Ethics of
Life-Sustaining Treatments
An Introduction to Health Care Ethics, Panicola et. al. (2007)
Practical Decision Making in Health Care Ethics, Devettere (2010)
Life-Sustaining Treatment
•
Medical treatment that prolongs biological life but does not reverse
underlying medical condition
•
Forms to consider for class
1. Ventilator – Maintains air flow to patient not able to breathe
normally on own [Quinlan, Howe]
2. ANH - Methods of delivering nutrition/hydration to patients who
cannot provide for self due to medical condition [Cruzan, Schiavo]
Forms of ANH
1. Nasogastric (NG) Tubes
• Inserted through nostril, pass through nasopharnx and esophagus,
end at stomach or duodenum (1st portion of small intestine)
• Short-term care
2. Percutaneous Endoscopic Gastronomy (PEG) tubes
• Inserted directly into stomach or jejunum (2nd portion of small intestine)
• Insertion is a medical procedure, requires sedation
• Long-term care
3. Total Parentaral Nutrition (TPN)
• Nutrition & hydration provided directly to central vein
• Indicated when gastrointestinal system cannot tolerate NG or PEG
tubes
Medical Complications with ANH
1. Pain & bleeding associated with insertion (PEG)
2. Possible perforation of organs (PEG)
3. Ulcers in the nostril or nasopharnx, sinus blockage and
infection (NG)
4. Aspiration pneumonia
5. Infection, especially with long-term use
6. Patients pull out tubes, need to reinsert … restraint may be
necessary
7. Becomes extraordinary means of care …
Medical Complications with ANH
7. Extraordinary means of care
Dehydration
• “natural anesthesia,” masks discomfort/pain
• ANH prevents dehydration, may cause greater suffering
When body can’t assimilate nutrition/hydration …
• bloating => pressure on organs => discomfort/pain
• ANH may cause undue discomfort
ANH not medically indicated when …
a. gastrointestinal tract obstruction
b. body no longer absorbs/assimilates/metabolizes nutrients
Non-Medical Issues with ANH
1. Denies patient
• Joy of tasting food
• Sense of community or social contact associated with
shared meals
2. $$$
• Less time than manual feedings, more cost effective
• Higher reimbursement for PEG tube feedings
Challenges with Withdrawing Life-Sustaining Care
1. In a particular situation, can the burdens associated with a lifesustaining treatment outweigh the benefit of maintaining life?
2. Is the withholding or the withdrawal of a life-sustaining
treatment ethical?
• Ventilator - death by asphyxiation
• ANH - death through dehydration or starvation …
• Question: Is withholding/withdrawing a ventilator or ANH
euthanasia by omission?
Perspectives on Withholding or Withdrawing
Life-Sustaining Treatments
AMA Code of Medical Ethics, E-2.20
“Withholding or Withdrawing Life-Sustaining Medical Treatment”
The social commitment of the physician is to (1) sustain life and (2) relieve
suffering. Where the performance of one duty conflicts with the other, the
preferences of the patient should prevail. The principle of patient autonomy
requires that physicians respect the decision to forego life-sustaining treatment
of a patient who possesses decision-making capacity …
If the patient receiving life-sustaining treatment is incompetent, a surrogate
decision maker should be identified. … Physicians should provide all relevant
medical information and explain to surrogate decision makers that decisions
regarding withholding or withdrawing life-sustaining treatment should be
based on substituted judgment (what the patient would have decided) when there is
evidence of the patient’s preferences and values … If there is not adequate
evidence of the incompetent patient’s preferences and values [Quinlan, Cruzan],
the decision should be based on the best interests of the patient (what outcome
would most likely promote the patient’s well-being).
AMA Code of Medical Ethics, E-2.20
“Withholding or Withdrawing Life-Sustaining Medical Treatment”
Though the surrogate’s decision for the incompetent patient should almost
always be accepted by the physician, there are four situations that may require
either institutional or judicial review and/or intervention in the decisionmaking process:
1. there is no available family member willing to be the patient’s surrogate
decision maker
2. there is a dispute among family members and there is no decision maker
designated in an advance directive
3. a health care provider believes that the family’s decision is clearly not
what the patient would have decided if competent
4. a health care provider believes that the decision is not a decision that
could reasonably be judged to be in the patient’s best interests [Barbara
Howe]
AMA Code of Medical Ethics, E-2.20
“Withholding or Withdrawing Life-Sustaining Medical Treatment”
When a permanently unconscious patient was never competent or had not left
any evidence of previous preferences or values, since there is no objective way
to ascertain the best interests of the patient, the surrogate’s decision should not
be challenged as long as the decision is based on the decision maker’s true
concern for what would be best for the patient [Michael Schiavo and the
Schindlers]
Contrast the AMA’s perspective on withdrawing life-sustaining
care with that of the Catholic Church – especially with regard to the
Terry Schiavo case …
Catholic Health Care Ethics
A. Pope John Paul II, “Address to the Participants in the International
Congress of ‘Life-Sustaining Treatments and Vegetative State: Scientific
Advances and Ethical Dilemmas’” (March 2004) … (in Course Readings, 135-136)
B. CDF, “Responses to Certain Questions … Concerning Artificial Nutrition
and Hydration” (on Blackboard)
C. Ethical and Religious Directives – 2009 revision
• Directive #58 and #59 (on Blackboard)
D. See also the contributions of the National Catholic Bioethics Center at
http://www.ncbcenter.org/ANHPreachingPoints.pdf