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.