Withholding Treatment from Non-Dying Patients Carol Bayley Ethics Champions Program June 2006 A Case Man had esophageal cancer 2 years ago. Treatment scarred his throat and eliminated his ability to taste. It also eliminated his cancer. For two years, the man has used a g-tube to supply nutrition. Now he has decided to stop using it. He says he has no quality of life and is afraid the cancer will come back. Two Principles • Beneficence (Do no harm; help) • Self-Determination (Respect a person’s decisions about his or her treatment) HOW DO WE RESOLVE THIS TENSION? (add poll) What is the lingering moral qualm? • This person is not dying; this is suicide. • This person is not competent; we can’t rely on his “decision.” • He might be competent, but he doesn’t know what is good for him; we should discharge him if he doesn’t agree to eat. • This man must be miserable, lonely and unhappy. How sad that the best we can do for him is let him die. He is not dying; this is suicide • Diabetic refusing insulin? • Hypertensive refusing meds? • Someone with gangrenous (toe, leg) refusing amputation? He is not competent • Capacity vs competence • Capacity is assumed unless pt is determined otherwise • Capacity isn’t measured by whether the decision comports with medical advice Capacity to make a medical decision • Understand diagnosis and prognosis • Understand the nature of the treatment • Understand the risk, possible benefit and the alternatives to the treatment • Able to reason about the above • Communicate decision He doesn’t agree with us; let’s discharge him • Abandonment • “doesn’t know what is good for him” • Coercion He is sad and lonely • Persuasion vs coercion • Capacity? (add poll) where is this case on the continuum? • • • • • • Gandhi’s hunger strike X X X X Withdrawing ventilator from Karen Quinlan When can a patient refuse medical treatment? • When the treatment is “extraordinary” • When the burdens of the treatment outweigh the benefits • When the benefits are too small (add poll) which are medical treatments? • • • • • • • • CPR Bathing Dialysis Oral antibiotics Oral spoon feeding Artificial nutrition through a central line Artificial nutrition through a peg tube Physical therapy How to resolve the tension between beneficence and selfdetermination? • Self Determination trumps • Beneficence is still the clinician’s duty • A patient’s values help determine what is in his or her best interest. Best interest is not exclusively best medical interest Take Home Messages • A patient has a right to refuse medical treatment, even if that refusal will result in the patient’s death. • This applies to any medical treatment. • Whatever a patient can refuse when capacitated a surrogate can refuse on behalf of the patient who lacks capacity. • Refusal of treatment is not suicide. But… • Elizabeth Bouvia (California) won the right to have her feeding tube removed to be allowed to die; she is still alive. • David Rivlin (Michigan), quadriplegic from a diving accident, could not get services to help him live independently and found himself trapped in a nursing home. He sued to be allowed to die, won and died.