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Abeera Devasar

Debate: The ethics of chemotherapy in end-stage cancer

Although death is inevitable, medicine can prolong life. End-stage cancer patients are faced with a choice between shifting to palliative care or continuing with third or even fourth-line chemotherapy. Treatment at this stage is likely to be futile (1), however patients or their families may demand it.  There is a delicate balance between respecting patient autonomy, allocating resources, and the duty of the doctor to provide the best possible care for the patient. Here, I will use normative ethics as a guiding framework to discuss this complex and ethically challenging topic.

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As consent is a necessary component of medical practice, patient autonomy should play an important role in decision making. If a patient deemed to have capacity requests chemotherapy, respect for autonomy would be a valid reason to provide it. To demonstrate decision making capacity, a patient must be able to communicate their decision, having understood, retained and evaluated the information provided (2). The reasons why some patients demand chemotherapy are complex, and specific to the individual’s own situation. Patients may feel a personal responsibility to not give up, so withdrawing treatment could induce feelings of guilt.

 

A deontological position may also be adopted by the family, who may be determined to try everything, regardless of the consequences. This decision is a challenging one, as the patient has to live (or die) with the consequence of their decision. Hence, the doctor's support and the patient's trust in them is of the utmost importance.

The patient's decision may be influenced by the way in which information was communicated to them. Doctors may push for treatment, as it prolongs the available time for discussing the possibility of death. On the other hand, the patient may request treatment due to a lack of information regarding their prognosis. However, a virtuous doctor demonstrates honesty and empathy, and should ensure that they provide the patient with all the information required to give informed consent. From a deontological perspective, the doctor has a duty to act in the patient's best interests. Prolonging life would be an act of beneficence, however subjecting the patient to the potentially severe side effects of chemotherapy (3) would contradict the principle of non-maleficence set out in the Hippocratic Oath.

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Sometimes autonomy is limited, as it must be balanced with the effective use of resources. This is ethically challenging, as the patient and their family may not understand the wider costs of providing futile treatment. Since it is difficult to define futility, a consequentialist approach is taken, relying on existing evidence and the doctor's expertise (4).  Some argue that treatment would prolong life, thus justifying the cost effectiveness of chemotherapy. However, this assumes that patients value time more than symptom relief. On the other hand, younger patients may receive chemotherapy despite a lack of clear evidence, as the benefit of prolonging life is perceived to be greater (5).

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According to the principle of utilitarianism, resources should be allocated fairly, and maximize greater good (6). Administering chemotherapy would require resources that could be spent on those with a greater chance of survival. Transferring patients to palliative care centers would free up beds for new patients, whilst allowing a dignified death.

 

Some patients voluntarily take a utilitarianism approach. For instance, they might agree to enter a clinical trial in the hope that in the future it would benefit themselves and others (7). On the other hand, unnecessarily withdrawing treatment could be considered a violation of rights-based justice – breaching Article 2 of the Human Rights Act: Right to Life (8). Although the doctor has a duty to preserve life, the use of costly resources for a treatment that is likely to cause more harm than good to the patient violates the principles of beneficence, non-maleficence and distributive justice.

Doctors have a professional duty to respect patient autonomy, while ensuring the just allocation of resources, and acting in the patient's best interests without causing them any further harm. Doctors should ensure that information is communicated effectively, and that the patient has a clear idea of their prognosis. Withdrawing treatment does not imply withdrawing care, and patients should understand how their symptoms will be managed under palliative care. Although the patient retains the autonomy to choose their treatment, the doctor should ensure that the patient has understood its limitations. Should a patient request it, the treatment may be trialed and later withdrawn if proved futile (9). Especially where the patient lacks capacity, the best interests of the patient should lie at the heart of all end-of-life decisions.

 

References

  1. Wright, A.A., Zhang, B., Keating, N.L., Weeks, J.C. and Prigerson, H.G., 2014. Associations between palliative chemotherapy and adult cancer patients’ end of life care and place of death: prospective cohort study. BMJ, 348, p.g1219. 

  2. The Scottish Government, 2000. Adults with Incapacity (Scotland) Act 2000. 

  3. Winkler, E.C., Hiddemann, W. and Marckmann, G., 2012. Evaluating a patient's request for life-prolonging treatment: an ethical framework. Journal of medical ethics, pp.medethics-2011. 

  4. Karnik, S. and Kanekar, A., 2016. Ethical issues surrounding end-of-life care: a narrative review. In Healthcare (Vol. 4, No. 2, p. 24). Multidisciplinary Digital Publishing Institute. 

  5. Randén, M., Helde-Frankling, M., Runesdotter, S. and Strang, P., 2013. Treatment decisions and discontinuation of palliative chemotherapy near the end-of-life, in relation to socioeconomic variables. Acta oncologica, 52(6), pp.1062-1066. 

  6. Beauchamp, T.L. and Childress, J.F., 2001. Principles of biomedical ethics. Oxford University Press, USA. 

  7. Reichlin, M., 2014. On the ethics of withholding and withdrawing medical treatment. Multidisciplinary respiratory medicine, 9(1), p.39. 

  8. The National Archives, 1998. Human Rights act. [online] Available at: http://www.legislation.gov.uk/ukpga/1998/42/contents 

  9. Winter, B. and Cohen, S., 1999. Withdrawal of treatment. BMJ, 319(7205), pp.306-308.

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