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cmf file 7 (1999) - when to withdraw or withhold treatment

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 health-care 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 mistake 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 with-holding treatment in the first place.

Clinical decisions

One of the complicating features in this area of discussion 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.

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.

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 the 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 discussion 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 patient or relatives, in fact, decisions for both actions are normally a basic part of good medical practice.

Giving treatment

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.

When to withhold

Treatments often carry risks, and a doctor needs to weigh up the balance between the potential for doing good and the potential for harm.

People who are refused anti-biotics when they have a sore throat often feel let down, but the doctor has been weighing up the small chance of the drugs making any difference, against the very real risk that over-use of antibiotics can lead to resistant bacteria developing.

Deciding whether to place an artificial hip in a young person with bone disease is complicated. Most hip joints only last ten years, so if the person is young he or she may need repeated operations. However, at the moment, the techniques used actually damage the bone, so that it is unlikely a surgeon would be able to perform the procedure more than twice. Delaying treatment for as long as possible may benefit the patient.

When a road accident victim arrives in a casualty department, staff have to work fast, but they must also assess whether it is appropriate to commence extreme measures to maintain the patient's life, or whether intervention is inappropriate.

Sometimes a doctor may wish to withhold treatment because although the patient thinks he or she is ill, the doctor doesn't agree and believes that any treatment could be harmful. On occasions, friends or family of a patient may ask for treatment out of misunderstanding or fear.

Respecting people

Christians base treatment decisions on the fundamental principle of respect for the sanctity of human life. This is not altered if a person is very old or very young, physically able or has severe disabilities.

For example, a recent discussion document from the British Medical Association says that the association 'finds unacceptable' the practice whereby people with conditions like Down's syndrome are unlikely to be offered life-sustaining procedures like organ transplants.

Where possible, people also have a right to make decisions about their own treatment. This includes the right to refuse any treatment even if that decision seems irrational. A person can write an 'advance directive' or 'advance refusal', which informs doctors and relatives about their likely opinion about treatment. These documents can be referred to if the person is no longer conscious.

Respecting people also means recognising their mortality. Over-treating patients fails to respect that a part of being human is to be mortal. It has also led to increasing demands for euthanasia, as people become frightened that they may be supported by medical technology beyond their ability to cope.

However, if there is any doubt about the best way to proceed, then treatments that prolong life should be continued.

Some reasons why a doctor may decide to avoid, delay, start or stop a particular treatment:

Avoid Delay Start Stop
there is no reason to think that it will help the patient is showing some signs of recovering, in which case wait. If the recovery does not continue then treatment could start it seems likely to help and risks are small compared to the likely benefits the patient is not showing any improvement after a reasonable amount of time
it might help, but cause serious harm as well the treatment only works for a limited period and then becomes ineffective or damaging while it is uncertain whether the treatment will help, give it a try and be prepared to stop if it doesn't work it is harming more than helping
the patient refuses treatment Symptoms are transitory but may indicate disease, so keep tablets with you and take if the symptoms reappear though unlikely to help, the patient may be one of a minority who could respond and the risk is small it was an experimental treatment and has failed
the patient is already getting better the patient is dying and the treatment is not one to ease suffering
the nature of the illness is unclear the patient asks for the treatment to stop

Best interest

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 assess-ment 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 interests 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.

Double effect

Some doctors and lawyers argue that a treatment has a double effect. Pain-killing 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 it 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.

Ten Key Concepts

The British Medical Association's Medical Ethics Committee recently published a consultation paper asking for people's views on all aspects of withdrawing or withholding life-prolonging medical treatment. The Christian Medical Fellowship's response included the following ten-point guide to underlying principles:

  1. Intentional killing is always unnecessary and wrong
  2. Life has a natural end and there is not necessarily anyone to blame when a patient dies
  3. Doctors tend to over-treat towards the end of life, causing demand for euthanasia
  4. Society needs to break its current taboo about facing death
  5. Considering the Christian faith is essential for a healthy exploration of the concept of death
  6. When accepting that cure is either not possible or not sought by the patient, care continues
  7. The most senior clinicians should be central figures in these ethical decisions
  8. Many of the difficult decisions are more 'clinical' than 'ethical'
  9. Medicine is a biological science with uncertain outcomes but research must improve its evidence base
  10. Principles for guidance which define ethical boundaries are more helpful than prescriptive guidelines

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 treat-ment 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.

Further reading

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