Editorials
Withholding and Withdrawing Life-sustaining Therapy
Ethical Considerations
The American Thoracic Society is to be
commended for producing so detailed a
policy statement on the difficult and
agonizing decisions associated with non-
treatment and cessation of treatment de-
cisions. One is struck by the explanatory
text even more than by the specific prin-
ciples and directives. Its thoroughness is
solid evidence that the issues have been
grappled with rather than glossed over,
and its argumentation clearly locates
those directives in the mainstreams of
contemporary American legal and bio-
ethical reasoning.
All the same, there are several points
in the Statement that seem to be not ful-
lyexplored. The following comments are
offered in the spirit of furthering the dis-
cussion of these difficult matters, not as
criticisms.
Perhaps the most troublesome passage
in the Statement occurs in Section I.
Physicians and other health care
providers have a responsibility to re-
spect patient autonomy by withhold-
ing or withdrawing any life-sustaining
therapy as requested by an informed
and capable patient. In this regard,
there is no ethical difference between
withholding and withdrawing. Help-
ing a patient forgo life support under
these circumstances is regarded as dis-
tinct from participating in assisted sui-
cide or active euthanasia, neither of
which is supported by this statement.
However, if carrying out such a re-
quest would violate the personal moral
code of a physician or other health
care provider, that individual gener-
ally has the right not to participate in
the process. If this occurs, others
should be made available to carry out
the patient's request. (1)
I should liketo comment on fiveelements
of this paragraph as containing notions
that physicians may be expected to find
ethically troubling.
First, I note that the responsibility to
withhold or withdraw life-sustaining
therapy on the request of an informed
AM REV RESPIR DIS 1992; 145:249-250
_
and capable patient may not be one that to assert, "In this regard, there is no ethi-
rests easily with physicians.(Howard Bro- cal difference between withholding and
dy's remarkable dialogue between a tradi- withdrawing." Physicians and nurses have
tionalist physician and a medical student long found the distinction between with-
[2] comes to mind here.) The notion that holding and withdrawing a powerful one,
an informed and capable patient would and it is a distinction that has long been
even contemplate declining life-sustain- recognized in the law.Extra effort, then,
ing therapy may strain credulity, partic- is needed to unpack the significant quali-
ularly in the instance when the therapy fier, "In this regard . . . ."
is not medically futile and the patient has We must be clear that all other factors
a good chance of recovery with it. Medi- in cases of supposedly ethically identi-
cine's traditional conception of its prac- cal withholding and withdrawing are par-
titioners' responsibilities includes pres- allel: the patient's wishes regarding the
ervation of life and promotion of heal- therapy must be the same; the provider's
ing, with the caution of not harming the motives must be the same; the outcomes
patient through those pursuits. The view must be the same. The implication of the
that "primum, non offendere" trumps ATS Statement is that a decision or ac-
"primum, non nocere" still strikes many tion to withhold and a decision or ac-
physicians as a dismaying development. tion to withdraw life-sustaining medical
The ATS Policy Statement identifies treatment thus are morally impermissi-
the new responsibility as rooted in a duty ble when either results in the informed
to respect patient autonomy. An alter- and capable patient's death when that re-
native and more palatable grounding sult is not accepted by the patient. Still,
might seek to connect a duty to withdraw we might assign differing degrees of cul-
life-sustaining therapy with a subjective pability, holding that withholding in such
notion of harm. A conception of the pa- . a situation is a form of negligence but
tient as identifier of harms, burdens of that withdrawing is a form of homicide.
treatment that become sufficiently oner- Too, situations may differ in respect of
ous that the patient is no longer willing the certainty of outcomes. The Karen
to shoulder them for the benefits they Ann Quinlan case involved a patient
bring, would be more congruent with the whom most believed would die if re-
traditional medical ethics. Whereas pa- moved from a respirator. Perhaps at one
tient autonomy can seem to have as its time in her history this was so. But, suf-
corollary physician subservience (a view ficient neurologic function was recovered
that Robert Veatch has dubbed "the en- so that, after the painful battles had been
gineering model" of patient/physician re- fought in the courts successfully by her
lations [3]), the patient-as-harm-monitor parents, withdrawing the ''life-sustaining''
locates both patient and physician with- treatment only showed that it wasn't at
in the traditional values of medicine and that time life-sustaining after all.
recognizes a proper role for the patient Third, one is struck by the absence in
in countering the increased potential for the ATS Statement of a requirement
harm that accompanies the power of paralleling that of the American Medi-
modern medical technology. Such a ra- cal Association's 1973 statement:
tionale, however, would only partly cap- The cessation of the employment of
ture the scope 0 f the ATSinjunction, for extraordinary means to prolong the
presumably a patient who has not expe- life of the body when there isirrefuta-
rienced a life-sustaining therapy will be ble evidence that biological death is
in no position to judge its burden and imminent is the decision 0 f the patient
thus to opt not to undergo that therapy. and/or his immediate family (4). (Ital-
Second; the ATS Statement proceeds ics denote my emphasis.)
249
250 EDITORIAL

The ATSStatement does not limit the oc- life support. Moreover, there is no deter- should move now to the role of assisting
casions that physicians may omit or cease mination to be made ofthe patient's mo- their dying patients to commit suicide.
life-sustaining therapy at patients' or tives. Although the Statement does not Clearly the book has struck a responsive
families' behests to those when such treat- endorse the use by the patient of the op- chord in the public. The success in avoid-
ment is medically futile, or when biolog- tion to forgo life-sustaining treatment in ing prosecution by doctors who have as-
ic death is clearly imminent. Such a de- order to commit suicide, it endorses no sisted their patients' suicides and dis-
cision is thus one step removed from med- effective guard against it. Furthermore, cussed those actions publicly (such as
ical judgment, and this gap again inasmuch as it enjoins physicians to "help Jack Kevorkian and Timothy Dutton)
implicitly asserts the primacy of patient's a patient forgo life-support" by provid- will continue to add to the expectation
wishes over physician's judgment. A pa- ing drugs in quantities sufficient to re- of the public that physician's proper role
tient or patient's family who are informed lieve suffering, even if they hasten death, sometimes involveshastening death. The
and capable may, nonetheless, seek to the Statement has no safeguard against ATSStatement, wittingly or not, has been
block treatment in circumstances when a patient's use of the physician to assist influenced by the social forces that are
there is significant chance of improve- in what, from the point of view of the redefining the traditional values of medi-
ment. Under the ATS Statement, physi- patient's intent, is suicide. cine and the relationship of physicians
cians confronted with such wishes may Finally, the suggestion of an implicit to their patients.
only opt out, and then only if a more will- engineering model of patient and physi-
ing replacement can be found. I shall re- cian relations recurs in the Statement for RICHARD T. HULL, Ph.D.
turn to this point again below. the physician who finds that carrying out Departments of Philosophy
The absence of a requirement of med- the request of a patient to forgo life sup- and Medicine
ical futility or imminent death also port violates a personal moral code. For, State University of New York
renders troublesome a fourth element in "if this occurs, others should be made at Buffalo
the ATS Statement. "Helping a patient available to carry out the patient's re- Buffalo. NY
forgo life-support under these circum- quest." The physician, it would seem, is References
stances is regarded as distinct from par- to be either the direct or indirect instru-
ticipating in assisted suicide or active eu- ment of the patient's will, obligated to 1. American Thoracic Society policy statement on
withholding and withdrawing life sustaining ther-
thanasia, neither of which is supported participate in the process of assisting the apy. Am Rev Resp Dis 1991; 144:726-31.
by this statement" (1).The circumstances patient to forgo life-sustaining treatment 2. Brody H. The chief of medicine. Hastings Cen-
are only "the request of an informed and or to find others who will do so. ter Report 1991; 21:17-22.
capable patient." There is no additional As I write this essay, the top book on 3. Veatch RM. Models for ethical medicine in a
revolutionary age. Hastings Center Report 1972;
requirement of medical futility, imminent the New York Times list of best-selling 2:5-8.
death, or evidence of excessive burden nonfiction is Derek Humphrey's Final 4. House of Delegates,American Medical Associ-
other than the patient's wishes to forgo Exit. It advocates the viewthat physicians ation. Statement adopted December 4, 1973.