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This case study examines the legal issues surrounding consent, including determining when consent is valid, the doctrine of necessity, doing what is in the best interest of the patient and withdrawing and withholding treatment. The implications of The Human Rights Act on withdrawing or withholding treatment are discussed.
Questions surrounding withholding treatment from severely impaired newborns have elicited three significantly different substantive and procedural responses: from the Reagan administration's Department of Health and Human Services through the Carter President's Commission on Ethical Problems, and subsequent congressional legislation on child abuse. Movement from a rigid and simplistic application of medical imperatives to ambiguous and abstract criteria of the child's "best interest" represented limited progress. A new legislative compromise principle is an imperfect but practical accommodation to moral and medical realities.
We have reviewed carefully the position paper and wish to provide the Association with our opinion with respect to the legal implications involved. This is one paper which clearly supports the "right to life" of newly born retarded or mentally defective infants. In our opinion, this position is entirely within the law. However, the paper does raise a number of significant legal questions which we believe warrant consideration. It is our respectful opinion that a physician, when faced with a situation of parental choice to withhold treatment, should seek the guidance of the Court and only withhold treatment or administer treatment with the back-up of a Court order.
To identify treatment-withholding intentions for 56 VA medicine inpatients who received a no-code order, 31 resident physicians who wrote the orders completed a checklist on which they indicated the interventions they intended to withhold from each patient. Review of patients' charts indicated that 24 (43%) contained no documentation of treatment limitation plans beyond the no-code order. To identify the general interpretations of no-code orders, "cross-covering" physicians indicated on a questionnaire the likelihood that they would withhold specific interventions from patients they were covering who had received a no-code order. Both the intention and interpretation of no-code orders were characterized by variability, and interpretation of the orders was characterized by uncertainty as well. Because of these discrepancies, we suggest a no-code order which provides greater specificity for individual patients.
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We have shown why it is that withholding medical treatment is not properly considered to be an assisted suicide. We have said nothing about the desirability or need for new legislation to support assisting a patient in a suicide. We have been concerned only to show that any plausible arguments for assisted suicide must stand on their merits and the attempt to justify a practice of assisted suicide by linking it to the withdrawing of medical treatment through an analysis of causation fails. In this closing section we place our discussion in a broader setting and draw out some of the implications of the distinctions we have made. One central point we wish to emphasize is the role of context in discussions of withholding treatment and assisting a suicide. We have noted the difference between the "normative" and "scientific" sense of "cause". The normative sense is used when holding a person responsible, either legally or morally, for what he or she has actually or scientifically caused (the cause-in-fact). When we hold a person responsible for the consequences of his or her actions, we do so in a way that is sensitive to the context of that action. There is no set formula for determining how broad a context must be considered, whether it be a year and a day, or some shorter or longer interval. The determination of context will involve judgments of relevance and reasonableness and will depend on any special relationships that may hold between the parties involved. Finally, we emphasize how essential context is to a determination of causation. If one fails to consider both the scientific and normative dimensions of causation and relies only on the scientific dimension, one ends up with the counter-intuitive judgments that, in the Olson case, the neurosurgeon who withdrew life support for Erickson is the cause of death, and similarly for the example given by Schaffner and the Nancy B. case discussed by Fish and Singer. Our advice is, "Don't go there".
Withholding or withdrawing life-sustaining treatment when death is not imminent goes beyond the issue of whether or not medical interventions are simply prolonging dying. It treads on the slippery slope of quality of life judgments. Courts, in keeping with a tradition of self-determination, continue to protect a patient's right to decide whether his or her life has quality enough to prolong it. Patients may refuse treatment despite predictably dire consequences of refusal, including death. This choice is not evidence per se of incompetence, despite any conflict with medical values. Judicious use of technology is urged when there is conflict between the worthy principles of prolongation of life and relief of suffering. The patient is the best judge of his or her life's quality.
Whether to withhold life-prolonging treatment from a severely handicapped newborn baby is a topical moral dilemma. Some recent prominent court cases in the UK highlight the ethical issues that have to be faced when considering such a decision.
PURPOSE: Patients who have nonmassive acute pulmonary embolism and a high risk of bleeding or contraindication to anticoagulants, such recent surgery or gastrointestinal bleeding, present a clinical dilemma. We sought to estimate whether such patients could be safely left untreated if serial compression ultrasound or serial impedance plethysmography were negative and cardiorespiratory reserve was adequate. SUBJECTS AND METHODS: The frequency of recurrent pulmonary embolism among patients with nonmassive acute pulmonary embolism and negative serial noninvasive leg tests who were not treated was estimated from two prospective studies of the noninvasive management of patients with suspected pulmonary embolism. One of the studies used serial impedance plethysmography of the lower extremities; the other used serial compression ultrasound. The prevalence of pulmonary embolism in patients with nondiagnostic ventilation/perfusion lung scans was determined from the Prospective Investigation of Pulmonary Embolism Diagnosis (PIOPED). RESULTS: The estimated frequency of fatal recurrent pulmonary embolism was 1% [95% confidence interval (CI), 0% to 5%) among untreated patients with nonmassive pulmonary embolism who had negative serial impedance plethysmograms and 0% (95% CI, 0% to 4%) among those with negative serial compression ultrasonograms. The frequency of nonfatal recurrent pulmonary embolism among untreated patients was 3%, regardless of whether they had negative serial impedance plethysmograms or negative serial compression ultrasonograms. These results were comparable with the frequency of recurrent pulmonary embolism among patients treated with anticoagulants or with inferior vena cava filters. CONCLUSION: Withholding treatment of nonmassive acute pulmonary embolism, if serial impedance plethysmograms or serial venous ultrasonograms are negative and cardiopulmonary reserve is adequate, is a possible strategy for the management of patients with a high risk of bleeding or other contraindication to anticoagulants. This strategy may be associated with fewer adverse events than treatment with anticoagulants or an inferior vena cava filter. Prospective trials comparing alternative treatments are needed.
BACKGROUND AND OBJECTIVE: Medical law and ethics require that intervention be based on patients' wishes. However, in particular the presumed wish of the patient, is often difficult to establish. Discussions with patients may want to inform or influence the patient's wishes. We investigated how far clinical decisions recognize the patient's wishes and how the presumed wishes of the patient is established and respected. PATIENTS AND METHODS: 503 physicians (25.6 % women; mean age 36.3) in 49 departments of the universities Bochum and Magdeburg filled in a validated questionnaire. RESULTS: 86,2 % of the physicians questioned ranked the patient's wish as important or very important. However, 54,4 % tried to modify it. Advanced directives play the most important role when the patient is unable to communicate. Danger to life and suicide are reasons for clinical decisions against the patient's wishes. But it is the main reason to end a causal therapy in terminally ill patients, especially in experienced physicians' opinion. CONCLUSIONS: Patients will plays a prominent role in treatment decisions; Even more so, physicians follow patients' wishes when withholding or withdrawing treatment. Our study could not find out how widely information of the patient plays a role in altering the patient's wishes in a paternalistic manner. Given a relative unfamiliarity with advance directives, affirmative attitudes towards their recognition are remarkable. As far as palliative and comfort care for terminal patients is concerned, contrary to widely voiced concern, clinicians do not have priorities different from those used in hospice care.
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