• Anica Jusić.
• Croatian Society for Hospice/Palliative Care, CMA, Zagreb, Croatia. anica.jusic@zg.htnet.hr
• Acta Med Croatica. 2008 Dec 1;62(5):447-54.

AbstractThe goal of palliative care is to provide the best possible quality of life for patients and their families in the process of dying as well as before, during the course of illness. Emphasis is on the role of team approach in every aspect of patient care. The moral principles of sacredness of life and the right of personal autonomy may occasionally come in conflict. The basic principle of the respect of life prohibits killing, which has been accepted in one way or another by all societies - for the reasons of survival. Similar to this, modern morality supports the principle of respecting autonomy and self-management based on informed, conscious personality of an individual. Still, if the needs of another person appear to be more important or desirable than reaching certain individual goals, then the right of an individual regarding autonomy may be legitimately limited. Decisions on not applying or terminating certain procedures must be based on thorough discussion and consideration of the nature and expected result of treatment. If the patient is not competent, then the discussion should involve a team providing care for the patient and a representative of the patient. When the physician and the team can clearly see that unfavorable effects of treatment will outweigh therapeutic benefits, then, according to medical ethics of the respecting beneficiary, the team is not obliged to provide that form of treatment. Except for palliative care, there is no medical treatment that is always obligatory. A physician that does not accept the patient's request to be killed does not limit the patient's autonomy. Autonomy is self-management and capability of the patient to kill him/herself is not limited by the physician's refusal to do so. Even in those cases when patients for various reasons say that death will be a relief, it does not mean that the physician is obliged to terminate life. The superior obligation of physicians is to alleviate pain. If euthanasia would be legal, it would discourage those that work in the field of medical education and search for new ways to diminish pain. The progress in the development of palliative care would be stopped worldwide. Supporting the belief that killing is forbidden could increase the benefits for the society, whereas forbidding the concept of "allowing to die" despite the use of all-powerful technologies does not seem to maximize beneficial effects. In fact, if the latter be valid, then all patients at intensive care units with all the possible life sustaining facilities would have to die. Yet, members of the unit health care team would be accused of a deed considered equivalent to murder. For autonomy to be accomplished, competence is required, and that is something that varies, passing through different stages. In medical context, a person is competent when he/she is able to understand the basic information about the illness, including prognosis, if she/he is able to understand the treatment suggested, differentiate between the risk and benefit, and come to a rational decision. A partially competent person can, if he/she wants and is able to, reach joint decisions with the rest of the team. If the person is not competent and has not delegated a proxy (representative) and has not provided written instructions for the future, the health care team does not know what the patient would want if competent. Then the team handles according to the principles of doing good and no harm. The role of the "directive for the future" and proxy-decision-makers becomes problematic for the following reasons. By the time when the directives should be implemented many forms of medical treatment have been further developed, so that the illness may have become curable or treatment easier. Older and weak people that need care and feel they pose a burden could feel forced to sign directives for the future if they are legally obligatory.

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