Withdrawal/Withholding Treatment Archives - Page 2 of 2 - Protection of Conscience Project Library

(Editorial) The sacred and the secular: the life and death of Terri Schiavo

CMAJ

Extract
. . . In medical and legal opinion, Terri Schiavo’s cognizance of her self and her life ended in 1990, when she suffered a cardiac arrhythmia and massive cerebral cortical encephalopathy that left her in a persistent vegetative state. Her facial expressions, along with a seemingly “normal” sleep–wake cycle, constituted but one dimension of the cruelty of this condition. . .

. . .More than one commentator has viewed the “right- to-life” fight to prolong Schiavo’s pitiable existence as an anti-abortion campaign “by other means.” . . .

. . . there seems little doubt that, in North America, ideology and religion have begun to seriously distort the type of consensus-building that is the proper business of democratic politics . . .

Where do physicians find themselves in such debates? Medicine is a secular and scientific profession that, for all that, must still contend with the sacred matters of birth, life and death. In practice, physicians must set aside their own beliefs in deference to the moral autonomy of each patient — or else transfer that patient’s care to someone who can meet this secular ethic. . .

. . .The emotionalism and rancour that swirled around the Schiavo case underscores a wider societal duty borne by the medical and scientific community. This is to remain alert to political and legislative tendencies that impose imprecise moral generalizations on the majority, at the expense of reason, scientific understanding and, not infrequently, compassion.

CMAJ. (Editorial) The sacred and the secular: the life and death of Terri Schiavo. Can. Med. Assoc. J.. 2005 Apr 26;172(9):1151.

Advance Directives and Dementia

Gregory E Kaebnick

Abstract
A competent person can avoid the onset of dementia by refusing life-sustaining medical care and by voluntarily stopping eating and drinking, bringing life to an end well before any health crisis. A competent person can also try to limit the duration of dementia by drafting an advance directive that sets bounds on the life-sustaining care, including artificial nutrition and hydration, that medical caregivers can provide when the person no longer has the capacity to make her own medical decisions. But between these two strategies there can lie a significant gap. A person could live with moderate to severe dementia for a considerable time, no longer able to voluntarily stop eating and drinking yet also not yet requiring the life-sustaining care forbidden by advance directive. This gap has been much discussed in recent years in the Hastings Center Report. Several years ago (in the May-June 2014 issue), Paul Menzel and M. Colette Chandler-Cramer argued for what they described as a moderate correction to the dominant view that food and water should always be offered to a patient with dementia if the patient expresses a desire to eat and drink. The problem is taken up again by the legal scholar Norman L. Cantor in this issue (July-August 2018), and Cantor, too, tries to find a moderate alternative.

Kaebnick GE. Advance Directives and Dementia. Hastings Cent Rep. 2018 Aug 16;48(4):2.

Crisis of Conscience: Reconciling Religious Health Care Providers’ Beliefs and Patients’ Rights

Katherine A White

Abstract
In this note, Katherine A. White explores the conflict between religious health care providers who provide care in accordance with their religious beliefs and the patients who want access to medical care that these religious providers find objectionable. Specifically, she examines Roman Catholic health care institutions and HMOs that follow the Ethical and Religious Directives for Catholic Health Care Services and considers other religious providers with similar beliefs. In accordance with the Directives, these institutions maintain policies that restrict access to “sensitive” services like abortion, family planning , HIV counseling, infertility treatment, and termination of life-support. White explains how most state laws protecting providers’ right to refuse treatments in conflict with religious principles do not cover this wide range of services. Furthermore, many state and federal laws and some court decisions guarantee patients the right to receive this care. The constitutional complication inherent in this provider-patient conflict emerges in White’s analysis of the interaction of the Free Exercise and Establishment Clauses of the First Amendment and patients’ right to privacy. White concludes her note by exploring the success of both provider-initiated and legislatively mandated compromise strategies. She first describes the strategies adopted by four different religious HMOs which vary in how they increase or restrict access to sensitive services. She then turns her focus to state and federal “bypass” legislation, ultimately concluding that increased state supervision might help these laws become more viable solutions to provider-patient conflicts.

White KA. Crisis of Conscience: Reconciling Religious Health Care Providers’ Beliefs and Patients’ Rights. Stanford Law Rev. 1999 Jul;51(6)1703-1749.

Toleration of moral diversity and the conscientious refusal by physicians to withdraw life-sustaining treatment

S Wear,S Lagaipa,G Louge

Abstract
The removal of life-sustaining treatment often brings physicians into conflict with patients. Because of their moral beliefs physicians often respond slowly to the request of patients or their families. People in bioethics have been quick to recommend that in cases of conflict the physician should simply sign off the case and “step aside”. This is not easily done psychologically or morally. Such a resolution also masks a number of more subtle, quite trouble some problems that conflict with the commitment to toleration and moral diversity that it is intended to support. These conflicts are detailed and evaluated.

Wear S, Lagaipa S, Louge G. Toleration of moral diversity and the conscientious refusal by physicians to withdraw life-sustaining treatment. J Med Phil. 1994 Apr;19(2):147-159.

Moral and Religious Objections by Hospitals to Withholding and Withdrawing Life-Sustaining Treatment

Anna Maria Cugliari, Tracy E Miller

Abstract
A patient’s right to decide about life-sustaining treatment may conflict with the policies of health care facilities that refuse on the basis or religious or moral convictions to honor certain decisions to forgo treatment. The New York State Task Force on Life and the Law examined the prevalence and nature of facility conscience objections to the refusal of life-sustaining treatment by conducting a survey of New York hospitals. Written questionnaires were distributed to hospitals in New York State. Fifty-eight percent of the New York State hospitals responded. Twenty-nine percent of the respondents indicated that their hospital would object on grounds of conscience either to withholding or to withdrawing life-sustaining treatment in at least one of the twelve hypothetical cases presented. Hospitals were more likely to have “no policy” for withdrawing than for withholding treatment. Only 10% of the hospitals that would object to decisions to forgo treatment on religious or moral grounds had stated the objections in writing. The patient’s medical condition and the type of life-sustaining treatment to be withdrawn or withheld are important factors in determining whether a hospital will object on grounds of conscience. The imminence of death appeared more decisive than the degree of debilitation or disability as a factor in the willingness to accept decisions to forgo life-sustaining treatment. Hospitals should establish clear, written policies about their objections to forgoing treatment so that patients and their families can evaluate whether the facility meets their needs.

Cugliari AM, Miller TE. Moral and Religious Objections by Hospitals to Withholding and Withdrawing Life-Sustaining Treatment. J. Community Health. 1994 Apr 01;19(2):87-100.

A Clash at the Bedside: Patient Autonomy v. A Physician’s Professional Conscience

Judith F Daar

Extract
Conclusion
The plight of Helga Wanglie . . . focused attention on the issue of physician autonomy in the context of patient decision making. That case challenged the court, as well as our society, to consider whether a physician has an obligation to provide medical treatment he or she believes is inappropriate. . .The concept of a physician’s professional conscience will become increasingly relevant as the cost of health care rises to the point where our demands for care greatly outweigh our ability to pay for such care . . . to downplay the role a physician’s professional conscience plays in medical decision making, as both courts and policy makers traditionally have done, does not advance patient autonomy; instead, it causes doctors to be more conservative and withholding in the range of options they offer their patients. If patient autonomy is to have meaning, recognition must also be given to a physician’s moral autonomy. This Article suggests that when patients clash with their physicians over treatment choices, the principle of patient autonomy does not automatically require that the physician be forced to comply.

Daar JF. A Clash at the Bedside: Patient Autonomy v. A Physician’s Professional Conscience. Hastings Law J. 1993 Aug;44(6):1241-1289.

Conscience and Clinical Care

Leah L Curtin

Extract
If the state itself does not presume to order the consciences of its citizens, how can employers, physicians or hierarchical superiors assume such authority? For those in positions of power, it is all too easy to stifle the criticisms and consciences of subordinates by a summons to authority – or by an accusation of insubordination. The irony of it is that whether you succeed or fail in your attempts to force obedience through such tactics, you will have lost your most valuable asset – a man or woman of integrity. Within the ethical, professional and legal restraints to which all of us are subject, we can and must create a system that allows for respectful dissent and conscientious objection.

Curtin LL. Conscience and Clinical Care. Nurs Manag. 1993 Aug;24(8):26-28.

Euthanasia and related taboos

Eike-Henner Kluge

Extract
Like it or not, physicians are going to be reading a lot about euthanasia in the next few years. . . . Many physicians are more or less comfortable with the idea of withholding or withdrawing “medically useless” treatment. In other words, they accept passive euthanasia. . . . .If the medical profession thinks a physician might become responsible for a patient’s death through inaction, but without automatically bearing moral guilt, why does it insist that a physician who becomes responsible for the death of a patient through action automatically becomes morally guilty? . . . Medical ethics should never be decided by consensus or because of what is politically expedient. . .I am not making a plea for active euthanasia. I am suggesting that Canadian physicians should look at this issue honestly and openly.

Kluge E-H. Euthanasia and related taboos. Can Med Assoc J. 1991 Feb 01;144(3):359-360.