hope of recovery truly benefits the patient. The tension between prolonging life and preventing suffering illustrates why beneficence alone cannot resolve this dilemma.

Nonmaleficence and the Double Effect

The principle of nonmaleficence states that health care professionals should not intentionally create needless harm or injury to patients, whether through acts of commission or omission (McCormick, 2008). Stated simply: health care professionals should do no harm. Health care workers should not give ineffective treatments, because such treatments have no possible benefits and may subsequently harm patients (Pantilat, 2006). A health care provider who violates nonmaleficence is considered negligent. Negligence occurs when a competent health care provider imposes careless or unreasonable risk of harm on a patient (McCormick, 2008). All nurses and health care professionals are accountable for their actions; those who are negligent must face moral and legal consequences if their actions fall below the standard of appropriate care.

However, the principle of nonmaleficence is not without controversy. In fact, doing no harm may contradict doing good to the patient. Health care practice is rarely black and white, as many available medical treatments carry possible adverse risks. In Mr. B's case, the vasopressors used to support his blood pressure carry significant risks. Levophed (norepinephrine bitartrate) is a catecholamine that may cause cardiovascular side effects such as arrhythmias and ischemic injury due to peripheral vasoconstriction. High doses of dopamine may cause hypertension and increase stroke risk. Artificial ventilation itself can cause pulmonary damage to the lung parenchyma.

The principle of double effect addresses this inherent tension. It acknowledges that one intervention may unintentionally cause harm while pursuing a good outcome. The double effect must satisfy four basic concepts (Mallia, 2003). First, the act itself should be good or at least indifferent. Second, the purpose must be to do well, not intentionally to cause harm. Third, the bad effect must not be the means by which the good effect is achieved. Fourth, the good and bad effects must be proportional. For example, a health care professional may give a potentially lethal dose of pain medication to a cancer patient suffering excruciating pain. The aim is not to kill the patient but to alleviate suffering—a morally sound application of double effect.

In Mr. B's case, two issues invoke nonmaleficence. First, he was receiving medications and treatments that evidently caused harm. Maintaining him on artificial support risked destroying his lungs. However, the intention was to provide oxygen for breathing, not to damage lung tissue. Similarly, he was maintained on medications to keep his blood pressure above critical levels. Despite the side effects, providing these medications was ethically sound under double effect. Second, hemodialysis was withheld despite progressive renal failure, because initiating it would likely make him more hemodynamically unstable. The principle of nonmaleficence thus supports continued aggressive treatment, as withdrawal would obviously cause harm to the patient.

Respect for Autonomy and Surrogate Decision-Making

Like beneficence, nonmaleficence alone supports continuing aggressive care for Mr. B. Yet nonmaleficence also asks: when do the harms of treatment (organ damage, medication side effects, prolonged dying) outweigh the diminishing likelihood of benefit? This tension reveals why multiple principles must be considered together.

The principle of respect for autonomy recognizes each person's right to freely choose for himself and to be an active participant in managing his own health (Mallia, 2003; Pantilat, 2006). Autonomy requires that decisions be free from coercion. Health care professionals have an obligation to provide informed consent, guiding the patient's decision with facts about treatment options, risks, and prognosis. Respect for autonomy emphasizes nurses' obligation to honor patients' choices and ensure those choices are implemented. It also includes the value of confidentiality—keeping patient information private to protect the patient-provider relationship and ensure privileged information remains within the health care team.

In Mr. B's case, respect for autonomy faces a critical obstacle: he is comatose and cannot decide for himself. Assuming he left no advance directives addressing extubation or life support, the first issue to resolve is who has authority to decide. The standard hierarchy is spouse, then adult children, then parents (Lang and Quill, 2004). In this case, his wife wishes to stop artificial support, while his son demands aggressive management. Following the principle of respect for autonomy and standard surrogate decision-making hierarchy, the wife's preference should be honored, as she holds primary decision-making authority. However, this conflicts with the son's medical expertise and his desire to continue treatment. The disagreement reflects how autonomy itself—when applied through surrogacy—can yield different conclusions depending on whose autonomy is centered and whose preferences are respected.

Justice and Resource Allocation

The principle of justice requires giving to a person what is due and ensuring fair distribution of resources in society. Today, hospitals frequently face shortages of nursing and medical staff, medications, bed space, and equipment. Justice helps determine how to allocate these limited resources among admitted patients. Ideally, people who are equal should receive equal treatment. However, when resources are insufficient, hospitals may allocate care through triage, consideration of patient quality-of-life outcomes, first-come-first-served allocation, or macro-allocation decisions (Jonsen and Edwards, 2008).

In allocating care for Mr. B, one must ask: is continuing intensive care for a patient with a grave prognosis still justifiable? The longer he occupies ICU resources—bed space, nursing time, equipment, medications—the more he may deprive other patients with greater chances of recovery. Resource scarcity raises fundamental questions about fair allocation and who benefits when resources are limited.