The philosophy of palliative care : a critique
Palliative care is unusual as a specialty within health care in that it has its own philosophy, which is summarised in the WHO definition of palliative care. This philosophy has influenced clinical practice so that specialist palliative care differs significantly from other aspects of health care. The thesis is a critique of that philosophy. It examines the moral problems inherent in implementing the philosophy in clinical practice. It concludes with suggestions for improvements which could be made to the philosophy statement so as to influence clinical care for the better. Thesis 1 is that decisions regarding the use of treatment to control symptoms or prolong life did not need to depend on complex doctrines such as double effect, but instead ought to be based on weighing up the benefits, harms and risks of treatment. Thesis 2 is that the relatives should not be an equal part of the remit of care. It is argued that whilst there is a special relationship, founded on an implicit promise and associated with specific obligations, between patients and health care professionals, this special relationship should not be extended to relatives of the patient. Thesis 3 is that quality of life as a global concept should not be used. Since quality of life depends on many incommensurable factors, and it is not possible to construct a coherent account of quality of life from our everyday notions of what it means, it is not possible to construct a quality of life scale. Thesis 4 is that there are constraints of expertise and propriety on attempts to influence the patient’s psychological, social and spiritual well-being. Thesis 5 is that within health care there ought to be a just distribution of resources to specialist palliative care, and then among terminally ill patients regardless of their illness.