Transcript Withholding Treatment from Non-Dying Patients

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?
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Gandhi’s hunger strike
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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?
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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.