Introduction
The medical profession is infused with too much dilemma when it comes to whether insisting the right to treat a patient when he or she refuses to undergo it. Professional medical practitioners must attend to the ethical responsibilities and conflicts they may experience as a result of their unique relationships in professional practice.
Due to the advances in medical and reproductive technology, clients’ rights, social and legal changes, the medical profession had constructed ethical standards that define their appropriate actions in times of dilemmas. This is why medical practitioners need to be able to apply ethical principles in decision making and consider their own values and beliefs and the values and beliefs of clients, of the profession, and of all other concerned parties.
As professionals, they have a responsibility to protect the rights of clients by acting as client advocates. In general, this advocacy derives from the ethical principles of beneficence (the duty to do good) and nonmaleficence (the duty to do no harm) (Davenport, 1997).
Discussion
When a patient refuses treatment, the medical practitioners generally maintain that if the patient does not want treatment, physicians do not have a duty to start it. Yet, once treatment is started, physicians have a duty to continue it if discontinuing it would lead to the patient’s death. They are not required to force a patient to go on a respirator if the patient refuses, but once the patient has gone on the respirator, doctors have a duty to keep him on it, even contrary to the patient’s wishes, if taking him off would result in his death.
Suffice it here to point out one important limit: a doctor is not ethically bound to assist a refusal of treatment which is suicidal, that is, made not because the treatment is futile or excessively burdensome but in order to hasten death (Keown, 2002, p. 253). For example, patient-assisted suicide remains to be a debated issue in the medical world. Although there are those states where it is not a crime, some have intervened in these cases to order life-sustaining treatment in the face of objection by a competent adult.
The most widely cited case in which this was done is John F. Kennedy Memorial Hospital v. Heston (1971), where a twenty-two-year-old unmarried woman refused a blood transfusion because she was a Jehovah’s Witness. She was forced to have one anyway on the theory that there is no difference between passively submitting to death and actively seeking it. The state regards both as attempts at self-destruction and may prevent them.
Since this case, however, the trend of cases has been away from this reasoning and toward subordinating the state’s interest in the prevention of suicide to the rights of patients to forgo or have withdrawn life-sustaining treatment (Berger 1995, p. 20). Myrtle (2004) mentioned that there is what we call an “advanced directive”, which asserts an individual’s right to accept or refuse treatment and gives direction to relatives, friends, and medical professionals.
The directive is necessary, according to Senator John C. Danforth, R-MO, an Episcopal clergyman, because “[m]edical technology has outstripped ethics. For too many thousands of people, the end of life is a nightmare. … [It is] turned over to technocrats whose job it is to eke out every last moment. This constitutes playing God by medicine.”
In support of Senator Danforth, and at the same time giving insight into the physician’s behavior, James H. Sammons, former executive vice president of the American Medical Association (AMA), said that: “From the day [physicians] enter medical school they are taught to cherish and preserve life. … While physicians should never directly cause death, they must always act in the best interest of the patients, and that sometimes includes allowing them to die” (cited in Myrtle, 2004).
Law that affect death and dying also reflects how society regards older people, the relationships that exist between and among the generations, society’s ambivalence in matters of a patient’s autonomy, and the pluralistic background of our religious heritage. Americans unable to reach agreement on substantive issues concerning the appropriateness of treatment of the dying have concentrated instead on procedural matters, such as advanced directives.
The United States Supreme Court, in Cruzan, reinforced this approach by focusing on the state of Missouri’s ability to require that substitute judgment decisions be reached from clear and convincing evidence. The Supreme Court Chief Justice Rehnquist held that:
- The United States Constitution did not forbid Missouri from requiring clear and convincing evidence of an incompetent’s wishes to the withdrawal of life-sustaining treatment.
- [The] State Supreme Court did not commit constitutional error in concluding that evidence adduced at trial did not amount to clear and convincing evidence of the patient’s desire to cease hydration and nutrition.
- Due process did not require the state to accept substitute judgment of close family members absent substantial proof that their views reflected those of the patient (qtd by Myrtle, 2004).
Myrtle (2004) informed that the Cruzan ruling originated in the ordeal of Nancy Cruzan, who had been comatose since a 1983 automobile accident. Her parents brought the matter into the courts after medical professionals refused to remove the feeding tube that kept her alive in a vegetative state. The court upheld the right of an individual to die but also held that the state could refuse that right absent clear and convincing evidence that the individual would have wanted to die. Advanced directives are a result of the need for evidence.
However, when the patient is terminal and death is imminent, no treatment is medically indicated, and the competent patient’s rightful refusal of treatment does not conflict with the health provider’s form of beneficence. There may be an emotional problem in admitting defeat, but there should be no ethical problem. It should be noted that, although the patient may not be competent at the end, refusal of treatment may be accomplished through a living will or a surrogate, especially through a surrogate who has durable power of attorney for health matters.
In the case when the patient is terminal but death is not imminent, for example when the disease or injury progresses slowly, and granted the consent of the patient or surrogate, it appears ethical to omit treatment on the ground that nothing can be accomplished in thwarting the progress of the disease. But it is not ethical to omit care, since human dignity is to be respected. To solve this dilemma, the AMA Council on Ethical and Judicial Affairs (1996) takes a clear stand on the issue:
- E-2.20 Even if the patient is not terminally ill or permanently unconscious, it is not unethical to discontinue all means of life-sustaining medical treatment in accordance with a proper substituted judgment or best interests analysis.
- The treatments include artificially supplied respiration, nutrition, or hydration. In its recent opposition to physician-assisted suicide, the AMA has strongly endorsed a program to educate physicians to the appropriateness of switching from therapeutic treatment to palliative care. The group has gone from a tentative, negative position (“not unethical”) to a much stronger positive stand (AMA, 1996).
On the other hand, we should also consider the reasoning behind the ethical correctness of not beginning or of stopping treatment in the case of the consenting patient who is terminally ill. First, the health care provider has no obligation to prolong dying merely for the sake of prolonging it. That is, it makes no sense to prolong life when the true result is the prolongation of the dying process. Furthermore, when treatment is only prolonging the agony of the patient, its continuation is unethical as an insult to human dignity (Cahill, 1977).
In such cases, the health care provider would be ethically justified in discontinuing treatment, except when the patient insists on treatment. Even in this case, however, there can be exceptions. When there is a severe shortage of medical resources, the physician might be justified in stopping nonindicated treatment even over the protests of the patient. We say “might be justified,” since justification would depend, among other things, on a new social consensus about the duties of health care professionals and on a reasonable certainty that a shortage exists.
There are also problems in discontinuing treatment when the patient’s surrogate(s) objects. It should be noted that cessation of life-sustaining treatment does not always bring about a swift and painless death, even though it may speed up the process of dying. For example, if kidney dialysis is discontinued, the person remains conscious and suffers vomiting, internal hemorrhage, and convulsions. The removal of a respirator does not lead to death immediately, and the patient suffers the pain and panic of suffocation.
The obligation to care for the patient demands that every ethical effort be made to alleviate these sufferings with drugs and other methods that will not prolong life. Much recent research suggests that physicians are particularly deficient in their willingness and ability to provide adequate pain palliation for dying patients (SUPPORT, 1995). This could be one of the main concerns that drive the interest in physician-assisted suicide. Beyond this, when such pain relief is not possible for the patient, or when the harm is not the pain, but the insult to dignity, there arises the difficult problem of actively cooperating in the suicide of the patient.
In the religious sense, refusal to treatment of the patient should be respected by medical practitioners. But if this refusal can result in imminent death, then physicians should argue about the doctrine of the sanctity of life. It holds that human life is created in the image of God and is, therefore, possessed of an intrinsic dignity which entitles it to protection from unjust attack. With or without this theological underpinning, the doctrine that human life possesses an intrinsic dignity grounds the principle that one must never intentionally kill an innocent human being. The ‘right to life’ is essentially a right not to be intentionally killed (Keown, 2002, p. 40).
Whether expressed in its religious or secular forms, the principle of sanctity/inviolability of life holds that the right not to be killed intentionally is enjoyed regardless of inability or disability. Rejecting any such distinctions as fundamentally arbitrary and unjust, it asserts that human life is not only an instrumental good, a necessary precondition of thinking or doing, but a basic good, a fundamental basis of human flourishing. It is, in other words, not merely good as a means to an end but is, like other integral aspects of a flourishing human life, such as friendship and knowledge, something worthwhile in itself.
Conclusion
Laws on refusal of treatment and patient-assisted suicide can be unclear. However, what laws cannot answer, ethics and morality could provide the answers of what needs to be done by health professionals when faced with a difficult dilemma. As medical practitioners, medical code of ethics should not just become theoretical concepts, because ethics are important references in the application of one’s moral and value system to a career in health care.
Ethics involves more than just ‘common sense,’ which is an approach for making decisions that most people in society use. Ethics goes way beyond this: It requires a critical thinking approach that examines important considerations such as fairness for all consumers, the impact of the decision on society, and the future implications of the decision.
References
Cahill, L.S. (1977). A ‘Natural Law’ Reconsideration of Euthanasia, Linacre Quarterly, 44: 47-63.
Keown, J. (2002). Euthanasia, Ethics, and Public Policy: An Argument against Legalisation. Cambridge, England: Cambridge University Press.
American Medical Association (AMA). (1996). Council on Ethical and Judicial Affairs. Current Opinions of the Judicial Council of the American Medical Association. Chicago: American Medical Association.
Berger, A.S. (1995). When Life Ends: Legal Overviews, Medicolegal Forms, and Hospital Policies. Westport, CT: Praeger Publishers.
Davenport, J. (1997). Ethical Principles in Clinical Practice. 2008. Web.
Flight, M. (2004). Law, Liability, and Ethics for Medical Office Professionals. Florence, KY: Delmar Publishing.
SUPPORT Principle Investigators. (1995). A Controlled Trial to Improve Care for Seriously Ill Hospitalized Patients: The Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT), Journal of the American Medical Association. 274(20): 1591-1598.