Question

1. What is the moral difference (if one exists) between withholding treatment and withdrawing treatment according to Panicola? Between killing a patient (euthanasia) and allowing a patient to die by forgoing treatment that is excessively burdensome? Explain.

2. Distinguish between ordinary means (proportionate) and extraordinary (disproportionate) means of medical treatment. Which are morally obligatory? Why? What does Pope John Paul II's encyclical, Evangelium Vitae say about this?

3. Is artificial nutrition and hydration a proportionate or disproportionate means of medical care? Explain, referencing the statements of Pope John Paul II, the US Catholic Bishops, and the ERD's. 4. What is Euthanasia? What are the moral arguments against Euthanasia? Explain using the ERD's and material from the text. 5. What are some of the major themes that come up in the chapter on Rethinking End of Life Care. What areas of end of life care need to be "rethought"? What major ideas stood out for you?

Answer 1

1) Difference between Withdrawing and Withholding of treatment

WITHDRAWING

The removal of a therapy that has been started in an attempt to sustain life but is not, or is no longer, effective.

Withdrawal usually concerns therapies such as mechanical ventilation and administration of vasoactive agents

WITHHOLDING

The decision not to make further therapeutic interventions.

The most frequent example of this is the do not resuscitate (DNR) order.

Withholding resuscitation efforts will almost inevitably result in death from a cardiac arrest should one occur. It is important to make this decision in advance because once the cardiac arrest occurs there is no time to think .

End-of-life decisions are often associated with the perspective of the respiratory specialist. On one side, the physician may be confronted directly with these decisions regarding their own patients with an end-stage respiratory failure caused by a chronic conditions such as chronic obstructive pulmonary disease (COPD). On the other hand, several degenerative pathologies – such as degenerative neuromuscular conditions – require at some point the resort to the respiratory unit, oftentimes while the patient is still fully competent.

The distinction between “withholding” and “withdrawing” a life-sustaining medical treatment does, in fact, represent one of the most controversial issues in the end-of-life .

The categories of withholding and withdrawing a treatment deal with the ones of active and passive euthanasia. Indeed, most bioethicists appear willing to define withdrawing a treatment as a form of “active” euthanasia (to perform an act that by itself causes the death of the patient), and withholding a treatment as a form of “passive” euthanasia (not to administer a lifesaving medical treatment, as a consequence of which the patient dies).

Most countries stick to the traditional interdiction of voluntary active euthanasia. This makes it very much likely that controversy will continue to centre on the practice of withholding and withdrawing medical treatment, with particular reference to life-sustaining treatments.To withhold or withdraw some forms of treatment, in fact, is the simplest way to defend patients from possibly unwanted negative consequences of life-prolonging medical technology, especially when the patient’s quality of life lowers dramatically.

when a patient withdraws a treatment that might prolong her life for some time, she accepts that her life will be shorter than it might have been; but to define the ‘patient’s good’ is in fact to strike a balance between different competing considerations, including those concerning the quantity and quality of the remaining life. It is perfectly acceptable to give up some time of one’s life in order to ‘acquire’ some more ‘quality time’ allowing one to prepare herself to die in a peaceful way. It is also evident that the principle governing this kind of medical decision is utterly different from the one sanctioning voluntary active euthanasia (VAE): the rationale for accepting VAE is a moral principle according to which the patient has a right, based on autonomy, to decide when to terminate her life and the capacity to confer to her physician the right to kill her; the rationale for accepting the withholding and withdrawing of medical treatment, on the other hand, is a moral principle according to which the patient has a right to decide the therapies she is willing to accept and those she does not want.

The Government should grant patients a consistent opportunity to withhold and withdraw all kinds of medical treatments is in fact to confer them a substantial warrant against the unwanted consequences of medical development and may weaken the drive towards the much more problematic option of changing existing regulations concerning the direct killing of patients.

2) One must start by defining which treatment is ordinary and which is extraordinary (proportional and disproportional are alternative terms).Ordinary is often used to describe those means of prolonging life which are available, offer a reasonable hope of benefit and do not cause unbearable pain and suffering. In contrast, the term Extraordinary is used to describe those means or measures which are not usually available, do not offer a reasonable hope of benefit and cause unbearable pain and suffering.

A treatment which is standard for a certain class of patient may be more likely to be morally „ordinary‟ than a treatment which is nonstandard. However this analogy may not always hold true. There may be reasons why the standard treatment is not morally required in the case of an individual patient. There is no obligation for a patient to take extraordinary or disproportionate measures to promote life and health if these measures will involve excessive burdens. One might think of the pain or discomfort, which can accompany some medical treatments or of the financial cost of the treatments to the patient, family, hospital or health service in general.

A treatment or life-sustaining measure can be extraordinary because it is too painful, frightening, hazardous or disruptive for the patient, or it is financially too burdensome for the patient, family, hospital or health service which must also consider other patients who would benefit more from the same resource allocation.

A treatment can be extraordinary because it is simply futile. Those who are dying of one illness have no obligation to accept treatment for a second life-threatening one, which is at a less advanced stage. Often however, a treatment will be extraordinary not because that treatment is in any way futile, but because its burdens will be disproportionate to the benefits it will bring. Borderline cases may be resolved by seeking the evaluative help of the competent patient.

Another view is that ordinary means of preserving life consists of the medical treatment that offers a reasonable hope of benefit for the patient or that can be obtained or used without excessive pain, burden, or expense. Extraordinary treatment is the medical treatment that cannot be used or obtained without excessive expense, pain or other burden or that does not offer a reasonable hope of benefit.

Two important considerations are the effectiveness and benefit of the proposed treatment. An effective treatment is that which demonstrably alters the natural history of an illness or alleviates an important symptom. A beneficial treatment is that which brings some good to the patient, not only medical benefit but also in terms of quality of life. Treatment may be effective but not beneficial by simply prolonging the life of a patient while at other times it might be both effective and beneficial. The key word here is benefit to the patient.