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In Uruguay, an ethic of care for the dying.

In Uruguay, an Ethic of Care for the Dying

Perhaps the most striking point to be made about biomedical ethics in Uruguay is that there has been insufficient interest on the part of the medical community to engage in systematic reflection or to set up mechanisms for addressing ethical issues.

For various reasons Uruguay underwent a process of secularization earlier than many European countries. The separation of the Catholic church and the state was formally instituted with the 1917 Constitution. Since that time ethical issues have been associated with "dogmatism" and "religion." From the end of the last century medicine in Uruguay, as in other countries, has been characterized by philosophical positivism. In this perspective, the "typical" Uruguayan physician has always maintained a humanistic attitude in certain recognized modalities in the physician-patient relationship. It is generally held that:

* The patient deserves respect and consideration because he or she is a human being whom physicians are not permitted to manipulate.

* The family is to be treated with deference. The physician seeks to accomplish the family's will whenever it does not come into conflict with his or her expert judgment.

* It is the physician, however, who in the last instance resolves all issues concerning the patient's health care. The patient, for his or her part, trusts the physician to make all decisions in his or her best interest.

* Uruguayan society attributes to the physician a paternal function that consists basically in curing the patient by the best available means and acting in his or her best interest.

* The physician is aware also that patients expect a friendly and encouraging attitude on his part. Nonetheless, it is more or less tacitly acknowledged that a physician can withhold "sensitive" information from the patient, knowing that the latter will not insist on having treatment decisions explained in detail.

These moral attitudes have been called into question by only a very limited minority among the 8,000 physicians who serve Uruguay's population of 3 million. Ethical issues not linked to the physician-patient relationship, or on which there is no positive law, are considered matters of personal moral philosophy and conceptually associated with religion.

The most relevant issue of professional ethics in Uruguayan medicine in the past ten years has been that of physicians participating in torture at the service of the military dictatorship that ended in 1985. This led the Sindicato Medico del Uruguay (Uruguayan Medical Association) to create an ethics committee, whose activities to date have been restricted to this topic. To my knowledge as yet no hospital in the country has an ethics committee. Nonetheless, initiatives in the field of bioethics--although very confined--are not completely lacking in Uruguay. A small group of health professionals has sponsored courses and lectures by professors from other nations in bioethics at the Catholic University of Uruguay. Catholic physicians have organized activities, and chairpersons of some departments in the school of medicine at the Universidad Mayor de la Republica have initiated lectures and debates on bioethics. Yet in spite of this relative "poverty" of systematic reflection in our country, one is aware that there are conscientious physicians in Uruguay who are very interested in ethical issues. Through the scientific literature they receive they have access to their foreign colleagues' ethical reflections and are well informed.

Ethics in the Care of the Dying

In this context the fundamental relation between physician and dying patient is one of paternalism on the part of the physician and willingness to relinquish responsibility on the part of the patient. In a large majority of cases, physicians prefer not to inform the patient that his or her condition is actually terminal. A conspiracy of silence is more or less implicitly established between the physician and the family. Although seldom articulated in detail, most Uruguayan physicians subscribe to an "ethic of care" with respect to the terminally ill. This ethic entails considering all available technical and human measures to care for the dying patient in a manner that best alleviates suffering. It also seems to be an accepted practice among Uruguayan physicians not to take resuscitation measures when there is no possibility of prolonging a patient's life with dignity.

Typically, family members do not make the final decision to discontinue artificial ventilation. The generally accepted procedure is that some twenty-four hours after cerebral death is detected the physician makes the decision to disconnect the ventilator and then informs the family that death has been caused by cardiac arrest. There is a general perception among physicians that family members are not able to make a valid decision because of the stress and emotional impact of a loved one's terminal condition. When several members of the family have equal authority to participate in treatment decisions (as, for example, brothers or sisters), physicians tend to believe that there is no possibility one member can decide for the others or that all can arrive at a consensus. Moreover, physicians think--with humanitarian and benevolent sensitivity--that it is not to the benefit of any member of the family to carry, for the rest of his or her life, the responsibility for having taken the decision to disconnect the ventilator of his or her loved one.

In the case of terminally ill cancer patients, it is not uncommon in our country for the physician ultimately to resort to a "lytic cocktail" comprised of an opiate, a sedative, and an analgesic administered in a continuous intravenous drip. It is claimed that this allows the patient to "escape" suffering, with brief lucid intervals punctuating the semiconsciousness in which he or she passes the better part of his or her final days. For both physicians and families, this procedure mitigates the anxiety created by the patient's terminal condition by obviating the need to discuss openly with the patient his or her impending death. Nutrition is customarily provided as an element of comfort care, and hydration is expected to be given until the end, except when there is cerebral death or irreversible coma.

Collectively, Uruguayan physicians overtly reject euthanasia--the Sindicato Medico del Uruguay ratified the 1984 declaration of the WHO. Nonetheless, it is well known that individually some make use of the "lytic cocktail" not only to mitigate the pain of the dying, but also at times to hasten death, not always with the knowledge of the family or the consent of society, in which the practice is in open opposition to the law.

In summary, the ethics of care for the terminally ill in Uruguay spring from deeply rooted attitudes and practices prevalent both in the general population and among health care professionals. The physician is seen as the champion of life and is expected to maximize the wellbeing and minimize the physical and psychological suffering of the patient. Further, it is the physician who determines the course of treatment, even when radical procedures are contemplated. He or she should try to obtain collaboration and agreement on the part of the family, but always reserves the right to make the final decision. If the physician's decision will subject the patient or family to psychological trauma or suffering he or she should seek a way to convey the information obliquely.

Selected References

Departamento Servicio Social, Encuesta aplicada a pacientes en el area de la internacion de la clinica medica B. (Montevideo: Clinica Medica B. Hospital de Clinicas Dr. Manuel Quintela, 1986).

U.P.M.S., Actitudes y creencias frente al diagnostico de cancer. *Decir o no decir? (Montevideo: Hospital Maciel U.M.P.S., 1987).

Comision de Etica Medica del Sindicato Medico del Uruguay, Los medicos y la tortura (Montevideo: Ed. Banda Oriental, 1988).

Fr. Omar Franca is director of the Institute of Philosophy and Ethics of the Catholic University of Uruguay, Montevideo, Uruguay.
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Title Annotation:Special Supplement: International Perspectives on Biomedical Ethics
Author:Franca, Omar
Publication:The Hastings Center Report
Date:Aug 1, 1988
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