Matters of life and death

It has been noted that the right of a competent adult to consent to and refuse treatment is unlimited, including the refusal of life-sustaining treatment. Probably the example most familiar to surgeons of this is Jehovah’s Witnesses who refuse blood transfusions at the risk of their own lives. There can be no more dramatic example of the potential tension between the duties of care to protect life and health and to respect autonomy, with autonomy always constituting the trump card.

The tension does not stop here, however. For there will be some circumstances where the protection of the life and health of patients is judged to be inappropriate, where they are no longer able to be consulted and where they have not expressed a view about what their wishes would be under such circumstances. Here a decision may be made to with­hold or to withdraw life-sustaining treatment on behalf of the incompetent patient. The fact that such decisions can be seen as omissions to act does not excuse surgeons from morally and legally having to reconcile them with their ordinary duty of care. Ultimately, this can only be done through arguing that such omissions to sustain life are in the patient’s best interests.

The determination of best interests in these circumstances will rely on one of three objective criteria, over and above the subjective perception by the surgeon that the quality of life of the patient is poor. There is no obligation to provide or to continue life-sustaining treatment:

  if doing so is futile — when clinical consensus dictates that it will not achieve the goal of extending life. Thought of in this way, judgements about futility should not be linked to evaluations of a patient’s quality of life;

  if patients are imminently and irreversibly close to death —in such circumstances it would not be in their best interest slightly to prolong life (e.g. through the application of intensive care) when, again, there is no hope of any sus­tained success. Not needlessly interfering with the process of a dignified death can be just as caring as the provision of curative therapy;

  if patients are so permanently and seriously brain damaged that, lacking awareness of themselves or others, they will never be able to engage in any form of self-directed activi­ty. The argument here is backed up by morally and legally reasoning that further treatment other than effective palliation cannot be in the best interests of patients as it will provide them with no benefit.

When any of these principles are employed to justify an omission to provide or to continue life-sustaining treatment, the circumstances should be carefully recorded in the patient’s medical record, along with a note of another senior clinician’s agreement.

Finally, surgeons will sometimes find themselves in charge of the palliative care of patients whose pain is increasingly difficult to control. There will come a point in the manage­ment of such pain when effective palliation might only be

possible at the risk of life because of the respiratory effects of the palliative drugs. In such circumstances, surgeons can with legal justification administer a dose which might be lethal. The argument employed to justify such action refers to its ‘double effect’ — that both the relief of pain and death might follow from such an action. As intentional killing — active euthanasia — is rejected as professional and legal medical practice throughout most of the world, a potentially lethal dose is only regarded as appropriate when it is motivated by palliative intent.

Debates rage about whether or not it is realistic in such circumstances to believe that surgeons can or should keep all ideas out of their minds about helping such unfortunate patients to die, especially as we have seen that clinical deci­sions are already made that foreshorten the lives of incompetent patients in specific circumstances. Deciding whether or not potentially lethal palliation is justified will require an evaluation — by either the patient, the clinician or both — of whether or not the life in question is too valuable on other grounds to risk. Once a negative conclusion is reached and the risks are incurred, it seems impossible in the face of continued and dramatic palliative failure then to purport to banish thoughts of the desirability of death from the scene. What is clear is that surgeons should document that their intent is purely palliative through only gradually and incre­mentally increasing doses of the drugs that they administer for this purpose.