Ethical Challenges in Withdrawing Life Support
Patients are compelled by powerful emotions (such as guilt) or by adherence to religious or secular traditions to behave in certain ways that may conflict with medical advice. 2 Honest discussions with patients and their families about the benefits and burdens of therapy and the medical uncertainty that exists are necessary to provide patients and families with the best opportunity to make informed decisions. We know that honest direct communication is most important for patients and families faced to make life determining decisions.
These health care workers must communicate within the medical ethics of their profession. Medical ethics is based on a four prima facie moral principles and attention to these principles’ scope of application. The four prima facie principles are respect for autonomy, beneficence, non-maleficence, and justice. “Prima facie,” a term introduced by the English philosopher W D Ross, means that the principle is binding unless it conflicts with another moral principle – if it does we have to choose between them. Respect for autonomy is the moral obligation to respect the autonomy of others in so far as such respect is compatible with equal respect for the autonomy of all potentially affected. Respect for autonomy is also sometimes described, in Kantian terms, as treating others as ends in themselves and never merely as means – one of Kant’s formulations of his “categorical imperative. ”1 Beneficence and non-maleficence are contained within the traditional Hippocratic Oath in which it is the moral obligation of medicine to provide net medical benefit to patients with minimal harm.
The fourth prima facie moral principle is justice. Justice is often regarded as being synonymous with fairness and can be summarized as the moral obligation to act on the basis of fair adjudication between competing claims. 1 We have now identified the four medical ethical principles that healthcare professionals must adhere to. I will now discuss the question of retaining or withdrawing life support for dying patients; providing food and fluids by tubes is a common form of life support for weak, injured, or unconscious patients.
If the patient has the mental capacity to make decisions, then the patient can tell the physician what he/she wants. This will not alter the dying process and therefore is not considered suicide. It is important to remember that when we are entrusted with decisions about the care of the dying, the patient’s comfort and wishes must guide our decision making. 3 Missouri v. Cruzan was a case directly related to withdrawing life-sustaining treatment. This case in 1990 supported the “distinction between letting a patient die and making that patient die. 3 There was “clear and convincing” evidence of Nancy Cruzan’s intent was not to be sustained on a feeding tube and the tube was withdrawn. There comes a time when nature should take its course, the proper judgments of physicians and family should be respected and the patient should be allowed to die a natural and dignified death. Medical interventions can be withdrawn or withheld by the physician when they will not benefit the patient. Most ethical conflicts involve issues of autonomy and beneficence, and most of these conflicts involve the family.
In principle, families do not have the right to reverse patients’ advance decisions when the patient loses consciousness. However, physicians may concede to the family’s demands for aggressive therapy after the patient loses decision-making capacity. The reasons for this are varied: physicians can be fearful that angry families will sue if therapy is withheld; physicians may feel that they can make things easier for the family while producing only minimal burden to the patient; or physicians may not be firm in their own convictions.
Nonetheless, the patient’s right to refuse therapy must be protected, recognizing that most patients are concerned about their families and do not wish to have family members undergo unnecessary anguish. Physicians should be sensitive to such family concerns, but in the end, it is the patient’s wishes that must prevail. 2 In closing, I would like to discuss the importance of advance planning and documenting your wishes on paper in a legal document. I am a hospice nurse and have witnessed both sides of this issue.
If the patient has put their expectations in a Living Will the family will make the decision of withdrawing life supporting measures more easily than if they are deciding what their loved one would have wanted. I did not have advance directives until I was faced with the unexpected death of my mother, who was on a ventilator for aggressive treatment of pneumonia. Her heart failed and the decision was to resuscitate her or allow her to have a natural death. I had spoken with my mother since her diagnosis of lung cancer about her wishes but nothing was documented.
I was only a daughter, without legal authority to make her medical decisions – that was left in the hands of her current husband. I looked at him and asked what he wanted as my mother’s heart grew weaker and leading to a point of ceasing and he said that they spoke about this and she wanted a natural death. I explained this to the intensive care nurse and her wishes through my step-father were granted. I knew at that time I needed my wishes in writing and the directives for my children if something would happen to me.