Medical Opinions Regarding Withholding or Withdrawing Support
Most of the court cases cited regarding withholding or withdrawal of life support were brought by patients or their proxies against physicians and medical institutions for failing to withhold or withdraw support. Furthermore, most of the legislation cited earlier has been advanced by the legal and not the medical profession. Whatever the reasons for this situation, it is widely perceived that the medical profession has occupied a right-to-life at all costs position in defiance of growing public sentiment for patient autonomy and the right to die. Yet despite this perception, physicians have become increasingly outspoken in their desire to withhold and withdraw life support in certain circumstances through the Presidents Commission, personal writings, and position papers in medical literature. Among the most important of these statements have been “Optimum care for hopelessly ill patients,” “The physicians responsibility towards hopelessly ill patients,” and “Initiating and withdrawing life support,” all of which were published in the New England Journal of Medicine. These papers argue persuasively for withholding or withdrawing therapies ranging from mechanical ventilation to fluids and nutrition from patients with terminal illnesses and irreversible coma or the persistent vegetative state, especially if the families agree.
The last position paper, by Ruark, Raffin, and other members of the Stanford University Medical Center Committee on Ethics, was based on six basic principles of medical ethics. The first principle was the preservation of life, which frequently must be tempered by the second principle, the relief of suffering. The third principle was that physicians do no harm, the fourth was that they respect the autonomy of patients. The fifth was the concept of a just allocation of medical resources, an issue of great consequence in the ICU. The sixth and final principle was the need to tell the truth to patients and their families. so
Basing its guidelines on these principles, the Stanford authors then analyzed the initiation or withholding and the withdrawal of both basic and advanced forms of life support. They noted that basic measures such as providing food and water often are initiated reflexively by physicians “without considering whether they are performing a truly caring act.” These and more sophisticated medical interventions should always serve what patients consider to be their own best interests after consultation with their families and physicians. Families should be involved in the decision-making process whenever possible, and physicians should elicit patient choices for each possible medical situation. Also, if a medical intervention is begun, it should be withdrawn directly when it ceases to be of benefit.