On the moral obligation to provide treatment

Ethical considerations:

• The end to be pursued, which must be good. To this end refers the usefulness of the treatment, which is to be considered in a broad sense: it may be for something other than cure.

• The effects that are tolerated. These may include inconvenience to the patient, financial problems (and the attention to other patients that is lost in caring for the patient), etc.

• For the action to be good, the one who acts must want good things overall; this requires that the tolerated effects be proportionate to what is intended.

The following rules are derived from this:

• There is a moral obligation to provide useful and proportionate treatment.

• It is a choice between a useful and disproportionate treatment or a useless and proportionate treatment.

• Inappropriate and disproportionate treatment should not be instituted.

We assume that there is good foresight, good means are used, etc.

Application to some common cases:

• Useful and proportionate treatment: Acutely ill, in coma. The goal is good (to bring him out) and achievable (it is a useful treatment) and the costs, although large, are proportionate. There is an obligation to treat if these means are available.

• Other useful and proportionate treatment: Sick person who has expressed a willingness to donate organs, in a state of "brain death", who is kept alive in the ICU with the aim of using his organs for transplantation. The goal is good and achievable (it is a useful treatment), and the tolerated effect (the costs) are proportionate to what is intended. Ethically correct.

• Useful and disproportionate treatment: Sick in persistent vegetative state, needing ventilator. The goal is good (life prolonging) and achievable (useful), but too expensive to maintain. It is right both to keep it and to switch it off.

• Other useful and proportionate treatment: Sick in a persistent vegetative state, not requiring a respirator. The goal to prolong his life is good and achievable (it is a useful treatment), and the costs of maintaining him are small and always proportionate. There is an obligation to continue caring for him/her. The question arises of not leaving the family alone with the problem: the social support that is so lacking in today's society.

• Useless and proportionate treatment: Giving complacency medication that is not even clear that it produces a placebo effect (it is useless, a whim), that is cheap medication (it is proportionate). It is acceptable both to give it and not to give it.

• Useless and disproportionate treatment: A patient in a state of "brain death", who is kept alive in the ICU, without being a donor. It will not be possible to achieve goal for this patient to live a little longer, as it is known that they die in a few days (it is useless treatment), and the cost of the means is disproportionate, and could be used for other patients who need it more. This is the ethically incorrect therapeutic incarceration.

Comment: the ethical correctness of these cases varies with the opinion of the patient (who says if it is too uncomfortable, e.g.), and with the technical means available in the health care in that place (which may make a large expense disproportionate).

Antonio Pardo