PALLIATIVE CARE: AN ETHICAL & LEGAL DUTY

the duty to ensure equitable access:

2) utilitarianismMinimizing pain and suffering is required by the principle of utility: promote the greatest happiness for the greatest number.

civilpossible liability for negligence

criminalpossible liability for neglect/harm

human rights“Access to medicines for the relief of pain is a human right.”9

Everyone has the right to ‘life, liberty, and security of person.’10

No one shall be subjected to torture or to ‘cruel, inhuman or degrading treatment’ or punishment.11

Everyone has the right to the ‘highest attainable standard of physical and mental health.’12

Everyone has the right to respect for ‘private and family life...’13

1) natural lawRelieving suffering, so as to help patients enjoy the goods of life, is an important goal of medicine, and it is required by the ethical principle of care. Moreover, the principle of justice requires the equitable, global distribution of healthcare resources.6

3) principlismProviding adequate relief to all is required by the principles of respect for autonomy, non-maleficence, beneficence, and justice.

There is a good case for legislation that would impose a clear duty on physicians and healthcare institutions to provide reasonable palliative care to all who could benefit from it.

— 3 — There may well be (depending on the jurisdiction) a legal duty on physicians and on healthcare institutions to provide reasonable palliative care.

1. Knaul FM et al, ‘Alleviating the access abyss in palliative care and pain relief—an imperative of universal health coverage: the Lancet Commission report’ The Lancet, October 12, 2017, 17. Accessible at: http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)32513-8/fulltext 2. Ibid., 49. 3. Ibid., 36–37.4. NCD Alliance, ‘Injustice of access abyss in palliative care and pain relief – a global health failing’, 3 February 2018. Accessible at: https://ncdalliance.org/news-events/blog/

It is “shocking...that the global health community has not seized the opportunity and responded to the ethical imperative to close the access abyss in the relief of pain and other types of suffering both at the end of life and across the course. What does this say about our values as a global society?”7

61 million people $145 million

the legal duty8 a human right?

the global need: an “access abyss”

More than 61 million people per year, including 5 million children, are affected by serious health-related suffering, of whom 80% live in low- and middle-income countries.1

Alleviating this suffering is “a global health and equity imperative.”2

The cost of alleviating this suffering is an estimated $145 million per year3—the annual budget of one, medium-sized hospital in the USA.4

KENNEDY INSTITUTE OF ETHICS / GEORGETOWN UNIVERSITY

John Keown, dPhil, Phd, dcl

an ethical consensus5

injustice-of-access-abyss-in-palliative-care-and-painrelief-a-global-health-failing5. See generally John Keown, The Law and Ethics of Medicine (Oxford University Press, 2012) chapter 11. 6. See generally Alfonso Gómez-Lobo and John Keown, Bioethics and the Human Goods: An Introduction to Natural Law Bioethics (Georgetown University Press, 2015); Alfonso Gómez-Lobo, Morality and the Human Goods: An Introduction to Natural Law Ethics (Georgetown University Press, 2002)7. NCD Alliance. (Emphases added.)

8. See generally Keown, chapter 11.9. Knaul et al, 11, citing e.g. L. Gwyther et al., ‘Advancing palliative care as a human right’ (2009) 38 Journal of Pain and Symptom Management 767. See also Keown, chapter 11. 10. Universal Declaration of Human Rights, Article 3. 11. Universal Declaration of Human Rights, Article 5. 12. The International Covenant on Economic, Social and Cultural Rights, Article 12(1). 13. European Convention on Human Rights, Article 5(1).

— 1 —There is a massive, global need, especially in poorer countries, for palliative care.

Key Points

— 2 —There is an obvious ethical duty on the global community, especially wealthier countries, to meet that need, which could be met at little cost.

— 4 —A failure to provide palliative care may also constitute a breach of human rights.