pp.110-111 in Bioethics in Asia

Editors: Norio Fujiki and Darryl R. J. Macer, Ph.D.
Eubios Ethics Institute

Copyright 2000, Eubios Ethics Institute All commercial rights reserved. This publication may be reproduced for limited educational or academic use, however please enquire with the author.

3.3. Are Physicians Reluctant to Withdraw Life-Sustaining Treatment?

Arleen A. Ricalde, Lorene Siaw, S. Y. Tan.

The St. Francis International Center for Healthcare Ethics, Hawaii, USA

We have to ask how good are we in taking care of terminally ill patients? Callahan (1995) said that the gHistory of caring for the dying from the 17th to the 20th century evolved from the sacred to secular, private to institutional and natural to artificialh. JAMA publicized a support study in 1995, with the results 1) Patientsf preferences regarding do not resuscitate (DNR) and other end of life issues were not commonly addressed; 2) 50% of patients were in moderate or significant pain; 3) Treatment approach did not change despite nurse interventions with prognostic information and patient preferences. The bottom line is we are not taking very good care of our dying patients.

We can define withholding as grefraining from initiating treatmentf, and withdrawing as gdiscontinuing treatment after it has been startedf. There is not an ethical difference between these two acts. g...behind the withholding/withdrawing distinction lies the more general acting/omitting distinction in one of its least defensible forms...neither law nor public policy should mark a difference in moral seriousness between stopping and not starting treatmenth (Presidentfs Commission, 1983). gThere is no ethical requirement that once treatment has been initiated, it must continue against the patientfs wishesh (The Hastings Center, 1987). There also no legal difference. gThe line between commission and omission is a distinction without a difference now that patients are permitted not only to decline all medical treatment, but to instruct their doctors to terminate whatever treatment, artificial or otherwise, they are receivingh (Compassion in Dying versus State of Washington, 1994). g...it would seem unreasonable to draw the line precisely between action and inaction rather than between various forms of inactionsh (Nancy Cruzan Case, 1989).

Clinical practice suggests that many physicians are reluctant to withdraw though not to withhold treatment at the end-of-life, despite legal and ethical consensus that there is no difference between these two acts. In order to determine the prevalence of these attitudes in Hawaii, we analyzed the responses of 1,028 physicians and medical trainees who were asked (using questionnaires) about life-sustaining treatment in a terminally-ill patient. First, we asked if they would intubate a competent terminally-ill patient with lung cancer who has decided to forgo mechanical ventilation. Secondly, we asked if they would take such a patient off a ventilator if already intubated.

The results were, the majority would withhold (98%) or withhold and withdraw (79%) treatment. 19% of physicians in Hawaii would withhold but not withdraw treatment. The top five reasons for withholding, but not withdrawing treatment, were: if they were to discontinue the ventilator, they would be killing the patient (n=81); such actions constitute physician-assisted suicide (n=74); patient wishes should usually be complied with (n=50); such actions would not be supported by the courts (n=30); such actions would not be supported by society (n=21). [this is a little modified from second part of 1st paragraph of abstract]

There were significant difference between medical students and practitioners, but no difference between psychiatry and surgery, and no difference between pediatrics and adult primary care. There was significant difference between non-primary care (psychiatry and surgery) and primary care (pediatrics and adult medicine). There was no difference between Hawaiian/Polynesian and Asian, but significant differences between Hawaiian/Polynesian and Caucasian, and between Asian and Caucasian.

In summary, roughly 1 in 5 physicians in Hawaii would withhold, but would not withdraw life-sustaining treatment in a terminally ill patient. The top two reasons are if there were to discontinue the ventilator, they would be killing the patient, and such actions constitute physician assisted suicide. A significant number of physicians, especially medical students and non primary - care doctors would withhold but not withdraw life-sustaining support because they misconstrue the latter action to represent euthanasia. This mistaken attitude is more prevalent in medical trainees, non-primary care and Hawaiian, Polynesian and Asian physicians. We propose an intensive educational effort at all physician levels to remedy this ethical misconception.

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