The Philosophy of Palliative Care Critique and reconstruction

The idea of a philosophy of palliative care emerged with Cicely Saunders' vision for 'a good death', and was developed further with the WHO definition of palliative care. It is now being applied not only to cancer patients, but to all patients in end of life situations. As this 'palliative care approach' advances, it is important to pause and comment on its effectiveness. It is a philosophy of patient care, and is therefore open to critique and evaluation. Using the Oxford Textbook of Palliative Medicine, 3rd edition as their basic reference, Randall and Downie present their argument that the palliative care approach has become too busy and over-professionalised, and that it therefore has significant weaknesses. They examine the framework of the specialty - quality of life, autonomy, dignity, patient-centredness, and the priority assigned to relatives in the remit of care - and the moral problems associated with implementing such a philosophy. The resource implications of various health care policies are also discussed in relation to the WHO definition. Whilst the authors defend the achievements of palliative care and those who work in the profession, they present suggestions for an alternative philosophy. Their philosophy prompts many ethical and philosophical questions about the future of palliative care.

Roots, traditions and philosophy. Quality of life. Autonomy, dignity, respect and the patient centred approach. Relatives. Control of symptoms and prolongation of life. Resuscitation and advance statements. Assessment and treatment of psychosocial and spiritual problems. Resource allocation. Critique and reconstruction : some suggestions for a better way.

Fiona Randall is a consultant in palliative medicine, with a background in health care ethics and philosophy. She has served on BMA ethics committees, the Association of Palliative Medicine ethics working party, and has been recently involved in drafting the UK law on decision making for patients lacking capacity. She is also on the editorial board of the Journal of Palliative Care Robin Downie has been a member of various government and professional committees and working parties dealing with issues of medical ethics. He is now an Honorary Professorial Research Fellow and Emeritus Professor of Moral Philosophy at the University of Glasgow.