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February 2, 1990, Vol 263, No. 5 >
ARTICLE | February 2, 1990

Ethical Principles in Critical Care FREE

John M. Luce, MD
[+] Author Affiliations

Reprint requests to Chest Service, 5K1, San Francisco General Hospital, 1001 Potrero Ave, San Francisco, CA 94110 (Dr Luce).


JAMA. 1990;263(5):696-700. doi:10.1001/jama.1990.03440050090040
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Article
References

THE MOST compelling principle of medical ethics always has been beneficence: acting to benefit patients by sustaining life, treating illness, and relieving pain. A correlative principle is nonmaleficence: refraining from harm. A third principle that has increasingly gained acceptance in the United States is autonomy: respecting the right of patients to determine much of their medical care. Closely related to this is disclosure: providing adequate and truthful information for competent patients to make medical decisions.1-3 A fifth ethical principle is social justice: allocating medical resources fairly and according to medical need.4

The first four ethical principles outlined above are the foundation of the fiduciary relationship in which physicians are expected to serve the best interests of their patients as the patients define these interests. This relationship is relatively easy to maintain when primary physicians follow up patients in their offices or in hospital rooms. However, the relationship may

REFERENCES

1 +
Jonson AR, Siegler M, Winslade WJ. Clinical Ethics . 2nd ed. New York, NY: Macmillan Publishing Co Inc; 1986;.
2 +
Paris JJ, Reardon FE.  Dilemmas in intensive care medicine: an ethical and legal analysis . J Intensive Care Med. 1986;;1:75-90.
3 +
Sheldon M.  Truth telling in medicine . JAMA. 1982;;247:651-654.
4 +
Fuchs VR.  The 'rationing' of medical care . N Engl J Med. 1984;;311:1572-1573.
5 +
Smedira NG, Evans BH, Cohen NH, et al.  Withholding and withdrawing of life support from the critically ill . Am Rev Respir Dis. 1988;;137:475. Abstract.
6 +
Fink C, O'Callahan J, Epstein E, May K, Smedira N, Luce JM.  The family perspective in withdrawing and withholding life support from the critically ill . Heart Lung. 1989;;18:302. Abstract.
7 +
Steinbrook R, Lo B.  Decision making for incompetent patients by designated proxy . N Engl J Med. 1984;;310:1598-1601.
8 +
Raffin TA.  Value of the living will . Chest. 1986;;90:444-446.
9 +
Rosner F.  Hospital medical ethics committees: a review of their development . JAMA. 1985;;255: 2693-2697.
10 +
Brennan TA.  Ethics committees and decisions to limit care in the experience at the Massachusetts General Hospital . JAMA. 1988;;260:803-807.
11 +
Lidz CW, Meisel A, Osterweis M, Holden JL, Marx JH, Munetz MR.  Barriers to informed consent . Ann Intern Med. 1983;;99:539-543.
12 +
Orlowski JP, Kanoti GA, Mehlman MJ.  The ethics of using newly dead patients for teaching and practicing intubational techniques . N Engl J Med. 1988;;319:439-441.
13 +
Bedell SE, Delbanco TL, Cook EF, Epstein FH.  Survival after cardiopulmonary resuscitation in the hospital . N Engl J Med. 1983;;309:569-576.
14 +
Youngner SJ, Lewandowski W, McClish DK, Juknialis BW, Coulton C, Bartlett ET.  'Do not resuscitate' orders . JAMA. 1985;;253:54-57.
15 +
Bedell SE, Pelle D, Maher PL, Cleary PD.  Donot-resuscitate orders for critically ill patients in the hospital: how are they used and what is their impact? JAMA. 1986;;256:233-237.
16 +
Zimmermafl JE, Knaus WA, Sharpe SM, Anderson AS, Draper EA, Wagner DP.  The use and implications of do not resuscitate orders in intensive care units . JAMA. 1986;;255:351-356.
17 +
Blackhall LJ.  Must we always use CPR? N Engl J Med. 1987;;317:1281-1285.
18 +
President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research.  Guidelines for the determination of death . JAMA. 1981;;246:2184-2186.
19 +
Caplan AL.  Ethical and policy issues in the procurement of cadaver organs for transplantation . N Engl J Med. 1984;;311:981-983.
20 +
Luce JM, Raffin TA.  Withholding and withdrawal of life support from critically ill patients . Chest. 1988;;94:621-626.
21 +
Ruark JE, Raffin TA, Stanford University Medical Center Committe on Ethics.  Initiating and withdrawing life support: principles and practice in adult medicine . N Engl J Med. 1988;;318:25-30.
22 +
Curran WJ.  Defining appropriate medical care: providing nutrients and hydration for the dying . N Engl J Med. 1985;;313:940-942.
23 +
Schneiderman LJ, Spragg RG.  Ethical decisions in discontinuing mechanical ventilation . N Engl J Med. 1988;;318:984-988.
24 +
NIH Workshop Summary.  Withholding and withdrawing mechanical ventilation . Am Rev Respir Dis. 1986;;134:1327-1330.
25 +
McGivney WT, Crooks GM.  The care of patients with severe chronic pain in terminal illness . JAMA. 1984;;251:1182-1188.
26 +
Denardo SJ, Oye RK, Bellamy PE.  Efficacy of intensive care for bone marrow transplant patients with respiratory failure . Crit Care Med. 1989;; 17:4-6.
27 +
Butt W, Barker G, Walker C, Gillis J, Kilham H, Stevens M.  Outcome of children with hematologic malignancy who are admitted to an intensive care unit . Crit Care Med. 1988;;16:761-764.
28 +
Schuster DP, Marion JM.  Precedents for meaningful recovery during treatment in a medical intensive care unit: outcome in patients with hematologic malignancy . Am J Med. 1983;;75:402-408.
29 +
Wachter RM, Luce JM, Turner J, Volberding P, Hopewell PC.  Intensive care of patients with the acquired immunodeficiency syndrome: outcome and changing patterns of utilization . Am Rev Respir Dis. 1986;;134:891-896.
30 +
Fein AM, Lippmann M, Holtzman H, Eliraz A, Goldberg SK.  The risk factors, incidence, and prognosis of ARDS following septicemia . Chest. 1983;;83:40-42.
31 +
Jennett B, Teasdale G, Braakman R, Minderhoud J, Knill-Jones R.  Predicting outcome in individual patients after severe head injury . Lancet. 1976;;1:1031-1034.
32 +
Berger MS, Pitts LH, Lovely M, Edwards MSB, Bartkowski HM.  Outcome from severe head injury in children and adolescents . J Neurosurg. 1985;;62:194-199.
33 +
Longstreth WT, Diehr P, Inui TS.  Prediction of awakening after out-of-hospital cardiac arrest . N Engl J Med. 1983;;308:1378-1382.
34 +
Levy DE, Caronna JJ, Singer BH, Lapinski RH, Frydman H, Plum F.  Predicting outcome from hypoxic-ischemic coma . JAMA. 1985;;253:1420-1426.
35 +
Levy DE, Bates D, Caronna JJ, et al.  Prognosis in nontraumatic coma . Ann Intern Med. 1981;;94:293-301.
36 +
Knaus WA, Draper EA, Wagner DP, Zimmerman JE.  Prognosis in acute organ-system failure . Ann Surg. 1985;;202:685-693.
37 +
Kruse JA, Thill-Baharozian MC, Carlson RW.  Comparison of clinical assessment with APACHE II for predicting mortality risk in patients admitted to a medical intensive care unit . JAMA. 1988;;260: 1739-1742.
38 +
Luce JM, Wachter RM, Hopewell PC.  Intensive care of patients with the acquired immunodeficiency syndrome: time for a reassessment? Am Rev Respir Dis. 1988;;137:1261-1263.
39 +
Luce JM.  Critical care medicine in the United States: past performance and future possibilities . Pharos. 1986;;49:2-6.
40 +
Hook EW, Horton CA, Schaberg DR.  Failure of intensive care unit support to influence mortality from pneumococcal bacteremia . JAMA. 1983;;249: 1055-1058.
41 +
Cullen DJ, Keene R, Waternaux C, Kunsman JM, Caldera DL, Peterson H.  Results, charges, and benefits of intensive care for critically ill patients: update 1983 . Crit Care Med. 1984;;12:102-106.
42 +
Inglehart JK.  The new era of prospective payment for hospitals . N Engl J Med. 1982;;307:1288-1292.
43 +
Kitzhaber J.  Uncompensated care: the threat and the challenge . West J Med. 1988;;148:711-716.
44 +
Starr P. The Social Transformation of American Medicine . New York, NY: Basic Books Inc Publishers; 1982;.
45 +
Butler PW, Bone RC, Field T.  Technology under medicare diagnosis-related groups prospective payment: implications for intensive care . Chest . 1985;;87:229-234.
46 +
Spivack D.  The high cost of acute health care: a review of escalating costs and limitations of such exposure in intensive care units . Am Rev Respir Dis. 1987;;136:1007-1011.
47 +
Munoz E, Chalfin D, Calabro S, Goldstein JD, Wise L.  Costs of pulmonary medicine and DRGs: access and quality of care for the future . Am Rev Respir Dis. 1988;;137:964-968.
48 +
Zawacki BE.  ICU physician's ethical role in distributing scarce resources . Crit Care Med. 1985;;13:57-60.
49 +
Schiff RL, Ansell DA, Schlosser JE, Idris AH, Morrison A, Whitman S.  Transfers to a public hospital: a prospective study of 467 patients . N Engl J Med. 1986;;314:552-557.
50 +
Inglehart JK.  Medical care of the poor: a growing problem . N Engl J Med. 1985;;313:59-63.
51 +
O'Neil J, Mundinger M.  Health service funding cuts and the declining health of the poor . N Engl J Med. 1985;;313:44-47.
52 +
Strauss MJ, Lo Gerfo JP, Yeltlatzie JA, Temkin N, Hudson LD.  Rationing of intensive care unit services: an everyday occurrence . JAMA. 1986;; 225:1143-1146.
53 +
Singer DE, Carr PL, Mulley AG, Thibault GE.  Rationing intensive care: physician responses to a resource shortage . N Engl J Med. 1983;;309:11551160.
54 +
Kalb PE, Miller DH.  Utilization strategies for intensive care units . JAMA. 1989;;261:2389-2395.

Figures

Tables

Interactive Graphics

Video

Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature

Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal

1 +
Jonson AR, Siegler M, Winslade WJ. Clinical Ethics . 2nd ed. New York, NY: Macmillan Publishing Co Inc; 1986;.
2 +
Paris JJ, Reardon FE.  Dilemmas in intensive care medicine: an ethical and legal analysis . J Intensive Care Med. 1986;;1:75-90.
3 +
Sheldon M.  Truth telling in medicine . JAMA. 1982;;247:651-654.
4 +
Fuchs VR.  The 'rationing' of medical care . N Engl J Med. 1984;;311:1572-1573.
5 +
Smedira NG, Evans BH, Cohen NH, et al.  Withholding and withdrawing of life support from the critically ill . Am Rev Respir Dis. 1988;;137:475. Abstract.
6 +
Fink C, O'Callahan J, Epstein E, May K, Smedira N, Luce JM.  The family perspective in withdrawing and withholding life support from the critically ill . Heart Lung. 1989;;18:302. Abstract.
7 +
Steinbrook R, Lo B.  Decision making for incompetent patients by designated proxy . N Engl J Med. 1984;;310:1598-1601.
8 +
Raffin TA.  Value of the living will . Chest. 1986;;90:444-446.
9 +
Rosner F.  Hospital medical ethics committees: a review of their development . JAMA. 1985;;255: 2693-2697.
10 +
Brennan TA.  Ethics committees and decisions to limit care in the experience at the Massachusetts General Hospital . JAMA. 1988;;260:803-807.
11 +
Lidz CW, Meisel A, Osterweis M, Holden JL, Marx JH, Munetz MR.  Barriers to informed consent . Ann Intern Med. 1983;;99:539-543.
12 +
Orlowski JP, Kanoti GA, Mehlman MJ.  The ethics of using newly dead patients for teaching and practicing intubational techniques . N Engl J Med. 1988;;319:439-441.
13 +
Bedell SE, Delbanco TL, Cook EF, Epstein FH.  Survival after cardiopulmonary resuscitation in the hospital . N Engl J Med. 1983;;309:569-576.
14 +
Youngner SJ, Lewandowski W, McClish DK, Juknialis BW, Coulton C, Bartlett ET.  'Do not resuscitate' orders . JAMA. 1985;;253:54-57.
15 +
Bedell SE, Pelle D, Maher PL, Cleary PD.  Donot-resuscitate orders for critically ill patients in the hospital: how are they used and what is their impact? JAMA. 1986;;256:233-237.
16 +
Zimmermafl JE, Knaus WA, Sharpe SM, Anderson AS, Draper EA, Wagner DP.  The use and implications of do not resuscitate orders in intensive care units . JAMA. 1986;;255:351-356.
17 +
Blackhall LJ.  Must we always use CPR? N Engl J Med. 1987;;317:1281-1285.
18 +
President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research.  Guidelines for the determination of death . JAMA. 1981;;246:2184-2186.
19 +
Caplan AL.  Ethical and policy issues in the procurement of cadaver organs for transplantation . N Engl J Med. 1984;;311:981-983.
20 +
Luce JM, Raffin TA.  Withholding and withdrawal of life support from critically ill patients . Chest. 1988;;94:621-626.
21 +
Ruark JE, Raffin TA, Stanford University Medical Center Committe on Ethics.  Initiating and withdrawing life support: principles and practice in adult medicine . N Engl J Med. 1988;;318:25-30.
22 +
Curran WJ.  Defining appropriate medical care: providing nutrients and hydration for the dying . N Engl J Med. 1985;;313:940-942.
23 +
Schneiderman LJ, Spragg RG.  Ethical decisions in discontinuing mechanical ventilation . N Engl J Med. 1988;;318:984-988.
24 +
NIH Workshop Summary.  Withholding and withdrawing mechanical ventilation . Am Rev Respir Dis. 1986;;134:1327-1330.
25 +
McGivney WT, Crooks GM.  The care of patients with severe chronic pain in terminal illness . JAMA. 1984;;251:1182-1188.
26 +
Denardo SJ, Oye RK, Bellamy PE.  Efficacy of intensive care for bone marrow transplant patients with respiratory failure . Crit Care Med. 1989;; 17:4-6.
27 +
Butt W, Barker G, Walker C, Gillis J, Kilham H, Stevens M.  Outcome of children with hematologic malignancy who are admitted to an intensive care unit . Crit Care Med. 1988;;16:761-764.
28 +
Schuster DP, Marion JM.  Precedents for meaningful recovery during treatment in a medical intensive care unit: outcome in patients with hematologic malignancy . Am J Med. 1983;;75:402-408.
29 +
Wachter RM, Luce JM, Turner J, Volberding P, Hopewell PC.  Intensive care of patients with the acquired immunodeficiency syndrome: outcome and changing patterns of utilization . Am Rev Respir Dis. 1986;;134:891-896.
30 +
Fein AM, Lippmann M, Holtzman H, Eliraz A, Goldberg SK.  The risk factors, incidence, and prognosis of ARDS following septicemia . Chest. 1983;;83:40-42.
31 +
Jennett B, Teasdale G, Braakman R, Minderhoud J, Knill-Jones R.  Predicting outcome in individual patients after severe head injury . Lancet. 1976;;1:1031-1034.
32 +
Berger MS, Pitts LH, Lovely M, Edwards MSB, Bartkowski HM.  Outcome from severe head injury in children and adolescents . J Neurosurg. 1985;;62:194-199.
33 +
Longstreth WT, Diehr P, Inui TS.  Prediction of awakening after out-of-hospital cardiac arrest . N Engl J Med. 1983;;308:1378-1382.
34 +
Levy DE, Caronna JJ, Singer BH, Lapinski RH, Frydman H, Plum F.  Predicting outcome from hypoxic-ischemic coma . JAMA. 1985;;253:1420-1426.
35 +
Levy DE, Bates D, Caronna JJ, et al.  Prognosis in nontraumatic coma . Ann Intern Med. 1981;;94:293-301.
36 +
Knaus WA, Draper EA, Wagner DP, Zimmerman JE.  Prognosis in acute organ-system failure . Ann Surg. 1985;;202:685-693.
37 +
Kruse JA, Thill-Baharozian MC, Carlson RW.  Comparison of clinical assessment with APACHE II for predicting mortality risk in patients admitted to a medical intensive care unit . JAMA. 1988;;260: 1739-1742.
38 +
Luce JM, Wachter RM, Hopewell PC.  Intensive care of patients with the acquired immunodeficiency syndrome: time for a reassessment? Am Rev Respir Dis. 1988;;137:1261-1263.
39 +
Luce JM.  Critical care medicine in the United States: past performance and future possibilities . Pharos. 1986;;49:2-6.
40 +
Hook EW, Horton CA, Schaberg DR.  Failure of intensive care unit support to influence mortality from pneumococcal bacteremia . JAMA. 1983;;249: 1055-1058.
41 +
Cullen DJ, Keene R, Waternaux C, Kunsman JM, Caldera DL, Peterson H.  Results, charges, and benefits of intensive care for critically ill patients: update 1983 . Crit Care Med. 1984;;12:102-106.
42 +
Inglehart JK.  The new era of prospective payment for hospitals . N Engl J Med. 1982;;307:1288-1292.
43 +
Kitzhaber J.  Uncompensated care: the threat and the challenge . West J Med. 1988;;148:711-716.
44 +
Starr P. The Social Transformation of American Medicine . New York, NY: Basic Books Inc Publishers; 1982;.
45 +
Butler PW, Bone RC, Field T.  Technology under medicare diagnosis-related groups prospective payment: implications for intensive care . Chest . 1985;;87:229-234.
46 +
Spivack D.  The high cost of acute health care: a review of escalating costs and limitations of such exposure in intensive care units . Am Rev Respir Dis. 1987;;136:1007-1011.
47 +
Munoz E, Chalfin D, Calabro S, Goldstein JD, Wise L.  Costs of pulmonary medicine and DRGs: access and quality of care for the future . Am Rev Respir Dis. 1988;;137:964-968.
48 +
Zawacki BE.  ICU physician's ethical role in distributing scarce resources . Crit Care Med. 1985;;13:57-60.
49 +
Schiff RL, Ansell DA, Schlosser JE, Idris AH, Morrison A, Whitman S.  Transfers to a public hospital: a prospective study of 467 patients . N Engl J Med. 1986;;314:552-557.
50 +
Inglehart JK.  Medical care of the poor: a growing problem . N Engl J Med. 1985;;313:59-63.
51 +
O'Neil J, Mundinger M.  Health service funding cuts and the declining health of the poor . N Engl J Med. 1985;;313:44-47.
52 +
Strauss MJ, Lo Gerfo JP, Yeltlatzie JA, Temkin N, Hudson LD.  Rationing of intensive care unit services: an everyday occurrence . JAMA. 1986;; 225:1143-1146.
53 +
Singer DE, Carr PL, Mulley AG, Thibault GE.  Rationing intensive care: physician responses to a resource shortage . N Engl J Med. 1983;;309:11551160.
54 +
Kalb PE, Miller DH.  Utilization strategies for intensive care units . JAMA. 1989;;261:2389-2395.

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