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At the end: How do you decide if a patient should be allowed to die?

Updated Tuesday, 30th July 2013

Decisions on prolonging life, or not, are never easy. Chris Belshaw explores some of the considerations.

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A switch on an intravenous drip Copyrighted  image Icon Copyright: Qiqming Zhou | Dripping away? A switch on an intravenous drip The case of Mr. Khan [discussed in an episode of Inside The Ethics Committee] raises a number of interesting and important issues. Some of these relate to finding an appropriate response to inter-cultural sensibilities, and in particular the role and dictates of the Muslim faith.

Others are more general. I want to to focus, but not exclusively, on the more general here.

Two important questions need to be distinguished in such end of life cases.

We can ask, first, does the patient want to stay alive?

And second, if he does, will he have a life worth living?

In Mr Khan’s case, the answer to neither question is straightforward. But it seems clear that over time his situation gets worse: his chances of making a good recovery – one delivering a worthwhile life – and his desire to continue living both seem, unsurprisingly, to decrease as time goes on.

Suppose that someone both wants to live and, with the right treatment, has good prospects of recovery. This is more or less Mr. Khan’s position at the beginning of the programme. Is subjecting a patient to intensive care then appropriate?

It may seem clear that it is. But there is one issue to notice.

Given costs and, limited resources, it may be that some judgement needs to be made about just which patients get the highest priority, or first place in the queue.

Suppose, in contrast, the patient both wants to die and, if she doesn’t die, will have a life that is not worth living.

Most people will agree that treatment aimed at preserving life is here inappropriate. But there is a complication to note.

Some people will insist that life is always valuable, that any life is better than no life, and so will hold that treatment should continue. Perhaps Mr. Khan’s family believe this. (I’m not sure they do, or whether they believe instead that where there’s life there’s hope, and think, for longer than is reasonable, that Mr. Khan just might pull through, and get his good life back.)

This leaves two less straightforward positions to consider.

First, a patient wants to live but any subsequent life will not be worthwhile.

Second, a patient wants to die even though a worthwhile life is on offer. Let’s first think about this one.

Just as we are now permitted to commit suicide, so also we are permitted to refuse medical treatment, even when that treatment is necessary for life. But this is as far as it goes.

We can insist that doctors stop treating us, knowing and intending that we then die; but we cannot insist that doctors help us to die. Should we be able to insist on this?

Issues about euthanasia and assisted suicide are currently much discussed, but it seems clear that the argument for changing, and relaxing, the law is stronger in cases where the patient wants to die, and life would be bad, than where she wants to die, even though life would be good.

No doctors want to be required to end a life they think is worth living. So in this sort of case, a right to refuse treatment is probably as far as we want to go.

Consider then the case where the patient want to live, but life won’t be worthwhile. There are two versions of such a life.

In the first the life is of neutral value – it’s neither good nor bad for the patient to carry on living. Perhaps life in an irreversible coma, or a persistent vegetative state is like this.

In the second, life is of negative value, and worse than nothing. A life of pain might be like this.

Should doctors in these case be concerned to give the patient what he wants, perhaps responding to demonstrations of autonomy? Or should they be focused on what is good for the patient, thinking instead of his best interests, or well-being?

This is more or less the dilemma facing the clinical team in Mr. Khan’s case. "More or less" as it is the friends and relatives, rather than Mr Khan himself, who are asking the doctors once more to intervene. They claim that this is what Mr. Khan would want.

So there’s a question about what is best here, and the ethics team are consulted. Perhaps they drag their feet. And perhaps this is where the cross-cultural complications come into play.

It seems clear, in these later stages, that it would be best for Mr. Khan to be allowed to die, rather than to continue a life of distress and pain. And it seems not to be clear, in spite of what the family says, that Mr. Khan wants to go on in such a condition.

So why not let him die? The worry here is that the team, and the committee, might be more concerned to avoid confrontation with the family, the risk of being sued, bad publicity about racial or religious insensitivities, than to do what is best for their patient.

The ethical issues in this sort of case are not straightforward.





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