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Withholding and Withdrawing Medical Treatment - Ethics and the Law in Intensive Care

[@Pace1996]

factor_chapter

https://paperpile.com/app/p/f6f1ee40-a88c-015f-b087-810d57d7a034

My words - the intensive care unit, shows the ethical dilemmas of medicine close to death at their most clear [47]

This book chapter highlights that there can be multiple different parties with their own views of what ethical and legal requirements can be [47]

Early it highlights the key dilemma. When is it right to stop? Is it when 'cerebral death' has occured? Or could it be earlier than that? Is there a point of futility.

Pace comes out with 'Doctors have a moral obligation to always act in the best interests of their patients, provided they keep within their own moral and ethical principles' There's a lot of parts to that sentence, and he just comes out with it without explaining what he means by any of:

  • moral obligation
  • best interests
  • why the caveat of "provided"
  • moral and ethical principles

He highlights that medical treatment is routinely withdrawn in intensive care in a first world setting, that in individual cases resource allocation isn't provided as a reason [48]

He brings up the double effect principle when it comes to medicines for preventing air hunger, after extubating a patient [49]

He then brings up a different version of the key dilemma, is the principle role of medicine to prolong life at all costs? [49 ] - My words not his

He argues against an 'extreme view of the sanctity of life doctrine'[49]

'Clearly waht is desired is not life as such, but enjoyable and worthwile experiences' - Again, no back up.

'Life itself has no intrinsic value. Life has value only if it is worth living' [49] - This is a consultant in anaesthetics saying this

He then provides theologicians backing this up: O'Donnell and McCormick.

Success of intensive care is not... to be measured only by the statistics of survival... It is to be measured by the quality of the lives preserved or restored; and by the quality of the dying of those in whose interest it is to die - Dunstan Hard Questions in Intensive Care 1985 Anaesthesia

He highlights there's no universal definition of quality of life. [50] That Quality of Life comes up against Sanctity of Life [50]

He argues for a starting premise of sanctity of life, and then accepting in some cases a "Quality of life approach can supersede" [50]

So he is saying there is a point that you should stop, that prolonging survival isn't the only relevant factor.

He argues that this is supported by Catholic thinking of "ordinary vs extraordinary means" [51], and points out maybe proportionate and disproportionate would be more appropriate. Recognising that sometimes the benefits of treatments may be outweighed by the burden. [51]

The factors mentioned here to work out benefit vs burden are:

  • Degree of risk
  • Cost
  • Physical / Psychological Hardship for patient
  • Patients overall condition and potential for improvement
  • Patient's resources and sensibilities
  • Doctor/Medical teams time, effort, other obligations

But these are all a bit vague!

The writer talks about the importance of individual patients perspective.

He mentions:

  • Interaction
  • Abscence of Pain
  • Dignity
  • Intellectual Capability
  • Independence
  • Awareness

As factors that could be seen to be important [52]

It seems to me that he argues against hope in the extremes. He says you can't make decisions based on the possibility of a future cure for a currently incurable illness [52] Again though, why not?

He argues that any treatment could in the right situation, be either appropriate or inappropriate. [52]

He argues there's something particularly hard when it comes to withdrawing ventilation, as the patient often dies so quickly [52]

He brings up acts vs omissions [53] Is doing something (withdrawing) worse than not doing something (withholding)? Is there really that distinction? When are you doing and when are you allowing to happen?

It seems to me that a lot of the fuss of acts v omissions is to allow us wriggle room, so we don't have to consider what we are doing to fall into the camp of "killing people". The other way to approach it would be to accept, yes you are killing someone, but that's ok. If by killing someone we mean "Acting in a way that will shorten another persons life", then the scenario where you stop ventilating another person is acting in a way that will shorten another persons life. You haven't created the situation where they required the ventilator, but you did act in a way to shorten their life. But you did that, recognising that the duration of life isn't the one overwhelming factor in all situations.

Pace bringss up the argument that we could say that it's the intent that matters, that if your intent is to stop a treatment because it is burdensome, not because you are intending to shorten their life, then that's how you can justify withdrawal. [55] I don't think I agree with this. Yes of course you are stopping it because this treatment is burdensome, but this pretence that you aren't also condoning the shortening of their life is rubbish. (On page 55 it looks like gillon agrees with me). They bring up double effect here. [55] Intended versus Forseen consequences. The principle of double effect is a legal principle. Pace recognises that double effect is useful for those who need to justify decisions whilst holding an absolutist view.

  • Re B. Baby - Court allowed to die
  • Re C. Baby - Judge brought up the idea of intellectual function being a hallmark of humanity, allowing baby to die.

  • Re J. Baby - Court allowed life prolonging treatment to be withheld

  • Bland - Adult in PVS - Sanctity of life not absolute

  • Barber Vs Super Court - Proportionate vs Disproportionate treatment - Burdens of treatments

  • Acts Vs Omissions in UK Law - Omissions can still be crimes, can still be murder if we had a "duty of care"
  • R v Arthur - "Doctors have no special powers to commit an act which causes death"
  • Re Potter - Accused got out of manslaughter by saying the drs killed when they removed organ transplant organs
  • Finlayson vs Advocate - Scottish case where the accused didn't get out of it

Legally stopping treatment can be an "act hastening death"[60]

Skegg provides two ways to get around this:

  • Turrning of the ventilator wasn't the legal cause of death. What is "good medical practice is not legal causation"
  • Turning off the ventilator is an omission rather than an act - This is what happened in Barber

The court in Barber also point out omissions are only a crime if you have a duty of care. But if a treatment is ineffective there is no duty to care in that manner. [61] YOu have a duty for proportionate care, not a duty for disproportionate care, this is what's put forwards in the arthur case. [61] This is useful from a legal perspective. But not from a philosophical one. You'd need to allow for there to be real thing as a duty of care, and also a real difference between acts and omissions. I think I would be tempted to allow a real thing as duty of care, but still don't think acts v omissions is any use.

The author brings up the importance of noting the difference between treatments that are appropriate for the acutely ill, and how they wouldn't be appropriate for the dying. [65] My issue is that the dying are often acutely ill.