This article appears in the February 2003 edition of the Catholic Medical Quarterly
Respect for Life: A Framework for the Future
Dr Gillian Craig
Some comments and suggestions
Ethical dilemmas that come to public attention show how difficult medical practice can be. There are no easy answers to the problems raised. Many people over the years have tried to contribute to the process by which ethical decisions are made in medicine, but in general the end result of all this thought has been of little practical value to the busy doctor. New life support techniques have produced new dilemmas for society and the medical profession to solve. We now have a plethora of guidelines.
It is customary for ethicists to talk in terms of four principles of beneficence, non maleficence, autonomy and justice1. The emphasis these days tends to be on autonomy i.e. the wishes of the individual patient. For the doctor the principle First do no harm is vital. We also need to remember the basic maxim Thou shalt not kill.
It is fashionable at present to consider 'therapeutic decisions' at the end of life in terms of benefits, burdens and best interests. These B words trip off the tongue in discussion, but do not stand up to careful scrutiny, as theologian Peter Jeffery2 has demonstrated in a closely argued chapter in his recent book Going against the stream. Jeffery argues that the starting point in any discussion on foregoing treatment must be respect for life. To be of practical value ethical frameworks must be workable, understandable, realistic and universally applicable. This is a tall order, but having ruled out solutions based on substituted judgement, or quality of life assessments, Jeffery favours a framework based on the concept of proportionality, which some people may find helpful. Decisions based on substituted judgement, i.e. on the view of a proxy decision maker or other third party, as to what an incapacitated persons wishes might be, are known to be flawed. Decisions made on quality of life judgements by third parties are also inherently flawed, and in America such judgements are not allowed as a legal reason for discontinuing treatment, according to Jeffery. This means, notes Jeffery, that health professionals can only make quality of treatment judgements, and not quality of life judgements, otherwise the acts are a disguised form of euthanasia3. The same danger is apparent when the patients 'best interest' is invoked as a reason for withdrawing life supportive measures.
Jeffery argues that the concept that a treatment can be withdrawn because it is conferring no benefit is so broad that it could be applied to anyone incurably ill with a fatal condition4. There are also objections to the burden argument, for as Jeffery points out, what is a burden to one person is quite acceptable to the next. Widening the concept to include the burden on the family, insurance company or state is anathema to most physicians whose prime responsibility is to the individual patient. However such considerations cannot be ignored completely. When resources are finite, the needs of other patients on the waiting list may enter the equation. Thus it is easy to see why some elderly incurable patients may be seen as expendable.
It will be readily apparent that every case will be different, and must be considered carefully and with sensitivity, taking into account the clinical situation and the views and wishes of the patient. When the patient is confused, unconscious or mentally in competent, the views of their nearest and dearest friends and relatives should be sought. It is the doctor's role to advise and offer appropriate treatment, which a competent patient may accept or refuse. When the patient is mentally incompetent, the burden of responsibility is more onerous, and treatment can be given only if it is strictly necessary. Those who look to the law to safeguard the interests of mentally incompetent patients may be sadly disappointed.
When all is said and done, the advice of the House of Lords Select Committee on Medical Ethics still has much to recommend it. After careful deliberation in 1993/94 in response to the Bland case, they concluded that it should be unnecessary to consider the withdrawal of hydration or nutrition unless the means of administration was in itself a burden to the patient 5. That eminently sensible conclusion was not available to the Law Lords in their judgement in the case of Airedale NHS Trust v Bland, for they allowed Tony Bland, a patient in a permanent vegetative state, to die6. I doubt whether their Lordships realised at the time how wide the repercussions of their judgement in that case would be.
Factors that spin on the wheel of fortune to determine the patient's fate.
- Clinical diagnosis
- Treatment available
- Patient's physical condition
- Patient's mental state
- Benefits and burdens of treatment
- Patient's best interest
- Patient's wishes
- Relatives views
- Views of senior clinician and clinical team.
Views of a Court under some circumstances.
A practical approach.
For practical purpose when considering whether artificial hydration or nutrition is appropriate the responsible doctor should consider the following basic points:-
- Is it necessary?
- Is it feasible?
- Can the patient tolerate the procedure?
- Does the patient wish to undergo the procedure?
- Is the patient capable of giving informed consent?
- Beware of making quality of life judgements. Nevertheless consider whether prolonging life will be a boon to the patient or an intolerable burden. Ask yourself and others, What would the patient want?
- Is the patient mentally incapacitated or lacking in self-awareness? If so obtain a second opinion from an experienced doctor according to BMA guidance if in the UK7. If the relatives disagree with a proposal to withhold artificial hydration and nutrition, listen carefully to their views, for they could be right. Take into account and respect deeply held religious views. If dissent remains after careful discussion, legal advice should be sought.
- Is the condition reversible or permanent? Have all reversible features been treated? If not, why not?
- Is the patient in a permanent vegetative state? If so, in the UK, there is a legal obligation to obtain permission from a Court before with holding artificial hydration and nutrition.
- Is the patient terminally ill and death imminent? If so follow the guidance of the National Council for Hospice and Specialist Palliative Care Services (NCHSPCS), as issued in July/ August 19978. Long term nutrition will not be a priority in this situation but attention should be paid to hydration 9. Subsequent NCHSPCS guidance for use in the last few days of life plays down the importance of hydration and is not entirely satisfactory10 General Medical Council guidance issued in August 2002 should be heeded11.
- If death is not imminent, and there are no clear indications that artificial hydration and feeding would be very distressing, or would have no effect, then give fluids and nutrition by what ever means seem most appropriate, unless there are clear contradictions. If you do not feel this approach is appropriate obtain a second opinion and consider the legal position before treatment is withdrawn11.
- Take heed of guidance issued by respected professional organisations, but do not allow yourself to be forced into actions that you consider immoral. Be prepared to justify your conduct and stand firm. Keep in touch with a supportive peer group.
- Be gentle with relatives and try to ensure that they have appropriate emotional and spiritual support.
- There comes a time when everything possible has been done, but the patient lingers on in a twilight existence that some see as a fate worse than death. Then it may be appropriate gently to suggest that it might be best to let them go, and hand them with love to God.
References and notes.
- Beauchamp T, and Childress J.F. Principles of Medical Ethics. First issued in 1978. 4th edition Oxford University Press 1994.
- Jeffery P. Going Against the Stream. Ethical aspects of ageing and care. Chapter 5, Mortal questions. Gracewing, 2001.
- Ibid page 158. Note however that the legal situation with respect to quality of life judgements in the USA is not clear and may vary from state to state. In California unconscious people do not enjoy the same legal protection as others- see Wesley J. Smith, p35 1-353 in Ethical Issues in Modern Medicine, 6th edition. McGrawHill 2002.
- Ibid page 159.
- House of Lords Select Committee. Report on Medical Ethics. 1994; para 251-7, London. HMSO.
- Airedale NHS Trust v Bland  1 All ER 821.
- Withholding and withdrawing life-prolonging medical treatment. Guidance for decision-making. BMJ Books. 1999.
- Ethical decision-making in palliative care. Artificial hydration for people who are terminally ill. National Council for Hospice and Specialist Palliative Care Services. London July/August 1997.
- Craig G.M. Palliative care from the perspective of a Consultant Geriatrician: the dangers of
- withholding hydration. Ethics and Medicine, 1999: 15.1:15-19.
- Changing Gear-managing the last days of life in adults. NCHSPCS London, December 1997.
- Withholding and withdrawing life-prolonging treatments: good practice for decision making. General Medical Council, London. August 2002.