HARD DECISIONS IN INTENSIVE CARE UNIT

Intensivecareunitkapak

ETHICAL DILEMMAS AND PATIENTS’ RIGHTS

Hamiyet Şenol Çakmak1
Gamze Ertaş2

1Samsun Training and Research Hospital, Department of Anesthesiology and Reanimation, Samsun, Türkiye
2Samsun Training and Research Hospital, Department of Anesthesiology and Reanimation, Samsun, Türkiye

Şenol Çakmak H, Ertaş G. Ethical Dilemmas and Patients’ Rights. In: Turan S, editor. Hard Decisions in Intensive Care Unit. 1st ed. Ankara: Türkiye Klinikleri; 2025. p.543-552.

ABSTRACT

Intensive care units (ICUs) are clinical environments where patients receive advanced medical care and life support, requiring a multidisciplinary approach. Various ethical dilemmas and patient rights issues arise in these environments.

The basic principles of medical ethics, autonomy, non-maleficence, benevolence, and justice, play an important role in patient management and decision-making processes in ICUs. Since most ICU patients cannot participate in medical decisions due to unconsciousness or physical incapacity, ethics committees and proxy decision-makers should be included in the process. The right to information requires effective communication with patient families, while the right to privacy and confidentiality requires the protection of patient data.

In ICU conditions where resources are limited, patient admission and resource allocation require ethical sensitivity. While triage systems aim to prioritize patients who will benefit most from intensive care, the principle of justice in bioethics ensures that all patients have equal access to healthcare. However, in crisis situations such as pandemics, ethical conflicts become inevitable regarding the allocation of intensive care beds and ventilators. End-of-life care decisions are among the most common ethical dilemmas encountered in intensive care units. Patients’ previously expressed medical preferences should be respected and decisions to withhold or withdraw treatment should be based on ethical and medical criteria, thus preserving patient autonomy.

In conclusion, instead of creating new laws to resolve ethical dilemmas in intensive care units in Turkey, a more effective approach would be to prepare regulations that support the existing legal framework and to collaborate with healthcare professionals, lawyers, and ethicists. In this way, patient rights will be protected, and medical practices will become safer and fairer.

Keywords: Intensive care ethics; Patient rights; Ethical dilemmas

Referanslar

  1. Hatemi H. Ethics, medical ethics, and deontology. Med Ethics. 2001;3(2-3). [Link]
  2. Akpir K. Yoğun Bakım Etiği. J Turk Soc Intens Care. 2010 Dec;8(2):0-0. [Link]
  3. Türk Tabipleri Birliği. Hasta Haklarına İlişkin Etik Bildirge. 1st ed. Ankara: Türk Tabipleri Birliği Yayınları; May 2010. [Link]
  4. Sprung CL, Cohen SL, Sjokvist P, Baras M, Bulow HH, et al. Ethicus Study Group. End-of-life practices in European intensive care units: the Ethicus Study. JAMA. 2003 Aug 13;290(6):790-7. [Crossref]  [PubMed]
  5. Kırşan M, Yıldırım D, Ceylan B, Korhan EA, Uyar M. Yoğun bakım ünitelerinde etik sorunlar: Sistematik derleme. Turk Klin J Med Ethics Law Hist. 2018;26(2):57-65. [Crossref]
  6. The Joint Commission. Rights and responsibilities of the individual (RI). In: Comprehensive accreditation manual for hospitals. Oakbrook Terrace, IL: The Joint Commission; 2021. [Link]
  7. Türkiye Cumhuriyeti. Hasta Hakları Yönetmeliği. Resmi Gazete, 1 Ağustos 1998;23420. [Link]
  8. World Health Organization. WHO patient rights charter. Geneva: World Health Organization; 1994. [Link]
  9. Curtis JR, Treece PD, Nielsen EL, Gold J, Ciechanowski PS, et al. Randomized Trial of Communication Facilitators to Reduce Family Distress and Intensity of End-of-Life Care. Am J Respir Crit Care Med. 2016 Jan 15;193(2):154-62. [Crossref]  [PubMed]  [PMC]
  10. Baile WF, Buckman R, Lenzi R, Glober G, Beale EA, Kudelka AP. SPIKES-A six-step protocol for delivering bad news: application to the patient with cancer. Oncologist. 2000;5(4):302-11. [Crossref]  [PubMed]
  11. Lautrette A, Darmon M, Megarbane B, Joly LM, Chevret S, Adrie C, Barnoud D, et al. A communication strategy and brochure for relatives of patients dying in the ICU. N Engl J Med. 2007 Feb 1;356(5):469-78. [Crossref]  [PubMed]
  12. Yetim B, Çelik Y. Sağlık hizmetlerine erişim: Karşılanmamış ihtiyaçlar sorunu. Toplum ve Sosyal Hizmet. 2020;31(2):423-440. [Crossref]
  13. Whitehead M. The concepts and principles of equity and health. International Journal of Health Services. 1992;22(3):429-445. [Crossref]  [PubMed]
  14. Beauchamp T, Childress J. Principles of Biomedical Ethics: Marking Its Fortieth Anniversary. Am J Bioeth. 2019 Nov;19(11):9-12. [Crossref]  [PubMed]
  15. Emanuel EJ, Persad G, Upshur R, et al. Fair Allocation of Scarce Medical Resources in the Time of Covid-19. N Engl J Med. 2020;382(21):2049-2055. [Crossref]  [PubMed]
  16. Coghlan N, Archard D, Sipanoun P, Hayes T, Baharlo B. COVID-19: legal implications for critical care. Anaesthesia. 2020 Nov;75(11):1517-1528. Epub 2020 Jun 11. [Crossref]  [PubMed]  [PMC]
  17. Akpınar A. Yoğun bakım ünitelerinde çalışan hekim ve hemşirelerin yoğun bakım kaynaklarını paylaştırmakla ilgili tutum ve görüşleri ile çağdaş adalet kuramlarının ilişkisi [tez]. Kocaeli: Kocaeli Üniversitesi Sağlık Bilimleri Enstitüsü. [Link]
  18. Truog RD, Mitchell C, Daley GQ. The Toughest Triage - Allocating Ventilators in a Pandemic. N Engl J Med. 2020;382(21):1973-1975. [Crossref]  [PubMed]
  19. White DB, Lo B. A Framework for Rationing Ventilators and Critical Care Beds During the COVID-19 Pandemic. JAMA. 2020;323(18):1773-1774. [Crossref]  [PubMed]
  20. Truog RD, Campbell ML, Curtis JR, Haas CE, Luce JM, Rubenfeld GD, et al. American Academy of Critical Care Medicine. Recommendations for end-of-life care in the intensive care unit: a consensus statement by the American College [corrected] of Critical Care Medicine. Crit Care Med. 2008 Mar;36(3):953-63. [Crossref]  [PubMed]
  21. Kuşlu S, Yılmaz M, Cengiz M, Ramazanoğlu A. Yoğun bakım ünitesinde yaşam sonu bakım kararları ve Türkiye'deki uygulamalar. In: Kızılkaya M, editor. Yoğun Bakım Çalışma Modelleri ve Etik Problemler. 1st ed. Ankara: Türkiye Klinikleri. 2019:34-38. [Link]
  22. Fletcher JC, Davis W. The decision to forgo life-sustaining treatment when patient is incapacitated. In: Fletcher JC, Spencer EM, Lombardo PA. (eds) Fletcher's introduction to clinical ethics. 3rd ed. USA: University Publishing Group; 2005. p. 207-234. [Link]
  23. Society of Critical Care Medicine, nineteenth annual educational and scientific symposium. San Francisco, California, May 29-June 1, 1990. Abstracts. Crit Care Med. 1990;18(4 Suppl):S165-S292. [PubMed]
  24. Baştürk Engin. Do-Not-Resuscitate (DNR) talimatının temel etik ilkeler açısından değerlendirilmesi. Turkiye Klinikleri Journal of Medical Ethics-Law and History. 2003;11(1):12-21. [Link]
  25. Özcengiz D. Yaşam sonu kararların Türk hukuku bakımından incelenmesi [yüksek lisans tezi]. Ankara: Ankara Üniversitesi Sağlık Bilimleri Enstitüsü, Adli Bilimler Anabilim Dalı; 2020. [Link]
  26. Tıbbi Deontoloji Nizamnamesi. Resmî Gazete Sayısı: 1960:10436. Erişim Tarihi: 13.02.2025. Erişim Adresi: [Link]
  27. İnsan Hakları ve Biyotıp Sözleşmesi. 2003. Erişim Tarihi:13/02/2025 Erişim Adresi: [Link]
  28. Bülow HH, Lippert A, Sprung C, Cohen MB, Sjøkvist P, Baras pd, Hovilehto S, et al. ETHICUS Study Group. Beslutninger om behandlingsniveau på intensive afdelinger i Europa [End-of-life practices in European intensive care units]. Ugeskr Laeger. 2005 Apr 4;167(14):1522-5. Danish. [Link]
  29. Türk Tabipleri Birliği Etik Kurulu. Yaşamın Sonuna İlişkin Etik Bildirge. İçinde: Türk Tabipleri Birliği Etik Bildirgeleri, İstanbul: TTB Yayınları. 2010:27-30. [Link]
  30. Türkiye Büyük Millet Meclisi. Türk Ceza Kanunu (5237). Resmî Gazete, 2004;25611. [Link]
  31. Sağlık Bakanlığı. Organ ve Doku Nakli Hizmetleri Yönetmeliği. Resmî Gazete. 2012:25191. [Link]
  32. Arsava EM, Demirkaya S, Dora B, Giray S, Gokce M, Güler A, et al. Türk Nöroloji Derneği Beyin Ölümü Tanı Kılavuzu. Turk Noroloji Derg. 2014;20:101-104. [Link]