Withholding and Withdrawing Treatment

00:05 or, you know, surrogate decision-makers make decisions about withholding and withdrawing.

00:11 Let's first of all define some terms. So, withholding the treatment means not starting the treatment.

00:18 Withdrawing means stopping the treatment once it's already been started.

00:23 Another term that I like to use is foregoing treatment because this allows you to cover both the withholding as well as the withdrawing of a treatment.

00:34 And the idea here is a patient always has the right to refuse a treatment.

00:40 If we're respecting autonomy, they should be able to decide whether or not they want a treatment or don't want a treatment.

00:46 So, when you forego something, it could be either it hasn't been started yet or it's been started and you want to stop it. So, that's allowing the patient to make the decision.

00:58 And if here is a decision about foregoing a life-sustaining treatment, then, you know, what we consider in ethics is that this is allowing the patient to die of their underlying disease process. It's not as a result of the withholding or withdrawing.

01:13 It's the underlying disease that causes the death of the person.

01:17 Now, some people will try to draw a distinction between withholding and withdrawing.

01:23 But it's important to point out that if you withhold a potential treatment, you know, that down the road might have some benefits, that's no different than, you know, not instituting a treatment.

01:36 So, it may or may not be effective.

01:40 When you withdraw a treatment, you know, you're saying that it's proven ineffective.

01:45 So, some people would say, well, that's easier to justify. You've given it a try. It doesn't work.

01:51 That gives further justification to withdrawing.

01:55 Now, some people also say there's a difference between an act in omission.

02:00 So, a moral act or an action seems more active, you're actually doing something whereas if you never instituted it in the first place, you're not acting.

02:11 But philosophers would disagree with that and say, that distinction between withholding and withdrawing really doesn't play out because the omission is still an action even if it's not, you know, stopping a treatment.

02:26 Now, it has to be recognized that there will be people that will have an emotional feeling that there is a psychological difference between withholding and withdrawing.

02:38 So, here, you know, it's harder to stop a treatment that's already been initiated.

02:43 So, you know, you've already put it in place. It seems, you know, emotionally harder to say, I'm going to stop this treatment that's already, you know, the patient's already receiving.

02:56 There may also be, you know, a discomfort with the actual withdrawing.

03:00 So, once you've instated, you've had some loyal to the patient that you need to follow through and see what that treatment's going to do.

03:07 It may be, well, you know, even though we're saying stopping a treatment, withdrawing the treatment is allowing the underlying disease process to cause the person's death.

03:20 This might be a, you know, a natural emotional reaction to say, I'm going to deny death by not stopping this treatment.

03:26 We're just going to keep going and let nature take its course rather than me being the one that stops the treatment.

03:35 It does create a feeling in the person that maybe they are part of the causal chain that leads to the patient's death even though it's the underlying disease process that causes the death.

03:45 And once a treatment is started and, you know, there's been these discussions about withdrawing, you keep going, you keep doing things may be a way to show the family, well, you're doing everything possible to try to keep their loved one alive.

04:02 And then, lastly, there may be patients and families that have religious grounds for why they would not withdraw treatment such as, you know, withdrawing a ventilator.

04:11 They would say, "Well, God is in control. I let God make the decision of when the person might die." In philosophy, they've really come down to the conclusion that there's no moral distinction between withholding and withdrawing.

04:28 The reason for this are, again, what I said before, patients can refuse treatment at any time.

04:34 Second, that there can be justifications for stopping a treatment should be the same as though as for not initiating it.

04:40 So, why you decided it too burdensome now, once it's already in place, should be the same as the justifications for why it's burdensome before you even start it.

04:52 And then, actually, you know, having a higher requirement for cessation might actually discourage trials of therapy.

04:59 So, maybe as we're going to talk about in a bit, you give a therapy a chance but once you see that it's not working, there might be the decision to withdraw it.

05:09 One important caveat when you say that there's no moral distinction between withholding and withdrawing is let's say you've got two patients and they're getting the last two ventilators at your hospital.

05:21 If you have both of them on it and now, a third patient comes in.

05:27 If you say, "Well, this patient also needs a ventilator. They're in respiratory distress.

05:32 They need the ventilator, taking one of those earlier patients off the ventilator, withdrawing the treatment from them and giving it to the new patient, there is a moral distinction between that.

05:43 In some way, the patient that's already on the ventilator has a first come, first serve.

05:49 They've already got some entitlement to the ventilator.

05:52 Taking them away from them to give it to a third person would be counter to, you know, good ethics.

06:01 You want to make sure that the patient that's coming in is taken care of but not at the expense of the patient that already has the ventilator.