Ethical Considerations in U.S. End-of-Life Healthcare Policies

Ethics has long been a pivotal topic in health care discussions, particularly in the United States. The concept of ethics suggests that every decision made involves a determination of right or wrong. Yet, what is deemed right or wrong can be subjective, varying significantly based on individual experiences and cultural contexts. Factors such as culture, climate, and personal morals heavily influence ethical judgments (Kreitner & Kinicki, 2016), leading to complex grey areas in ethical policy, especially concerning end-of-life issues. Ethics is fundamentally defined as the beliefs, ideas, or values that underpin why certain actions are perceived as good or bad (Petrovic-Lazarevic, 2004).

The U.S. healthcare system has endeavored to establish ethical guidelines for end-of-life issues. This essay will explore the history and development of policies related to end-of-life care, assess alternatives, and examine the interplay between science and politics. The success and implementation of current policies will be evaluated, along with an examination of their effectiveness in addressing public health concerns. Areas for potential improvement will also be identified.

History of Policy

The impetus for policy development in this area began in 1980 when economist Eli Ginzberg introduced the term "the high cost of dying," highlighting the substantial resources allocated to terminally ill patients and the last months of life. As GDP spending rose from the 1960s, questions emerged about the sustainability of such expenditures and strategies to mitigate costs. By 2005, researchers were gathering data to advocate for end-of-life policy development, aimed at controlling costs and addressing the quality of care, as many terminally ill patients died in pain and isolation (Wiener & Tilly, 2003).

End-of-life policies encompass advanced directives, hospice care, death location, specialized services, and pain management prescriptions. Major funding sources include Medicare, Medicaid, and private insurance, with specific focus required on hospice aspects within Medicare and Medicaid. Policy restrictions include payment, benefits, eligibility, and quality assurance (Wiener & Tilly, 2003). The formulation of the policy involved determining the target demographic, establishing guidelines for ethical interventions, and enhancing the quality of care through effective physician-patient communication (Myatra et al., 2014).

Exploring Alternatives

Current practices such as hospice and palliative care are widely recognized as crucial for end-of-life care. However, emerging methods like death midwives, death doulas, and death with dignity acts offer additional options. Death midwives provide holistic, non-medical support, working alongside medical staff to fill emotional and spiritual gaps (The death midwife, 2018). Similarly, the International End of Life Doula Association (INELDA) aims to transform the end-of-life experience by offering emotional and spiritual support (INELDA, 2017).

The End Life Symptom Management Order protocol addresses opiate usage for palliation, but its late initiation in care is a concern. While useful, it cannot stand alone, necessitating additional measures to handle emotional and physical pain effectively (Walling et al., 2008). The Death with Dignity National Center promotes education and legal reform to empower terminally ill patients to choose their end (History, 2018). While controversial, this approach could become more integrated into future policies.

Science and Politics

Scientific evidence forms the backbone of policy development, yet politics often influences the interpretation and application of data. Political agendas may skew scientific findings to serve specific goals, sometimes even fabricating data or ignoring established facts (King, 2016). Ethical considerations are crucial, as integrity in data collection and presentation is vital for authentic scientific contributions.

Despite the scientific foundation, political factors like public opinion and fiscal priorities also play significant roles in shaping policy. Ethical dilemmas arise when scientific data is manipulated for political ends, highlighting the need for scientists to maintain high moral standards (Zohoor, 2003).

Policy Impact and Implementation

The success of end-of-life policies heavily depends on physicians accurately predicting the remaining life expectancy of patients. Hospice care, requiring a prognosis of six months or less, often faces challenges due to the inherent difficulty of predicting death (Scitovsky, 2005). Despite these challenges, hospice care significantly impacts end-of-life quality, emphasizing the need for continued research to refine prognostic accuracy.

Policy implementation involves guidelines to limit inappropriate care and enhance end-of-life quality. Physicians play a critical role in identifying terminal illnesses and initiating hospice care, regulated by the Centers for Medicare Services to ensure quality standards (Hospice funding: What you need to know, 2018).

Evaluating Success and Areas for Improvement

While current policies address gaps in end-of-life care through hospice and palliative care integration, challenges persist. Factors such as cultural beliefs, reimbursement issues, and public awareness need further attention (Schreibeis-Baum et al., 2016). Despite 70% of patients expressing a desire to die at home, only about 25% utilize hospice care, indicating significant room for policy improvement (Fine, 2004).

Enhancing data on Medicare and Medicaid benefits, increasing government involvement in palliative care funding, and re-evaluating the timing of hospice initiation are potential improvements. Additionally, exploring alternatives like death with dignity acts could offer patients more control, though ethical and political challenges must be addressed.

Conclusion

Death is a process for most individuals, involving multiple chronic conditions over time (Institute of Medicine, 2015). A robust end-of-life policy is essential for healthcare systems, as every individual will eventually require such care. Ethical considerations are complex, with diverse perspectives on appropriate end-of-life actions. By addressing pain, loneliness, and cultural variations, policies can better meet the needs of patients and families, ensuring dignified and compassionate end-of-life care.

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