This talk covers ethical dilemmas in Neurology/Neurosurgery clinical practice, and the practical ways of dealing with those ethical dilemmas. There are guidelines available for these dilemmas. Following them would help in our clinical practice.

1. ETHICAL DILEMMAS
IN NEUROSCIENCES:
Finding practical ways
to address them
DR SUDHIR KUMAR MD DM (Neurology)
CONSULTANT NEUROLOGIST
APOLLO HOSPITAL, HYDERABAD

2. INTRODUCTION
Ethical and moral dilemmas are common in
clinical practice, especially in neurology practice.
Guidelines are few, and there are often
conflicting opinions on various issues.
It is important to understand/discuss the ethical
dilemmas so as to satisfy patients/families; to
keep our conscience clear, as well as to prevent
medical law suits.

3. COMMON ETHICAL
DILEMMAS
Getting informed consent from patients (such as
those with aphasia, dementia or in comatose state);
Decision to mechanically ventilate/not to ventilate in
patients with incurable neuromuscular diseases;
Do not resuscitate (DNR) orders;
Providing high end ICU/specialized care for patients
with persistent vegetative state;
Euthanasia;
Can brain dead be certified as dead?

4. INFORMED CONSENT IN A PATIENT
WITH APHASIA (1)
A patient should be involved in decision making
process, regarding his diagnosis and treatment
planning
A patient with aphasia may not understand written or
verbal matter; moreover, he may not be able to
communicate by speaking or writing.
All attempts should be made to try and make him
understand treatment options using simple words,
pictures or videos, etc.
If it is impossible, then, the informed consent is taken
from a relative or caregiver.

5. INFORMED CONSENT IN APHASIA
(2)
These situations are routinely encountered while
we are considering thrombolysis in acute stroke;
As the benefit of thrombolysis is proven in acute
stroke patients with aphasia, every attempt
should be made to take informed consent from
the relative or caregiver for the thrombolytic
procedure.
“Hurried” informed consent- as time is crucial in
acute stroke thrombolysis, many
patients/relatives feel that they were “hurried”
into taking a decision!

6. INFORMED CONSENT IN
COMATOSE
Comatose patients are commonly encountered in
emergency room, where they are brought in after
severe head injury or massive brain stroke, or
suicidal attempts.
Most often, relatives are also not available.
It is fairly ethical for the doctor/nurse to proceed with
the treatment (resuscitation, surgery or medical
treatment), if they are needed to save life. No courts
would find fault with that.
If the evidence of clinical benefit is not clear cut, then,
second opinion may be sought from other experts.

7. MECHANICAL VENTILATION IN
ALS/DMD (1)
Certain neuromuscular disorders relentlessly
progress, finally resulting in respiratory failure,
and death.
Amyotrophic lateral sclerosis (ALS) and
Duchenne’s muscular dystrophy (DMD) are
common examples in this category.
When these patients come to ER in the terminal
stages with respiratory failure, should we or
should be not mechanically ventilate them?

8. MECHANICAL VENTILATION IN
ALS (2)
Mechanical ventilation improves the quality of life as
well as it prolongs life in patients with ALS.
Given a choice, about 20% of ALS patients express
their wish to remain on long term mechanical
ventilator (LTMV); and 80% decline it and prefer to
die. (Amyotroph Lateral Scler, 2006)
Non-invasive ventilation (BiPAP) should be
considered in patients with ALS.
Need to discuss with patients/relatives- the pros and
cons of ventilation, life as an immobile person on
ventilator, the ultimate outcome in ALS, costs
involved, etc.

9. MECHANICAL VENTILATION IN ALS (3)
Prolonged ventilation in ALS- costs involved
Is it justified ventilating and providing ICU care
for an irreversible condition?
Can we disconnect the ventilator if
patients/relatives wish so, after a few days/weeks
of ventilator support?
If there is only one ventilator/ICU bed, can we
disconnect it from ALS; and provide to another
patient coming in with a reversible illness, such
as GBS/snake bite with neuro-paralysis?

10. SUPPORTIVE CARE IN TERMINALLY ILL
Patients with disseminated malignancy, multi-organ
failure, etc are a group, where death is imminent;
however, it can be delayed with modern
mechanical/pharmacological supports, such as
mechanical ventilation, pressor supports, higher
antibiotics, dialysis, etc.
In these situations, a “competent” patient has the
right to refuse supportive treatment, and choose to
die with dignity. He would not be penalized for
“attempting suicide”; and his doctor would not be held
guilty for “abetment of suicide”, if the patient dies after
refusal of the treatment.

11. WITHDRAWAL OF LIFE SUPPORTS
(1)
• Withholding and withdrawal of life support is a process through
which various medical interventions are either not given to patients
or removed from them with the expectation that the patients will die
from their underlying illnesses.
• In US, patients/relatives have the right to refuse treatment,
including Ryle’s tube feeding, mechanical ventilation; in terminally ill
cases. This includes patients who are in vegetative state or in
comatose state.
• In some cases, physicians may terminate treatment if they consider
it “futile” care, which is unlikely to benefit a patient (even if family
wishes to continue treatment). But in these cases, physicians are
advised to see prior approval from courts to withhold treatment.

12. WITHDRAWAL OF LIFE SUPPORTS
(2)
Withdrawal of life supports differs from
euthanasia. In euthanasia, the death is hastened
by a medication administered by the doctor. In
withdrawal, certain treatments are withheld, and
no medicines are given to hasten death.
MCI-2002 guidelines allow a team of doctors to
take a decision to withdraw life support system
from a patient, in situations where recovery is not
expected.

13. RIGHT TO LIVE AND DIE
Article 21 of constitution lists “right to live” as a
fundamental right. A person has the right to live with
dignity and personal liberty.
Right to live may also include right to die with dignity.
In terminally ill cases, where there is no scope of
recovery, the patient/relative may choose a decision
of withdrawing life supports, so as to hasten death.
The court does not consider this as “extinguishing life
(which is illegal)”. It is considered as progression of
natural death process, initiated by the disease.

14. EUTHANASIA (1)
Euthanasia, often called as mercy killing, is a method
where the doctor intentionally hastens/brings about the
death of the patient; after request from the
patient/caregiver, in order to relieve pain and suffering.
Active voluntary (after consent from patients/relatives)
euthanasia is legal only in Netherlands, Belgium, Columbia
and Luxembourg.
Active euthanasia requires administration of an agent to
hasten death.
Passive euthanasia involves withdrawal/withholding of
supportive treatments (such as antibiotics, adrenaline,
ventilator, etc) and is legal in US.

15. EUTHANASIA (2)
Assisted suicide- when the patient brings about
his or her own death with the assistance of a
physician, it is termed as physician assisted
suicide.
Assisted suicide is legal in Switzerland and the
US states of California, Oregon, Washington,
Montana and Vermont.
Use of pain medications to relieve suffering, even
if it hastens death, is considered legal in US.

16. EUTHANASIA (3)
Physician sentiment regarding euthanasia- In a
US survey, it was found that 55% of physicians
would not assist in patient’s death; 16% were in
favor of euthanasia, and the remaining 29% said,
it depends on circumstances.
On the other hand, in UK, 64% physicians
support assisted dying where the patient has
incurable and painful disease.

17. EUTHANASIA IN INDIA (1)
Active euthanasia by administering an injection is
illegal in India,
Passive euthanasia is legal in India after a March
2011 judgement by Supreme Court. (Aruna
Shanbaug case)
It is permitted by Supreme Court in two
situations- 1. Brain dead patient, where the
ventilator can be switched off; 2. Persistent
vegetative state, where the feeds/water can be
tapered off, along with addition of pain-managing
palliatives.

18. EUTHANASIA IN INDIA (2)
Guidelines as laid down by the Supreme Court:
1. The decision can be taken by parents, spouse, other
relatives, or friend. Can be taken even by the doctor.
It should be in the best interest of the patient.
2. Even if the decision to withdraw life supports has
been taken by close relatives, prior approval from
High Court is required to execute the decision.
3. Chief Justice of High Court would constitute a bench
of at least two judges, who would decide to grant
approval or not.

19. BRAIN DEATH (1)
Brain death diagnosis and certification important for two
reasons; 1. Unnecessary/futile care can be discontinued
after the diagnosis of brain death; 2. Organ donation can
be considered.
In India, UK criteria is utilized (requiring only brainstem
death; and not the whole brain death). In US, both cortical
and brainstem functions should cease before declaring
brain death.
Protocol requires four physicians (treating physician, in
charge of hospital, a neuro specialist, another doctor from
any specialty)
Two evaluations six hours apart.
Mostly clinical assessment.

20. BRAIN DEATH (2)
EEG not mandatory; (if EEG is done, isoelectric EEG
is not mandatory to declare brainstem death)
If in doubt, additional tests such as angiography may
be done.
Time of brainstem death certification is taken as the
time of death (in a person whose life supports are
continued until heart stops). A person can not die
twice.
Ventilator can be disconnected after brain death
declaration.

21. CONCLUSIONS
Ethical dilemmas are common in routine
neurology practice,
Good knowledge of laws regarding these issues
is needed,
Patient/family should be properly counseled,
Informed consent is a must,
Further debates among public and lawmakers
are needed to further resolve the issues.

22. THANKS
Phone: 98661 93953
Email:
drsudhirkumar@yahoo.com
Blog:
www.bestneurodoctor.blogspot.com/
Facebook:
www.facebook.com/bestneurologist