Becoming an End-of-Life Companion, Part 10: Ethics

We recently talked about ethics in hospice care, and how quickly different ethical principles can end up in conflict with one another. Here's what I took away.

❧ There's more than one way to think about ethics
Utilitarians ask what serves the greater good, doing as much good as possible, while deontologists ask whether something is simply the "right" thing to do, regardless of outcome.

❧ Hospice care rests on four core ethical principles:
1. Respecting the patient's autonomy.
2. Caring for the patient and acting in their best interest.
3. Doing no harm.
4. Making just decisions, both legally and in terms of social and distributive justice.

❧ These principles often collide
Take a person in severe pain who wants to die. Relieving that pain falls under the principle of care, and honoring their wish falls under autonomy. But granting that wish could conflict with the principle of doing no harm, and with the principle of just decisions, which also means respecting the law.

❧ There's a difference between an ethical conflict and an ethical dilemma
A dilemma is when there's no good solution: doing the right thing in one direction means failing to do another right thing elsewhere. Unfortunately, hospice care is full of dilemmas like this.

❧ A common one: who gets the next free bed?
Is it the person closest to death, or the one who needs support the most, even if they might still live for another year? There's rarely a clean answer.

❧ Many of these decisions land squarely with the hospice team
External authorities often can't help, or aren't the right fit, so it becomes essential to have a clear, transparent decision-making process that the whole team shares responsibility for.

❧ Hindsight is unfair
Because there's often no obviously "right" choice, and because a patient's condition can shift dramatically and unpredictably, a decision that made sense at the time can later turn out to be the wrong one. That can weigh heavily on hospice staff. It's worth remembering that a decision should be judged by the information available at the moment it was made, not by what became clear afterward.

Having to make decisions for people at the end of their lives is extraordinarily hard. It's easy to get caught between the emotions, values, and wishes of the patient, their family, society, and yourself. I think it's important to stay aware of just how much emotional and psychological pressure these people are under, and to be kind and forgiving when things don't go as hoped.