Disputes over withdrawal of life support
In ‘Withholding and withdrawing life-prolonging medical treatment: Guidance for decision making’, 2007, the British Medical Association published guidance to doctors on when they should withdraw or withhold medical treatment.
The main points of this guidance are as follows:
Primary goal of medical treatment
The main aim of medical treatment is to benefit the patient by restoring or maintaining health as far as possible, maximising benefit and minimising harm [Section 1.1].
Withdrawing and withholding treatment
If treatment fails, or ceases, to give a benefit to the patient (or if the patient competently refuses treatment), the primary goal of medical treatment cannot be realised, removing the justification. In the absence of some other justification, treatment that does not benefit the patient may, ethically and legally, be withheld or withdrawn and the goal of medicine should change to the abatement of symptoms [Section 1.1].
In practice, the decision to withhold or withdraw treatment is very difficult. One illustration of this is the 1993 House of Lords decision in the case of Tony Bland. Mr Bland was in a persistent vegetative state with no awareness of the world and no hope of recovery. He was not terminally ill but withdrawal of artificial nutrition would result in his death. Following judgments made in other jurisdictions and confirming that artificial nutrition constitutes a medical treatment, the House of Lords agreed that it could be withdrawn.
Prolonging a patient's life usually, but not always, provides a health benefit to that patient. The BMA has stated that it is not an appropriate goal of medicine to prolong life at all costs, with no regard to its quality or the burdens of treatment [Section 1.2]. There are no legal, or necessary morally relevant, differences between withholding and withdrawing treatment [Section 6.1]. However, treatment should never be withheld, when there is a possibility that it will benefit the patient, simply because withholding is considered to be easier than withdrawing treatment [Section 6.2].
Voluntary refusal of treatment
A voluntary refusal of life-prolonging treatment by a competent adult must be respected [Section 9.1]. Where a patient has lost the capacity to make a decision but has a valid advance directive refusing life-prolonging treatment, this must be respected [Section 10.1]. A valid advance refusal of treatment has the same legal authority as a contemporaneous refusal and legal action could be taken against a doctor who provides treatment in the face of a valid refusal [Section 10.3].
Consent
In England, Wales and Northern Ireland no other individual has the power to give or withhold consent for the treatment of an adult who lacks decision-making capacity but treatment may be provided, without consent, if it is considered by the clinician in charge of the patient's care to be necessary and in the best interests of the patient [Section 13.3].
Those with parental responsibility for a baby or young child are legally and morally entitled to give or withhold consent to treatment. Their decisions will usually be determinative unless they conflict seriously with the interpretation of those providing care about the child's best interests [Section 15.1].
Treatment in a young person's best interests may proceed where there is consent from somebody authorised to give it; the competent young person him or herself, somebody with parental responsibility or a Court. However, a young person's refusal may not, in law, necessarily take precedence over the consent of either parents or a Court [Section 16.2].
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