Limits to Life-Sustaining Treatment

Grounds For and Against

A. Consent Elements
1. Patient's informed consent/refusal of treatment/demand for treatment/de
mand to die
2. Substituted judgment: decision made by another, but based upon an attempt to determine what the patient himself/herself would choose if competent.
3. Proxy consent/refusal/demand: decision made on behalf of the patient by a designated agent, ideally based upon the agent's judgment as to what is in the patient's best interests.
4. Family's or friends' wishes in the matter: decision based upon the best interests, values, etc. of the family and/or friends themselves.
5. Consensus judgment: of any or all of the following: patient, family, friends, health-care professionals, hospital ethics committee.

B. Quality of Life Judgments
6. Patient's quality of life: determined wholly from the perspective of the patient himself/ herself.
7. Evaluation of the patient's quality of life from the perspective of an observer: e. g., "I don't know what that state of life feels like from the inside, but I consider it unacceptable."
8. Disvalues of treatment: Pain, risks, indignities, uncertainties, displacement, disruption of relationships.
9. To prevent the patient from "losing hope"
10. Family's quality of life: cf. Section D, especially item 24.

C. Medical Judgments
11. Determination that death has already occurred
12. Efficacy of treatment: "Treatment wouldn't do any good anyway."
13. Reversibility of illness
14. Imminence of death: "She doesn't have long to live no matter how much we do."
15. Standard-medical-care policy: assumes that a given procedure is obligatory if its use is "standard medical care" in cases of this clinical type.
16. Medical-indications policy (Ramsey 1978): assumes that a given procedure is obligatory as long as there exist "medical indications" or "biological indices" for its use.
17. Implications of the patient/ professional relationship: "Patients expect their physicians to. . . . "
18. Principles of professional ethics
19. Goals of medicine: e. g., to extend life, to relieve suffering, to restore health, etc.
20. Educational values: "To attempt to extend this patient's life for a short period could teach me how to save lives of future patients."
21. Research values: "Medical science could learn something from this patient which would save lives of future patients."

D. Other-Regarding Judgments
22. Patient's obligations to others: "The patient owes it to his children to allow them
some time to adjust to the prospect of his death," or "The patient owes it to his
familv to spare them the agonv of a prolonged death watch."
23. Family's obligations to patient: "The family owes it to the patient to spare her
this suffering." or "The family owes it to the patient to see that everything is done
that can possibly be done."
24. Family's obligations to its members and others: "The family members owe it to
themselves not to prolong their agony in a protracted death-watch," or "They
owe it to his friends to allow them time to adjust to the prospect of his death."
25. Societal obligations to patient: e,g., to provide treatment resources, to spare
the patient from pain and indignity.
26. Societal needs: e.g., for the resources required to sustain this patient, for the moral example the patient could provide.
27. Public health issues
28. Allocation of resources issues: e.g., effects of denying resources to others, issues of equity, social worth of patient, expenses of treatment.
29. Effects on health services personnel who must work with the patient

E. Conceptual Elements
30. Ordinary/extraordinary measures distinction
31. Natural/ artificial support distinction
32. Killing/ allowing-to-die distinction
33. Active/passive measures distinction
34. An "act of mercy"
35. Providing "a good death"
36. To avoid "playing God"
37. To avoid acting "contrary to Nature"
38. To avoid "prolonging dying"
39. To satisfy the precept "do no harm"
40. Deontological religious standards: accordance with God's will, the Ten Com-
mandments, other biblical dictates, etc.
41. To satisfy requirements of law

F. Moral Principles
42. The Golden Rule: "because this is what I would want done if I were in the patient's
shoes (or bed)." 43. Principle of sanctity of life
44. Principle of right to life
45. Principle of value of life
46. Slippery slope objections: even though this act may not be wrong in itself, undertaking it may incline us in the future to perform acts that are clearly objectionable.
47. Appeal to the "symbolic meaning" of treatment (or nontreatment)
48. Appeal to the long-term consequences of this decision: e,g., disabilities become intolerable; the infirm may feel social pressure to refuse treatment.

G. Factual Appeals
49. "A miracle cure might come along."
50. Appeal to uncertainty of diagnosis, prognosis: "We cannot know for certain that death is near."

FROM: Glenn C. Graber, Alfred D. Beasley, John A. Eaddy, Ethical Analysis of Clinical Medicine (Baltimore and Munich: Urban & Schwarzenberg, 1985), pp. 184-185.

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