On the morality of withdrawing treatment from patients

Ethical considerations:

• The aim pursued, which must be good. When we speak of withdrawal of treatment, the aim is usually to avoid excessive expense , an annoying or distressing treatment for the patient, etc.

• The effects that are tolerated. This refers to the disadvantages that follow from not treating the patient. This may be aggravation or death, shortening of life expectancy, etc.

For a withdrawal of treatment to be ethically correct, there must be proportion between what is intended and what is tolerated. That is, the ends must be good, and the tolerated effects, if any, proportionate to what is intended. We assume that there is good foresight, good means are employed, and so on.

Examples:

• Withdrawal of ICU treatment from a patient who has no prospect of recovery. What is being attempted is good (avoiding a useless expense, since the treatment is known to be ineffective). What is tolerated is the death of the patient (which, moreover, is at the doorstep). If the patient is unconscious and will not regain lucidity, it is clearly proportionate, and the action is good.

• Withdrawal of nutrition and hydration from a terminally ill patient who is not in the ICU. If you are trying to make the patient die already, the action is wrong. If you are only trying to avoid needling him to hydrate him with an IV and he is in very poor condition, it may be proportionate (depending on the patient's life expectancy).

It should be noted that the most widespread terminology ("let the patient die") is extremely confusing, as the physician's intention may be different: he may not intend as goal of what causes the patient to die. If that were the physician's intention, his action would be wrong.

But if the patient's death is not intentional, the withdrawal of an expensive and useless treatment is not euthanasia (which consists of intentionally causing the patient's death). It is a concern to contain the medical expense within fair limits. If this useless treatment were to be continued for a few days, the tolerated effect would be that other patients who could use the wasted resources could not be treated.

Undoubtedly, it is possible to act differently if other factors have an influence. Thus, the intention that a family that has not been made position of the status does not think that we are killing their loved one can justify maintaining this treatment, useless for the patient, but momentarily useful so that they do not think badly of Medicine, until we convince them that there is nothing to be done.

Antonio Pardo.