The Withdrawal of Treatment

Lucy Elisabeth James

Abstract The withdrawal of treatment is one of the most emotionally challenging and ethically complex aspects of end-of-life care. As our ability to prolong life progresses, the necessity to address issues such as the withdrawal of treatment increases in parallel. This paper approaches the subject from an ethical point of view and aims to establish the utility of ethical frameworks in the 21st century. To achieve this, the withdrawal of treatment is outlined and the arguments both for and against this topic are considered. Ethical frameworks are summarised and applied to the Airedale NHS Trust v. Bland [1993] case. The article argues that through asking ethical questions, one seems not to shed light on the matter, but only emphasises its complexity. In conclusion, although a traditional ethical framework may be applied to the issue of the withdrawal of treatment, multiple criticisms accentuate its impracticality and irrelevance in the modern medical world.

Introduction be performed for the benefit of others, Ethical frameworks will be studied, and In my first year of University a close friend thus all healthcare providers must strive are applied to the Airedale NHS Trust v. of mine was involved in a critical accident. to do the most good for the patient. Bland [1993] case study. He remained on life support for the Non-maleficence is one of the principal following six months before physicians precepts of medical ethics and involves decided that the most appropriate action The withdrawal of treatment healthcare providers avoiding causing to take would be to withdraw support. harm to their patients in every situation. The burdensome experience taught me The withdrawal of life-sustaining Lastly, justice states that the doctor that end-of-life care, and in particular the treatment with the deliberate intention should try to be as fair as possible when withdrawal of treatment, is a challenging of causing death to another provides a offering treatments to patients and issue both emotionally and intellectually. definition for passive euthanasia (Keown, allocating scarce medical resources. The As an aspiring medic, it became a topic 2004). In ethical and medical literature doctor must also be capable of justifying that I was keen to explore, and after these terms are often used interchange- these actions (Winter & Cohen, 1999). enrolling on ‘Ethics in a Complex World’ ably; however for the purpose of this These values (which are neutral between (a Curriculum Innovations module that is paper the ‘withdrawal of treatment’ shall competing religious, cultural, and ethical part of Flexible Learning at the University theories) are able to be shared by of Southampton), I was provided with Airedale NHS Trust v. Bland [1993] everyone. However, the principles do not the perfect opportunity in which to do case study provide a method for choosing and fail so. In 1989 Tony Bland was injured in the to provide answers as to how to handle In healthcare, four moral principles are Hillsborough disaster and this left him a particular situation. The four principles used in the analysis of medical ethics: in a persistent vegetative state (PVS). simply offer a common set of moral autonomy, beneficence, non-maleficence Months later, Bland’s physician ex- commitments (Gillon, 1994). In order and distributive justice (Picard & Lee, pressed an intention to withdraw all to address this problem, this paper will 2013). Autonomy is defined as a rule treatment. This proposal was met with enquire whether long established ethical that states patients must have a right to warning however from the coroner approaches, such as consequentialism control what happens to their bodies, and police who stated that such action and deontology, are more appropriate and these decisions must be respected would constitute murder. Despite this, when dealing with the issue of the by everyone. The second principle, Bland’s parents agreed with the phy- withdrawal of treatment. To achieve beneficence, is an action that should sician; in short, they felt there was no this, the withdrawal of treatment will benefit to Bland in keeping him alive. It be outlined and the arguments both for Author details was three years later that the Airedale and against this topic shall be considered. Lucy Elisabeth James Hospital Trust made an application to Institute for Life Sciences, University the High Court. Attracting considerable of Southampton, Key words: Withdrawal of treatment; interest, the case eventually conclud- Email: [email protected] ed; in 1993 treatment was withdrawn Phone: 07792765690 Consequentialism; Deontology; Ethics and Bland died nine days later.

Working Papers in the Health Sciences 1:6 Winter ISSN 2051-6266 / 20140030 1 be used. In the UK, medical treatment Table 1. Arguments for the withdrawal of treatment can legally be withdrawn if it is deemed futile (British Medical Association, Argument Explanation 2009; General Medical Council, 2013). In practice, however, it is a profoundly The omission will relieve the patient of Some patients have a medical condition difficult decision. This was illustrated by his or her suffering. for which there is no relief, and they may the Airedale NHS Trust v. Bland [1993] therefore suffer whilst awaiting natural case. death. Bland became the first patient in English Hospital resources may become free for Hospital resources used by those who legal history to be allowed to die by those who are able to be treated. wish to have treatment withdrawn may the courts through the withdrawal cost a large amount. For example, the of life-sustaining treatment including cost of an intensive care bed is estimated artificial nutrition and hydration (ANH). at £1500 per day (BBC News, 2010). Interestingly, the case significantly contributed to the foundation of the Table 2. Arguments against the withdrawal of treatment Mental Capacity Act of 2005 (Law Reform Commission, 2009; Szawarski & Kakar, Argument Explanation 2012). The topic of ANH however remains controversial to this day, and a comment Much of the opposition towards this is- The ‘slippery slope’ argument views de- made by Lord Mustill during the Airedale sue is based on the ‘slippery slope’ argu- cisions as the potential beginning of a NHS Trust v. Bland [1993] case still seems ment. trend; the fear is that voluntary passive very relevant euthanasia could lead to involuntary pas- “It would in my opinion be too optimistic sive euthanasia becoming a common oc- to suppose that…in the future the doctors currence. (or perhaps the judges of the High Court) There is no definitive way to measure For example, after Prof. Pullicino took 71 will be able without difficulty to solve all whether a patient’s treatment is futile, or year-old Francisci off the dying pathway future cases…” to predict when death will occur. (who had treatment withdrawn by week- (Szawarski & Kakar, 2012). end doctors days beforehand), Francisci lived for another fourteen months (Don- The issue of the withdrawal of treatment nelly, 2013). often evokes an emotional response, Allowing a patient to die through starva- Death through the withdrawal of ANH, particularly from those who are directly tion may cause more harm than if they for example, can take up to two weeks to involved with such cases. Despite this, a were administered medication to cause occur (WebMD, 2013). limited number of studies exist detailing instant death, known as ‘active euthana- how frequently the withdrawal of sia’ (Rachels, 1997). treatment takes place, or the opinions Other terminally ill patients may feel If a patient believes they have become a of physicians regarding this matter. One obliged to have their treatment with- ‘burden’ they may feel pressured to have survey exploring NHS doctors’ attitudes drawn. their treatment withdrawn. towards end-of-life care found that 91% would consider practicing passive Healthcare professionals may feel un- Some healthcare professionals may not euthanasia (Ward & Tate, 1994). In comfortable with the idea of the with- want to be held accountable for the delib- addition, another study concluded that drawal of treatment. erate death of a patient. few UK healthcare professionals believe The withdrawal of treatment may be used For example, the patient’s relatives may they give up on patients too soon; staff for immoral reasons: When a patient need inheritance money that would fol- felt more strongly that sometimes the lacks the mental capacity to decide about low after the patient’s death, and they treatment offered to patients is overly their healthcare, it must be questioned could therefore disregard the patient’s burdensome (Dickenson, 2000). whether his or her family have the ‘cor- best interests. For some patients this In contrast, Lynoe and Rydvall (2008) rect intentions’ if advising a physician could be avoided by determining the pa- found that the general public are less in about what the patient would want. tient’s wishes in advance, but for many favour of the withdrawal of treatment this is not possible. and it therefore appears that a consensus The withdrawal of treatment may be Many figures highlight the lack of re- is not reached between physicians and used for immoral reasons: Treatment sources in the UK. For example, there the public. It is interesting to speculate could be withdrawn purely to generate may be just 3.5 intensive care beds per whether this reflects the ethical training hospital resources that are in such great 100,000 people in the UK (BBC News, that doctors undertake, or whether the demand. Incidentally, if this truly is a de- 2010). Moreover, in the time that it has general public and physicians have a sired result, one may propose that this taken to write this sentence, the estimat- different understanding of the duty of a provides a reason for voluntary active ed net population growth for one day doctor. Alternatively, it may suggest that euthanasia to be legalised. has increased from 122,345, to 122,404, the public have higher expectations of implicating the difficulties that exist for what the healthcare system can achieve. healthcare providers (Worldometers, 2013).

Working Papers in the Health Sciences 1:6 Winter ISSN ISSN 2051-6266 / 20140030 2 Arguments for and against the the text which states to “...maintain the utilitarian, is concerned to maximise the withdrawal of treatment utmost respect for human life” is ambig- satisfaction of preferences. Instead of -de uous and leads the topic open to inter- fining moral actions as those which max- The withdrawal of treatment is pretation (Rampe, 2009). Furthermore, imise pleasure and minimise pain, prefer- undoubtedly a complex issue. To the Good Medical Practice guide, that ence utilitarianism promotes actions that demonstrate this, it is important to sets principles to which a UK doctor must fulfil the interests of those involved. explore the arguments for and against abide, is also ambiguous regarding the A classical utilitarian approach may be the withdrawal of treatment. ethics of end-of-life care. This states the used to address the issue of the with- A number of the points listed in opposi- doctor should “take all possible steps to drawal of treatment. For this purpose, it tion to the withdrawal of treatment were alleviate pain and distress whether or not shall be assumed that treatment is with- recently used against the Liverpool Care a cure may be possible” (General Medical drawn with good intention only. Pathway (LPC). This system was originally Council, 2013); could this constitute the implemented in the late 1990s to allow withdrawal of treatment? Case study 1 – Applied withdrawal of terminally ill cancer patients to die with Religion and cultural differences further treatment dignity and in as little distress as possible. complicate decisions relating to the with- In the case of Tony Bland, if the physi- Since then, the LCP had been extended drawal of treatment as the beliefs of ma- cian was to have followed a utilitarian to allow the withdrawal of treatment for jor religious groups, such as Christianity approach, he would have concluded all dying patients. By many, the pathway (Catholic), Christianity (Protestant), Juda- that the withdrawal of treatment is mor- was widely accepted as good practice ism, Islam and Hinduism, vary consider- ally acceptable. For a patient who is no for end-of-life care; however it became ably when regarding this matter and val- longer capable of intellectual pursuits controversial due to multiple allegations ues even differ within each faith (Ankeny (pleasure), and physically suffers (pain), about its use. An investigation found that et al, 2005; Firth, 2005; Donovan, 2011). Mill would state that the withdrawal of the Cambridge University Hospitals NHS Furthermore most religiously-based ar- treatment to end the patient’s life would Foundation Trust was ‘in line for a one guments become irrelevant in the eyes maximise happiness and minimise pain. million-pound bonus from the Govern- of a non-believer. For these reasons, this Moreover, the family and friends will be ment for promoting end-of-life care, in- paper suggests that perhaps a traditional spared the pain of watching the patient cluding the LCP’. Once more, in a national ethical framework, such as a consequen- suffer through a terminal illness, and hos- dying audit, it was reported that not even tialist approach, should be considered pital resources will be free for those with two thirds of patients had their care plan when addressing the issue of the with- a more treatable condition. discussed with relatives or carers (Sturdy, drawal of treatment. 2013). In July 2013 an independent re- Case study 2 – Voluntary withdrawal of view recommended the LCP be phased Applying an ethical approach treatment out in England within the next six to In the case of voluntary withdrawal of twelve months (Department of Health, Consequentialism is a type of moral the- treatment, the traditional utilitarian jus- 2013). ory that guides decisions by the value of tifications that would exist against killing The withdrawal of treatment leads one their consequences (Jacquette, 2004). do not apply. As Singer p77 (2011) states, to ask a number of ethical questions; The best acknowledged and widely ac- the hedonistic utilitarian would defend a • Who should decide whether the with- cepted form of consequentialism is util- prohibition on killing as this will increase drawal of treatment is ethical? itarianism. Utilitarianism was advocated the happiness of people who would oth- • Should a doctor’s duty always be to by philosopher and jurist, Jeremy Ben- erwise worry about being killed. Howev- preserve life? tham, who is known for his principle “the er, providing that it is practiced lawfully, The Hippocratic Oath was written to greatest happiness of the greatest num- the withdrawal of treatment is only per- guide ethical decisions such as these. The ber” (Anderson, 2004). Bentham used formed for patients who wish for their Oath embodies the duties and obliga- the word ‘happiness’ to refer to maximal life to be ended. In his own words, “...if tions of doctors and includes the prom- pleasure and minimal pain, and believed we do not wish to be killed, we simply ises to “...do no harm...” and to “...keep that happiness could be measured as do not consent” (Singer, 2011). Conse- secret...” whatever is seen or heard in a matter of quantity. The greatest hap- quently, patients need not live in the fear the lives of the physician’s patients (Ram- piness principle refers to the fact that a that their lives could be taken from them. pe, 2009). Although written over 2400 person can only be so happy if the people Singer, a preference utilitarian, would years ago (and therefore thought of as surrounding them are also happy. also favour voluntary passive euthanasia irrelevant by many in the modern med- John Stuart Mill, an English philosopher, and may claim that a patient’s desire to ical world) some view a newly modified fully accepted Bentham’s dedication to die is a reason for allowing the withdraw- version of the Hippocratic Oath as critical the greatest happiness principle; howev- al of treatment. in guiding the ethical code for physicians. er he was keen to reformulate the utili- There are many advantages of following Despite this, the Oath fails to specifical- tarian theory to show that not all pleas- a utilitarian approach when addressing a ly address the issue of the withdrawal of ures are of equal value. Mill believed in complex issue such as the withdrawal of treatment. two classes of pleasure: higher and lower treatment. The framework avoids appeal Inspired by the Hippocratic Oath, the (Fieser, 2001). These were used to refer to divine revelation and therefore many WMA Geneva Declaration is both - cur to a patient’s intellect and body, respec- use this ethical system in order to live a rent and internationally acceptable; but tively. Since Mill, the utilitarian frame- moral life apart from religion (Rae, 2000). again, this does not directly address the work has been developed further. For In addition, some already use a form of a withdrawal of treatment. A quote from example, Peter Singer, a contemporary consequentialist framework in everyday

Working Papers in the Health Sciences 1:6 Winter ISSN 2051-6266 / 20140030 3 decision making procedures. Therefore, cision maker is also irrelevant. that to be moral, one must act in such a making moral decisions using a utilitar- Bentham calls for one to assign values way that they would be willing for those ian approach appears just a natural ex- to various pleasures and pains; yet it is actions to become a universal law (Soc- tension of using a similar method to help not possible to know the level of pain cio, 2012). In the case of Bland, a Kantian make non-moral decisions. or pleasure that could be inflicted due ethicist would state that the physician Despite this, there are also many criti- to a decision (Yeo & Moorhouse, 1996). must only withdraw treatment from a cisms of the framework. Firstly, it cannot Measuring the values of certain benefits patient if he or she is willing for this to be dismissed that the utilitarian approach and harms is not simple. How must one become a universal law, so that the with- requires one to make a decision based on go about assigning value to a life? And drawal of treatment may be performed the outcomes of an action, and it is never how would one compare the value of for all patients in a PVS. The physician un- possible to understand the complete set hospital resources to the value of human der Kantian law must feel that the omis- of consequences that an action may pro- dignity? Utilitarianism appears to reduce sion is the right thing to do out of rational duce (Slowther et al, 2004). In the case of morality to simple maths; this seems duty. However, this approach is again not the withdrawal of treatment, one would wrong when regarding such an ethically without its weaknesses; for example, it expect the outcomes to be the dignified complex issue. requires the deontologist to understand death of a patient and the freeing up of Furthermore, it could be argued that one the duty of a doctor, and this is a matter hospital resources. But what if the with- does not have the time to ponder over which is frequently debated. drawal of treatment inflicted considera- complex ethical approaches in this way ble, unexpected suffering on the patient? (Fieser, 2001). However, a contemporary Discussion And what if the patient (in a conscious utilitarian would state that if the prob- and sane state) would not have wanted lem has been faced many times before When evaluating a medical issue it ap- his or her treatment withdrawn, yet was and has always led to the same conclu- pears that traditional ethical frameworks, unable to express this? Furthermore, sion, then one may forgo the calculus such as classical utilitarianism, may arrive what if a lifesaving drug was developed and act immediately. To continue, not at the most moral decision, yet their crit- several months after the patient’s life had everyone may agree on the decision that icisms seem to render them impractical. been terminated? Since it is not possible would lead to the greatest happiness for For instance, the utilitarian approach re- to know what is going to happen in the the greatest number. Fortunately, in the quires one to make a decision based on future, it may be wrong to base ethical UK, although the physician has the re- the outcomes of an action, yet it is nev- decisions on this. sponsibility of withdrawing treatment, er possible to understand the complete However, a utilitarian would argue that the views of relatives and other health set of consequences that an action may this is not a reason for dismissing the professionals are taken into account to produce. Moreover, when addressing withdrawal of treatment. Instead, a utili- ensure that a well-informed decision is ethically challenging dilemmas, it seems tarian would acknowledge that one is not made (Bewley, 2000). that more questions materialise in com- able to predict the future with certainty, In addition, the utilitarian views all hap- parison to answers. If, for example, one and therefore should follow the path that piness as equally good, regardless of who were to enquire whether a doctor’s duty is believed to most likely bring about the receives it. Therefore making a ‘bad’ indi- is to prolong life, Singer (2012) may state best consequences. Although it is possi- vidual happy, for the utilitarian, is just as that the role is to do whatever is in the ble that a cure could be developed within important as making a ‘good’ person hap- patient’s best interests (Singer, 2012). the few months after a terminally ill pa- py. Lastly, every human has a different However in answering the question, it tient’s death, this cure would probably definition of happiness and we all have has provided a new set of queries; what not be available for distribution for many different preferences (Maris & Jacobs, are a patient’s ‘best interests’? And who years. Consequently, a utilitarian would 2011). Preference utilitarianism is often defines these? state that the considerable pain a patient criticised on the grounds that some pref- In addition to those highlighted above, would suffer during these months would erences may be misinformed or fanatical; this article has generated a number of far outweigh the pleasure of the few indi- a patient could ‘prefer’ to die simply be- important questions that require further viduals who may benefit from such unex- cause they are clinically depressed. attention: pected treatments. Hence, a utilitarian ethical approach • Can we ever accurately define medical Secondly, the approach appears to have may be used to address the issue of the treatment as futile? At this point, are we no room for special moral obligations withdrawal of treatment, but the multi- stating that life is futile? Perhaps an alter- to one’s family and friends (Montgom- ple criticisms of this framework appear native term such as ‘inadvisable’ could be erie, 2000). For example, if the son and to render it impractical in everyday life. used to define the status of treatment as daughter of a terminally ill patient were Alternatively, a non-consequentialist ap- this is easier to apply. opposed to the idea of the withdrawal of proach may be applied; briefly, deonto- • Who has the rights to our bodies? A treatment, yet the patient wished for the logical (duty-based) ethics shall be con- doctor? The government? omission, then a utilitarian would argue sidered. Immanuel Kant is well known • Is it fair for some to be allowed to die that the greatest happiness would come for his theory of duty-based ethics (Chris- when others (despite an equally poor from allowing the withdrawal of treat- tians & Merrill, 2009). Kant believed that quality of life) are made to live because ment as this would benefit not only the motive is the key to morality and sub- they require active euthanasia rather patient, but the rest of society. The son scribed to the fact that the Categorical than the withdrawal of treatment? and daughter in this situation would have Imperative, good will, and duty are the • Who should decide whether the with- their wishes ignored. Using this frame- foundations for moral actions. drawal of treatment is ethical for a pa- work, the motives or character of the de- Kant’s Categorical Imperative teaches tient without mental capacity? Will the

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