Dr Michael Ashby1
1University Of Tasmania, Australia
Biography:
Michael Ashby is a Consultant Physician in Palliative Care and Pain Medicine, and Professor of Medical Ethics and Death Studies School of Medicine, University of Tasmania and Joint Editor-in-Chief, Journal of Bioethical Inquiry.
He has interests in law, ethics and the humanities as they apply to palliative care, the interface between psychodynamics and death and dying, grief and loss. He has extensive experience of mediation, supervision and open disclosure techniques and is now working on the concept of ‘realistic’ medicine and a palliative approach in acute medicine for frail elderly people with chronic diseases and dementia.
Abstract:
Despite the technical limitations debated over the years in the jurisprudence, philosophy and clinical literatures, the so-called ‘doctrine’ of double effect has stood the test of time as a defence of pain management in palliative care. Since the 1957 instruction to the jury by (later) Lord Patrick Devlin in R v Adams, the force majeure of pain relief, with opioids in particular, for a dying person renders lawful such treatment even though over half a century of accrued clinical experience with modern opioid pain management in accepted palliative care practice has been shown to be safe and does not cause death of itself (in contrast to chronic pain and opioid addiction disasters).
The enormous increase in incidence of various forms of dementia (most notably Alzheimer’s) globally and the growing recognition of its role in causing death (dementia is headed for the number one slot of death causation in Australia and similar wealthy countries) means that end of life care now needs to address the specific needs of this large group of people. Worsening BPSD (Behavioural and Psychological Symptoms of Dementia), and delirium, as death approaches present an big challenge for all parts of the health system, especially acute hospitals. Public policy through a royal commission and other reports, and coronial procedures have engendered fear and resistance to the kind of sedation often required to control these symptoms and retrieve comfort and dignity. Significant work is required in medicine, nursing, ethics and law to ensure that the kind of progress achieved in palliative care pain management can be replicated for dementia patients who otherwise face a grim journey with terrible consequences for legacy and family grief.