Terminating Futile Medical Treatment and Passive Euthanasia: Is there a Difference?

- Yu Kam Por, Ph.D.

General Education Centre
The Hong Kong Polytechnic University
Hung Hom, Kowloon, Hong Kong

E-mail: geykp@polyu.edu.hk
Eubios Journal of Asian and International Bioethics 12 (2002), 137-138.
Recently in Hong Kong, the Medical Council issued a guideline relating to the withholding or withdrawing of life sustaining treatment. According to the guideline, doctors may terminate futile treatment on a patient upon consultation with the patient's family. The mass media reported this as the implementation of passive euthanasia. The Hospital Authority and the Secretary for Health and Welfare both immediately disagreed saying that passive euthanasia is acceptable. On the other hand, the mass media has been accused of misrepresenting the position of the Medical Council. It was argued that terminating futile medical treatment is not the same as passive euthanasia, and equating the two is mistaken and misleading. It has also been argued that euthanasia is illegal but terminating futile treatment is not only legal but also ethical.

What I want to do in this paper is to examine the nature of passive euthanasia and terminating futile treatment and see if a distinction between the two can be clearly and usefully drawn.

Terminating futile treatment and passive euthanasia both imply withdrawing or withholding medical intervention and the foreseeable outcome of death. If what is being done in the two cases are the same, and the outcome of the two are also the same, on what ground can the two be said to be different? In the case of terminating futile treatment, the medical intervention that is withdrawn or withheld is described as futile, but in the case of passive euthanasia, the medical intervention that is withheld or withdrawn is also regarded as not beneficial to the patient.

One possible distinction is that for terminating futile treatment, only extraordinary or medical intervention is withheld. The patient continues to receive ordinary support, such as provision of nutrition, but passive euthanasia may imply not providing any support whatsoever to the patient.

However, terminating futile treatment means not only terminating surgery or medication, but the restraint from using cardiopulmonary resuscitation (CPR) or to feed nutrition to the patient such that the patient may stay in the Intensive Care Unit (ICU) for the rest of his life for an indefinite period. If helping a patient to get nutrition and breathe can be counted as extraordinary intervention, then the distinction between ordinary and extraordinary support does not hold.

Another possible distinction is that the goals of the two are different. Terminating futile treatment does not aim at terminating the life of the patient, but only aims at releasing the patient from being the captive of modern technology. The limit of medicine is recognized and medical intervention is withdrawn and let nature have its own way. It is said that with passive euthanasia, the patient's state of living is regarded as desirable, such that the ending of the patient's life is regarded as better than maintaining the patient's life.

For the case of terminating futile treatment, the treatment is regarded as futile because it will not do any good to the patient's life. So the value judgment involved in the two cases are the same, namely, the prolonged state of living is worse than the sooner death.

Although I reject several alleged distinctions between terminating futile medical treatment and passive euthanasia above, I do think that the two different ways of talking represent different frames of mind and have different practical implications. Basically the talk of passive euthanasia is a patient-oriented language. The focus is on what is good to the patient and what the patient wants. But the talk of futile treatment is a doctor-oriented language. The focus is on the view or professional judgment of the doctor.

Such a different choice of perspective and language has different implications. Who is going to make the value judgment (or value judgment in the disguise of professional judgment)? Who is going to make the end of life decision? In the case of passive euthanasia, it is reasonable to let the patient to decide for himself or herself whether his or her life is worth living. But in the case of terminating futile treatment, it has to be the doctor to decide whether the treatment is really futile. As a result, the doctor rather than the patient is regarded as more capable of making the judgment.

Advocates of euthanasia (for that matter passive euthanasia) do not necessarily regard a low quality of living as worse than death, but they just hold that life is not necessarily better than death, and there should be space for individuals to make this value judgment. As a result, patients should be allowed to make a choice, at least in some situations. By substituting passive euthanasia with terminating futile treatment, individual variation of choice is ignored, one state is regarded as necessarily worse than another. For example, staying three more months in the ICU is regarded as worse than immediate death. Such a practice obscures the different value preferences of different individuals.

If my argument above is sound, terminating futile treatment and passive euthanasia are the same in substance. But they are different ways of expressing the same thing. Different expressions are used and different frames of mind are adopted. Such differences are not inconsequential because they have different practical implications. In both the cases of passive euthanasia and terminating futile treatment, what is being done (action) and what is being omitted (omission) are the same. The outcomes of the two are also the same. So any distinction between the two cannot be based on the action or the outcome. I then examined the two alleged differences. The first assertion is that the two have different omissions. The second assertion is that the two have different goals. I examined these two assertions and I rejected both of them.

So I come to the conclusion that the two are substantially the same. They are just different ways of saying the same thing. Such a different way of describing what is being done obscures the value judgment involved. In the case of passive euthanasia, the value judgment that a prolonged life is worse than immediate death is explicitly made. However, in the case of terminating futile treatment, the same value judgment is being made, but not explicitly made. The two different uses of language represent different frames of mind. The shift to the language of terminating futile treatment replaces the patient's perspective with the doctor's perspective. Instead of emphasizing the patient's preference, the doctor's professional judgment is emphasized. I conclude that the use of the concept of terminating futile treatment tends to obscure the issue instead of solving it, and it runs the risk of substituting the patient's autonomy with the doctor's paternalism.

References

Chan Ho-mun and Ko Wing-man, "The Misconception of Euthanasia, the Ends of Medicine, and the Autonomy of the Patient" (in Chinese), in Yu Kam-por (ed.), Values and Society, Vol. 1, Beijing: China Social Sciences Publishing House, 1997, pp. 74-101.

The Medical Council of Hong Kong, "Professional Code and Conduct (November 2000 version)". (
http://www.mchk.org.hk/draft.htm)

Susan B. Rubin, When Doctors Say No: The Battleground of Medical Futility, Bloomington: Indiana University Press, 1998.

Yu Kam-por, "Euthanasia and Ethical Thinking" (in Chinese), Values and Society, Vol. 2, ed. Chan Ho-mun, Beijing: China Social Sciences Publishing House, 1998, pp. 469-475.

Marjorie B. Zucker and Howard D. Zucker (eds.), Medical Futility: and the Evaluation of Life-sustaining Intervention, Cambridge: Cambridge University Press, 1997.


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