When to Withdraw or Withhold Treatment
by Duncan Vere
One common guide is to look for the patient’s ‘best interest’. This can help when treating young children, or adults who are not fully conscious. In the past, best interest was almost always seen as prolonging life. However, a more complex assessment is needed now that medical technology can keep a person’s body alive, perhaps inappropriately.
Most people accept that there is no absolute duty to prolong life at all costs. Consequently it is in the best interest of the patient to stop treatment before it becomes excessively burdensome. The legal ruling in the case of Tony Bland (the football fan who in 1989 at the age of 17 suffered extreme brain damage at the Hillsborough Stadium disaster and went into a deep coma called persistent vegetative state – PVS) set a precedent in saying that prolonging life can be perceived as a harm and potentially as assault,
However it is important to remember that one of the things that makes human beings special is their ability to form relationships and in particular their ability to form a relationship with God. A test of ‘best interest’ could potentially ignore the fact that a severely injured person might not be able to relate to others, but God still relates to him.
Some doctors and lawyers argue that a treatment has a double effect. Painkilling drugs given to cancer patients relieve suffering,
but on occasions they also accelerate their death. This so-called ‘double effect’ is seen as being acceptable as the intention was not to kill the patient, but to reduce his pain.
The phrase ‘double effect’ is unfortunate in that is suggests that two things were intended, both the reduction of pain and the death. It is often clearer to talk about the intention of a treatment. In the above case the intention is to make the person more comfortable. An unintended effect is that death may happen a bit sooner.
This of course does not preclude someone giving a drug and saying that their intention is to stop pain, while causing death was the real aim. However, looking at patient and drug records can often reveal the real intention or motivation behind individual treatment decisions.
Another complication with decisions about giving pain relieving drugs to cancer patients is that until the patients have received the drugs no-one knows whether they will do harm. Some patients find that once the pain is controlled they show a measure of recovery. In fact, far from shortening the person’s life, experts in palliative care say that when properly used, pain relief shortens the life in only 1 in 1,000 cases.
Laws and Guidelines
The legal profession is increasingly being asked to give rulings about medical practice. While it is good that medical practice should be legally sound, there are dangers in having to get every difficult decision backed by a court ruling. To start with, in many cases the time taken to get a court decision would be too long and cause more harm than good.
At the same time, doctors are calling for guidelines. Some of these requests come because they want to know what best practice is,
others are generated by a desire to protect themselves from legal action should things go wrong. The problem with guidelines is that they are often too inflexible to be in the best interest of the individual patient. It is often more useful to provide a decision-making framework that draws from accepted ethical boundaries.
Legal judgements made in courts can be even more restrictive. If a judge decides that, on the basis of the presented evidence, a certain course of treatment needs to be followed, then it is difficult to make any changes if the doctors decide that the diagnosis was wrong, or the treatment is not having the desired effect.
As British Law adapts to conform more with European systems, there will be an increasing tendency for decisions to be made according to prescribed ‘rule books’ rather than individual judgements being made about individual cases and situations.
Withdrawing and Withholding Treatment. A submission from the CMF to the Medical Ethics Committee of the BMA. Available from the CMF.
Duncan Vere is a hospital general psysician (retired) with a special interest in drugs and treatments. He is Professor (Emeritus) of Therapeutics in the University of London and a Fellow of the Royal College of Psysicians and the Faculty of Pharmaceutical Medicine.
Christian Medical Fellowship (CMF) Files No. 7, 1999