When to Withdraw or Withhold Treatment
by Duncan Vere
Withdrawing or withholding medical treatment is more often an issue of good clinical judgement than an ethical dilemma. Where the ethics of a situation are complicated, an understanding of basic ethical principles is more useful than rigid guidelines.
When people are ill they tend to go to a doctor, nurse or another healthcare professional to ask for some form of treatment. The problem may be a sore throat, in which case the person may be hoping for a prescription for antibiotics. The issue may be more serious and the person wants to be referred to a hospital specialist. It might be that the person is so ill that he is admitted directly to a hospital, possibly by ambulance.
Healthcare professionals are faced with the task of diagnosing the cause of the person’s illness, and then working out what would be the best approach for treatment. This is a complex process and can easily be misunderstood by the patient.
In some cases, treatment may have to start before a diagnosis has been made. However, this carries the risk that the treatment may itself mask the true nature of the disease.
A good doctor should always be considering whether the initial diagnosis was correct and be prepared to change his or her opinion if doubt starts to arise.
Sometimes patients mistakes this change of opinion as the doctor making a mistake. However the art of medicine involves making decisions on limited amounts of information and expecting to adjust or correct them as new evidence emerges. In this CMF File we want to consider what the reasons are for initially giving a treatment, for possibly withdrawing a treatment that has started but is not achieving the intended results, or for withholding treatment in the first place.
One of the complicating features in this area of discussing is that technology has developed to the point where it can be used to sustain the physical life of a body seemingly indefinitely. It may even keep the body ‘ticking over’ beyond the point when some would say that the person has died. This raises the fear that the person might be subjected to extreme medical intervention that desperately tries to sustain life, when it would be more appropriate to let him or her die. On the other hand is the worry that the ‘machines’ might be turned off too soon.
The art of medicine involves making decisions on limited amounts of information and expecting to adjust or correct them as new evidence emerges
We also have the ability to treat conditions that if left alone would do little damage to the person. The majority of men are found to have enlarged or cancerous prostate glands at autopsy. However, these diseased organs did not cause them to die. In most cases it would have been inappropriate to operate and remove the gland because the procedure carries risks, would be costly and has a lengthy recovery phase. An operation would be unnecessary over-treatment. In this case a doctor’s task is to try and spot the few people for whom an operation to remove the prostate would be beneficial.
Respecting people also means recognising that they are mortal
A doctor also has to be aware that individual patients respond differently to the same treatment. Some drugs have side effects that are well reported and the doctor should be on lookout for these ‘type A’ risks. However, he or she should also be aware of unusual and unpredictable ‘type B’ reactions that affect a minority of patients.
The discussions of withdrawing or withholding treatment is often seen as an ethical discussion. However, in all but the most extreme cases. it is more appropriate to see it as a matter of good clinical judgement.
At the same time a decision to withdraw a treatment is often seen as more ethically complex than not starting the treatment in the first place. While stopping a treatment may be more traumatic for the patients or relatives, in fact, decisions for both actions are normally a basic part of good medical practice.
A medical treatment can have two basic functions. First it can aim to cure the person. This is the sort of treatment that we hope to receive when we visit our GP. Our desire is to go in, describe the problem, have a few tests and come away with the treatment that solves it.
To an extent, curing is about warding off death, because if illness is not stopped then a person may die. You could say that curing helps people to have a good quantity of life.
The second function is to relieve a person’s suffering, without curing the underlying problem. This aims to give the best possible quality of life. In giving pain relief to people with cancer, hospices acknowledge that the person is dying, but seek to give the best possible care.
People hold different views about whether artificial feeding given to dying patients is ‘treatment’. Most doctors and nurses think it is a basic part of good care, reducing suffering and responding to human need.
To be continue..
Christian Medical Fellowship (CMF) Files No. 7, 1999