Refusing and Withdrawing Medical Treatment

Just as the aforementioned cases facilitated development of professional, institutional, and legal standards for withholding and withdrawing care, so they also sparked continued debate over the ethical basis for forgoing treatment. Ethical reasons for withholding and withdrawing medical treatments can be usefully grouped under three general headings. First, the ethical principle of autonomy implies respecting the wishes of a competent patient who refuses medical interventions. Patients express autonomous wishes in a variety of ways. At the time treatment is offered, a competent patient may refuse it. Or at some prior time, a now incapacitated patient may have made a reasoned decision that certain interventions should not be provided. Often, patients express such a preference through a directive to physicians (living will) that provides both ethical and legal support for respecting the patient’s competent choices. Alternatively, a decision may be made by others who claim to represent the wishes of the now incompetent patient. Here the ethical mandate to respect patient autonomy corresponds to the legal requirements of substituted judgement established in Brophy v. New England Sinai Hospital.

A second ethical basis for forgoing medical treatment is the ethical obligation to promote the patient’s good and avoid harm to the patient. There are at least two ways in which principles of beneficence and nonmaleficence give ethical underpinning to withholding or withdrawing treatment. On the one hand, a surrogate decision maker may decide to forgo medical interventions because this is considered to be in the patient’s best interest. On the other hand, benefit is also at stake when treatment is forgone because the health care team judges that treatment is futile and provides no medical benefit to the patient.

A third ethical basis for forgoing medical treatment appeals to the ethical standard of justice. Justice arises in situations where medical resources are scarce or the dollars to pay for them are limited. In such cases justice furnishes an ethical reason for rationing beneficial care to particular patients; health care dollars or resources can be put to better (more just) use elsewhere in the health care system. Unlike arguments that find their source in ethical principles of autonomy, beneficence, or nonmaleficence, arguments appealing to justice generally spring from health care policies that seek to provide the best care to a population of patients. Support for applying particular justice rules in the clinical setting depends upon establishing that particular instances of health care rationing are part of a larger system of rules for distributing health care that itself meets ethical standards of justice.