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Beyond the Equivalence Thesis: how to think about the ethics of withdrawing and withholding life-saving medical treatment

Abstract

With few exceptions, the literature on withdrawing and withholding life-saving treatment considers the bare fact of withdrawing or withholding to lack any ethical significance. If anything, the professional guidelines on this matter are even more uniform. However, while no small degree of progress has been made toward persuading healthcare professionals to withhold treatments that are unlikely to provide significant benefit, it is clear that a certain level of ambivalence remains with regard to withdrawing treatment. Given that the absence of clinical benefit means treating patients is not only ethically questionable but also taxing on resources that could meet the needs of others, this ambivalence is troubling. Equally, the enduring ambivalence of professionals might be taken to indicate that the issue warrants further attention. In this paper, we review the academic literature on the ethical equivalence of withdrawing and withholding medical treatment. While we are not in outright disagreement with the arguments presented, we suggest that asserting theoretical and decontextualized claims about the ethical equivalence of withdrawing and withholding life-saving treatment does not fully illuminate the moral questions associated with the relevant clinical realities. We argue that what is required is a broader perspective, one rooted in an understanding that withdrawing and withholding life-saving treatment are different practices, the meanings of which are fully comprehensible only through an appreciation of their place within the practice of healthcare more generally. Such an account suggests that if one is to engage with the inappropriate protraction of life-saving treatment resulting from healthcare professionals’ disinclination to withdraw it, then the differences between these practices should be taken seriously.

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Notes

  1. 1.

    The concept of a field is an indispensable part of practice theory. It is particularly important to note that a field is not simply a generalized arena of social interaction; it is a broader, more abstract notion, which includes what Neil Fligstein and Doug McAdam term “internal governance units” [15].

  2. 2.

    We are grateful to one of this journal’s reviewers for reminding us of this text and its importance, particularly with regard to its influence on others, including John Harris—whose work we subsequently discuss—who attended the seminars in which Glover first developed his argument.

  3. 3.

    Per a query by one of our reviewers, it is worth pointing out that we do not mean to suggest that this particular book is somehow central to understanding bioethics; acquaintance with it is not indispensable to those working within the field. That said, one could hardly get to grips with the field without encountering a book of this sort and at least some of the essays collected within it. Rather like many such collections and introductory texts, this volume seeks to set out the range and scope of bioethics. In so doing, it offers a sketch of the field’s sense of itself, a fact that is consistent with the point we are trying to make.

  4. 4.

    Apart from a minor reordering of chapters, the section remains unchanged in the third edition [33].

  5. 5.

    Indeed, the moral equivalence of withdrawing and withholding life-saving treatment is often an explicit premise in the ethical analysis of assisted suicide (cf. [1]).

  6. 6.

    In a personal communication with the authors, Sulmasy and Sugarman suggest that, while they cannot be certain, they may have coined the Equivalence Thesis in their article [34]. Furthermore, they say that they do not recall having read Frances Kamm or Judith Lichtenberg prior to writing their paper but acknowledge that they would certainly have read Rachels.

  7. 7.

    In this formulation, Sulmasy and Sugarman fail to mention the significance of the ceteris paribus clause. For example, while it is permissible to withhold care on the legitimate expectation that this care would not benefit the patient, the ET does not suggest that it is permissible to withdraw care if this care happens to be having an unexpectedly positive effect.

  8. 8.

    Thomas considers those who advocate for what he calls the doctrine of the moral equivalence of acts and omissions, particularly Rachels [26] and Lichtenberg [28], as treating it as a “pre-theoretical moral truth” [29]. He also cites a collection of essays edited by Bonnie Steinbock as some of the most important papers written on the topic [43].

  9. 9.

    It is worth making clear that although it is entitled “Killing and Starving to Death,” Rachels’ 1979 essay is concerned not with medicine or healthcare, but with our moral responsibilities toward those experiencing famine [46].

  10. 10.

    Of course, Rachels is not suggesting that “every act of letting die is equally as bad as every act of killing,” merely that “whatever reasons there may be for judging one act worse than another, the bare fact that one is killing, while the other is letting die, is not among them” [45, p. 111].

  11. 11.

    One could take the concept of futility to suggest that talk of withdrawing or withholding treatment should be abandoned. Treatment is not treatment if it is futile, and if treatment is not futile, then it should not be withdrawn or withheld. However, on pain of practical irrelevance, the concept of futility cannot be restricted in the way required; while philosophical discussion can be predicated on certainty, medical practice cannot. This point further suggests that withdrawing and withholding life-saving treatment should be understood not in purely conceptual terms but as forms of medical practice, thus falling within the scope of practice theory.

  12. 12.

    See the points made in fn. 11.

  13. 13.

    On the nature of prognostic uncertainty in medical practice and care at the end of life, see Nicholas Christakis [52].

  14. 14.

    We do not mean to suggest that there are no examples of moral philosophy or applied ethics that discuss practice in a manner similar to the perspective offered by what we are calling practice theory. Certainly, Alasdair MacIntyre’s discussion of both practice and tradition is one such example [53,54,55]. Similarly, not least because of their Wittgensteinian commitments, the philosophical works of both Peter Winch [14, 56, 57] and Stephen Toulmin [12, 14] can be understood, broadly speaking, as aligning with practice theory; and, of course, both scholars have things to say about morality and ethics. However, it is important to note that, for the most part, talk of practice in the bioethical literature is not equivalent to talk of practice in social theory. Perhaps the closest example of bioethical scholarship that moves in the direction we discuss is Judith Andre’s work Bioethics as Practice [58].

  15. 15.

    Nigel Pleasants considers the discourse of social theory to lie somewhere between the social sciences and philosophy and, furthermore, considers Winch to be “a founding contributor” to this field, discipline or mode of thought [59].

  16. 16.

    For an overview of practice theory, see Joseph Rouse [12] and, in anthropology, Sherry Ortner [11].

  17. 17.

    The way in which such notions can be related to MacIntyre’s conception of a practice or, more accurately, a tradition indicates the diversity of practice theory as well as something of the family resemblances that hold such accounts together as theories of practice. It is also suggestive of their relevance to moral philosophy on the one hand and to the substantive ethics internal to particular practices, traditions, or modes of social life on the other. See fn. 14.

  18. 18.

    Of course, neither scholarly analyses of the ethics of withdrawing and withholding life-saving treatment nor the professional guidelines that inform such practices can really be thought of as being prior to medical practice. The fact that bioethicists attend to the problem, together with the fact that professional guidelines have been developed to structure what takes place in practice, indicates that the issue already has some degree of clinical reality. As such, academic analyses, professional guidelines, and the realities of practice are mutually interrelated, not least through the entanglement generated by the respective practices involved in clinical medicine, the pursuit of bioethics, and the development of professional ethical guidelines.

  19. 19.

    Further detail on the way Winch understands modes of social life can be found in the preface to The Idea of a Social Science and its Relation to Philosophy [57, pp. ix–xvii].

  20. 20.

    Jecker and Emanuel make a similar point [40], while Fred Frohock discusses the importance of the history of decision-making [61].

  21. 21.

    Analytic moral philosophy and applied ethics tend not to recognize that moral responsibilities can deepen as a result of our interactions with one another. However, this is not the case for the ethics of care, nor is it true for more continental moral philosophies, such as those that emphasize ethical demand (e.g., K.E. Løgstrup), the face of the other (e.g., Emmanuel Levinas), and the I–Thou relationship (e.g., Martin Buber). We have no space to go into detail here; so suffice it to say that such perspectives could well be used to suggest that the simple fact of prior treatment generates an increased moral obligation toward the patient on the part of those responsible for such treatment.

  22. 22.

    Solomon subsequently published an article on professionals’ views of life-sustaining treatments [8]. However, the sentiment is not contained within it, and we have not found it elsewhere.

  23. 23.

    Or, as a number of recent United Kingdom court cases concerning the withdrawal of life-saving medical treatment from children have shown, such decisions can take place over a matter of months.

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Acknowledgements

This paper was written with the support of ENDCARE, an Erasmus+ funded project on ethics and care at the end of life.

Funding

EU ERASMUS+ Programme Agreement No. 2015-1-MT01-KA203-003728: Harmonisation and Dissemination of Best Practice – Educating and alleviating the concerns of Health Care Professionals on the proper practice of end of life care (ENDCARE).

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Correspondence to Nathan Emmerich.

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Emmerich, N., Gordijn, B. Beyond the Equivalence Thesis: how to think about the ethics of withdrawing and withholding life-saving medical treatment. Theor Med Bioeth 40, 21–41 (2019). https://doi.org/10.1007/s11017-019-09478-9

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Keywords

  • Equivalence Thesis
  • Withdrawing
  • Withholding
  • Medical practice
  • Acts and omissions