Withholding and Withdrawing Life Support

I cannot but have reverence for all that is called life. I cannot but avoid compassion for all that is called life. This is the beginning and foundation of morality…It is good to maintain and cherish life; it is evil to destroy and check life

Albert Schweitzer

Possibly …no contemporary superstition is so stupid and pernicious as the indiscriminate adoration of the word life, used without any definite meaning but effectively hiding the fact that life includes the most loathsome forms of disease and degradation. sanity and wisdom consist not in the pursuit of life but in the pursuit of the good life…

Morris Cohen

Of all problems that can be considered life and death ethics, none has caused the same level of moral anguish as that of withholding and withdrawing life-support systems. The attitudes and values expressed in the quote by Dr. Schweitzer are a positive affirmation of life, and it is often sentiments such as these that bring individuals to the practice of health care.

Today, however, the practitioner is faced with the frustrating problem of available technology that allows for life extension but cannot restore the patient to a life free of pain and misery or even, in some cases, to an awareness of the environment. This frustration often leads to a new attitude toward life, one that finds expression in statements like the one above by Morris Cohen.

The practitioner’s duty to respect life and preserve it where possible may at times come into direct conflict with the duty to alleviate pain and suffering. The Hippocratic Oath binds physician and other health care providers to take upon themselves the duty to adopt practices that shall benefit the patient and protect them from hurt or wrong. what is to be done when the care we offer appears to have no value to the patient? What is to be done when the quality  of life restored has negative value, when itself appears to be an added injury.

Medical science can now save biological life so effectively that we have been forced away from using a cardiopulmonary definition of death to the certification of death by brain function. We have also as a product of our technology and therapeutics moved into  a time of being able to fend off brain death, only to expose the patient to continued misery and suffering. Health care providers have reached a quandary in which the duty to respect and preserve life comes into direct conflict with the duty to prevent and relieve pain.

We have examined several classes of patients for whom decisions of withdrawing and withholding care have been reasoned through. These decisions have gained some cultural, legal, and ethical acceptance. Reasoning for the profoundly handicapped infant, the PVS  ( Persistent Vegetative States) patient, those who chose informed non-consent, and the mentally retarded each require a different basis. In some instances, the framework of what is to be done has been postponed and the issue have become, instead, who is to decide.

Some instances of non treatment seem to have gained acceptance and are rather noncontroversial. The ninety eight year old with severe dementia and not a relative in the world who contracts pneumonia might be allowed to die quietly. The real question in regard to health provider duty do not lie in the  extremes, such as infant born with no brain inside its skull, but in the middle ground where there will be a potential for person-hood and meaningful life. In extreme cases where no potential exist, or where the best interest of the individual seem best served by withholding or withdrawing treatment, a form of passive euthanasia has been allowed.

Euthanasia, which literally means a gentle or easy death, has been divided into two major groupings, passive and active. The process of doing nothing to prolong life or fend off death is called Passive euthanasia. Active euthanasia, as defined is the active participation of ending life, and is currently forbidden by most codes of ethical conduct.

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