between parties that cannot be resolved after ’second opinions’. However, we
repeat our conviction that there should be as little legal involvement in
medical decision-making as possible.
9. Does withdrawing or withholding artificial nutrition and hydration form a
separate category of decision from any other type of treatment which might be
withheld or withdrawn?
Yes.
If so, why?
The patient will inevitably die as a consequence of withdrawing food and fluids,
though the time of death may be unpredictable. Most health professionals feel
this is wrong – in the five years since the death of Antony Bland a conservative
estimate of 1-2,000 patients have gone into PVS and died of it. Only ten or so
cases have come before the courts in that period to request permission to
withdraw food and fluids. This suggests that whatever the difficult
philosophical issues, the intuitions of about 99% of family and professional
carers are that such an action is wrong.
Does society need to agree clear and strict criteria for withdrawing or
withholding artificial nutrition and hydration?
No.
If so, what kind of criteria?
N/A
Are the criteria and safeguards discussed in this paper (e.g. a period of
monitoring before a decision is made; an independent second medical opinion)
sufficient?
No.
10. When decisions about withdrawing or withholding have to be made, what are
the main factors which health professionals currently take into account when
discussing the matter with competent patients?
Likely prognosis is the main issue, but the integrity of the health professional
in question is important – he or she can so bias the presentation of information
as to obtain the decision they would prefer the patient made.
When deciding how to proceed for patients who cannot express an opinion?
Communicating difficult and uncertain issues to the family, with the highest
integrity.
11. How should “best interests” be defined for incapacitated people? What
criteria should be taken into account?
In general, we agree with the document’s discussion at 2.9.4. We would certainly
see capacity for relationships as valuable, but the absence of such capacity
where there appears no sentience does not reduce the intrinsic worth of that
person in God’s eyes. They are always of value because they remain made in the
image of God and He has a continuing relationship with them.
12. If a patient has left no indication of who should be consulted on his or her
behalf, how widely should views be sought from people caring for an
incapacitated adult?
Although there are no legal rights involved, it would certainly be good practice
to seek the views of those directly involved in care. However, caution is needed
because of the emotional reactions of loved ones, and their other interests,
which may or may not be ulterior motives.
Should the views of blood relatives take precedence over others?
No. The social work concept of ‘Most caring other’ is probably the best guide.
13. Is conflict common between different categories of health professionals or
between health professionals and relatives?
No, but it is not that unusual in most practices and departments.
Could conflict between health professionals be avoided or is it a positive spur
to well-rounded discussion?
‘Conflict’ in the sense of adversarial discussion can be constructive and should
not be avoided at all costs.
Are there good models for resolving disputes within and between health teams,
carers and relatives?
Prevention is better than cure. Good communication is important, and the time
pressures on understaffed and overworked teams are therefore regrettable. The
dialogue between the ‘partnership of two experts’ is based on mutual respect and
open communication, with the aim being to find consensus.
14. Is there still place for separate sets of professional guidance, attempting
to reflect the particular perspective of each profession or is it desirable that
all guidelines attempt to reflect a wide multi-disciplinary approach?
No. The different health disciplines should all be partners in the same
enterprise, and guidance must reflect commonly accepted principles.
15. Should there be more research into how decisions about withdrawing or
withholding treatment are made?
Yes, but rather than subjective research on the behaviour of health
professionals who may not know why they are doing what they are doing, we would
favour objective research on outcomes to allow the best clinical evidence base
possible. These decisions are often more ‘clinical’ ones than ‘ethical’ ones.
16. Do you consider that there is broad concern about the use of the “double
effect” argument concerning treatment at the end of life?
No. We hold the principle of intention as critical in this whole area and have
stated above that we believe intentional medical killing is always wrong. Once
explained properly, our experience is that health professionals and the public
readily understand and support the concept.
Incidentally, we find the phraseology ‘double effect’ unnecessary and unhelpful,
seeming in itself to suggest ‘double standards’, ie hypocrisy. We favour the
single word ‘intention’. The doctor’s intention is the relief of pain or
suffering even though this may very occasionally shorten by hours or days a life
which it is not possible to save.
Of course, there may in practice be hypocrisy, as doctors can pretend one
intention while having another, or there may be unconscious self deception about
motives. There are also issues about the ‘knowledge gap’ – we may intend one
thing but because of limited foresight achieve another, the ‘meaning well but
doing badly’ situation.
However, despite these issues, ‘intention’ is the most helpful concept we have
in this area. It has legal standing, and there are safeguards. A safeguard to
‘How do we know what the doctor’s intention actually was?’ would be to ensure
that major decisions were taken out in the open with the widest possible
discussion of foreseeable consequences and involving the patient as fully as
possible. In addition, where the administration of treatments is concerned,
there would be pharmacological safeguards in prescription records of drug dosage
and frequency.
If so, is the concern shared by health professionals and the public?
Such concern as there is partly reflects genuine confusion, which should be
amenable to explanation and education. However, confusion is also encouraged by
the euthanasia movement as a cynical campaign strategy. It is in their interests
to try and convince professionals and patients that ‘doctors are doing
euthanasia already with these big doses of powerful painkillers and what we need
now is a law to clarify the position’.
Would health professionals welcome more debate about the implications of “double
effect”?
Some need this helpful and very clear point explained more effectively.
17. Are there additions or amendments that should be made to the list of general
points concerning withholding or withdrawing treatment mentioned in section 2.11
of the discussion paper?
We would only emphasise that parts of this generally excellent summary seem to
take too simplistic a view of the likely natural history of clinical conditions
and of their responses to therapy. Patients can surprise us by getting better
against the odds.
18. Do you know of any existing local or national guidelines which the BMA
should take into account if it moves ahead to draw up new guidance?
No.
Do you know of any innovative ways of resolving problems connected with
withdrawal or withholding of treatment?
No, other than our approach which establishes the boundaries within which
individual decisions are taken. We do not believe that more prescriptive
guidelines will ever give the best results. In these dilemmas, a decision-making
framework is of more value than a formula.
Ten key concepts in summary:
1. Intentional killing is always unnecessary and wrong.
2. Life has a natural end and there is not necessarily anyone to blame when a
patient dies.
3. Doctors tend to overtreat towards the end of life, causing demand for
euthanasia.
4. Society needs to break its current taboo about facing death.
5. Considering the Christian faith is essential for a healthy exploration of the
concept of death.
6. When accepting that cure is either not possible or not sought by the patient,
care continues.
7. The most senior clinicians should be central figures in these decisions.
8. Many of the difficult decisions are more ‘clinical’ than ‘ethical’.
9. Medicine is a biological science with uncertain outcomes but research must
improve its evidence base.
10. Principles for guidance which define ethical boundaries are more helpful
than prescriptive guidelines.
References
1. Submission from the Christian Medical Fellowship to the House of Lords Select
Committee on Medical Ethics. 1993
2. Personal view. Doctors fighting, fleeing or facing up to death. Goodall J.
British Medical Journal, 1 August 1998; 317: 355-6
3. Editorial. Where’s the chief knowledge officer? Muir Gray J A. British
Medical Journal, 26 September 1998; 317: 832
4. Guidelines in general practice: the new Tower of Babel? Hibble A, Kanka D,
Pencheon D, Pooles F. British Medical Journal, 26 September 1998; 317: 862-3
5. Withdrawing and Withholding Treatment: a consultation paper from the BMA’s
Medical Ethics Committee. 1998. p5
6. Ibid. p14
Christian Medical Fellowship
October 1998
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