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.