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Theoretical Medicine and Bioethics

, Volume 40, Issue 1, pp 21–41 | Cite as

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

  • Nathan EmmerichEmail author
  • Bert Gordijn
Article

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.

Keywords

Equivalence Thesis Withdrawing Withholding Medical practice Acts and omissions 

Notes

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).

References

  1. 1.
    Orentlicher, David. 2001. Matters of life and death: Making moral theory work in medical ethics and the law. Princeton: Princeton University Press.Google Scholar
  2. 2.
    Fins, Joseph J. 2006. A palliative ethic of care: Clinical wisdom at life’s end. Sudbury, MA: Jones and Bartlett.Google Scholar
  3. 3.
    Beauchamp, Tom L., and James F. Childress. 2009. Principles of biomedical ethics. 6th ed. Oxford: Oxford University Press.Google Scholar
  4. 4.
    Veatch, Robert M. 2003. The basics of bioethics. 2nd ed. Upper Saddle River, NJ: Prentice Hall.Google Scholar
  5. 5.
    Wilkinson, Dominic and Julian Savulescu. 2014. A costly separation between withdrawing and withholding treatment in intensive care. Bioethics 28: 127–137.CrossRefGoogle Scholar
  6. 6.
    English, Veronica, and British Medical Association. 2008. Withholding and withdrawing life-prolonging medical treatment: Guidance for decision making. 3rd ed. Malden, MA: Blackwell.Google Scholar
  7. 7.
    Berlinger, Nancy, Bruce Jennings, and Susan M. Wolf. 2013. The Hastings center guidelines for decisions on life-sustaining treatment and care near the end of life. 2nd ed. Oxford: Oxford University Press.CrossRefGoogle Scholar
  8. 8.
    Solomon, Mildred Z., Lydia O’Donnell, Bruce Jennings, Vivian Guilfoy, Susan M. Wolf, Kathleen Nolan, Rebecca Jackson, Dieter Koch-Weser, and Strachan Donnelley. 1993. Decisions near the end of life: Professional views on life-sustaining treatments. American Journal of Public Health 83: 14–23.CrossRefGoogle Scholar
  9. 9.
    Dickenson, Donna L. 2000. Are medical ethicists out of touch? Practitioner attitudes in the US and UK towards decisions at the end of life. Journal of Medical Ethics 26: 254–260.CrossRefGoogle Scholar
  10. 10.
    Cartwright, Colleen Maria, Ben P. White, Lindy Willmott, Gail Williams, and Malcolm Holbrook Parker. 2016. Palliative care and other physicians’ knowledge, attitudes and practice relating to the law on withholding/withdrawing life-sustaining treatment: Survey results. Palliative Medicine 30: 171–179.CrossRefGoogle Scholar
  11. 11.
    Ortner, Sherry B. 1984. Theory in anthropology since the sixties. Comparative Studies in Society and History 26: 126–166.CrossRefGoogle Scholar
  12. 12.
    Joseph, Rouse. 2007. Practice theory. In Handbook of the philosophy of science: Philosophy of anthropology and sociology, vol. 15, ed. Stephen P. Turner and Mark W. Risjord, 639–681. London: Elsevier.Google Scholar
  13. 13.
    Bennett, Jonathan. 1995. The act itself. Oxford: Oxford University Press.Google Scholar
  14. 14.
    Schatzki, Theodore R. 2001. Introduction: Practice theory. In The practice turn in contemporary theory, ed. Theodore R. Schatzki, Karin Knorr Cetina, and Eike von Savigny, 10–23. London: Routledge.Google Scholar
  15. 15.
    Fligstein, Neil, and Doug McAdam. 2012. A theory of fields. New York: Oxford University Press.CrossRefGoogle Scholar
  16. 16.
    Stevens, M.L.Tina. 2003. Bioethics in America: Origins and cultural politics. Baltimore: Johns Hopkins University Press.Google Scholar
  17. 17.
    Rothman, David J. 2003. Strangers at the bedside: A history of how law and bioethics transformed medical decision making. New York: Aldine de Gruyter.Google Scholar
  18. 18.
    Jonsen, Albert R. 1998. The birth of bioethics. New York: Oxford University Press.Google Scholar
  19. 19.
    Belkin, Gary S. 2014. Death before dying: History, medicine, and brain death. New York: Oxford University Press.Google Scholar
  20. 20.
    President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. 1983. Deciding to forego life-sustaining treatment: A report on the ethical, medical, and legal issues in treatment decisions. Washington, DC: United States Government.Google Scholar
  21. 21.
    President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. 1981. Defining death: A report on the medical, legal and ethical issues in the determination of death. Washington, DC: United States Government.Google Scholar
  22. 22.
    Beecher Henry, K., Raymond D. Adams, A. Clifford Barger, William J. Curan, Derek Denny-Brown, Dana L. Farnsworth, Jordi Folch-Pi, et al. 1968. A definition of irreversible coma: Report of the ad hoc committee of the Harvard medical school to examine the definition of brain death. JAMA 205: 337–340.CrossRefGoogle Scholar
  23. 23.
    Glover, Jonathan. 1977. Causing death and saving lives: The moral problems of abortion, infanticide, suicide, euthanasia, capital punishment, war and other life-or-death choices. Harmondsworth: Penguin.Google Scholar
  24. 24.
    Lamb, David. 1995. Therapy abatement, autonomy and futility: Ethical decisions at the edge of life. Aldershot: Ashgate.Google Scholar
  25. 25.
    Harris, John. 1985. The value of life: An introduction to medical ethics. London: Routledge.Google Scholar
  26. 26.
    Rachels, James. 1975. Active and passive euthanasia. New England Journal of Medicine 292: 78–80.CrossRefGoogle Scholar
  27. 27.
    Kamm, Frances Myrna. 1983. Killing and letting die: Methodological and substantive issues. Pacific Philosophical Quarterly 64: 297–312.CrossRefGoogle Scholar
  28. 28.
    Lichtenberg, Judith. 1982. The moral equivalence of action and omission. Canadian Journal of Philosophy 12: 19–36.Google Scholar
  29. 29.
    Thomas, Laurence. 1982. Acts, omissions, and common sense morality. Canadian Journal of Philosophy 12: 37–46.CrossRefGoogle Scholar
  30. 30.
    Emmerich, Nathan. 2015. What is bioethics? Medicine, Health Care and Philosophy 18: 437–441.CrossRefGoogle Scholar
  31. 31.
    Jecker, Nancy S., Albert R. Jonsen, and Robert A. Pearlman. 2007. Bioethics: An introduction to the history, methods, and practice. 2nd ed. Boston: Jones and Bartlett.Google Scholar
  32. 32.
    Jecker, Nancy S., Albert R. Jonsen, and Robert A. Pearlman. 1997. Bioethics: An introduction to the history, methods, and practice. 1st ed. Boston: Jones and Bartlett.Google Scholar
  33. 33.
    Jecker, Nancy S., Albert R. Jonsen, and Robert A. Pearlman. 2011. Bioethics: An introduction to the history, methods, and practice. 3rd ed. Boston: Jones and Bartlett.Google Scholar
  34. 34.
    Sulmasy Daniel, P., and Jeremy Sugarman. 1994. Are withholding and withdrawing therapy always morally equivalent? Journal of Medical Ethics 20: 218–224.CrossRefGoogle Scholar
  35. 35.
    Wilkinson, Dominic, and Julian Savulescu. 2014. A costly separation between withdrawing and withholding treatment in intensive care. Bioethics 28: 127–137.CrossRefGoogle Scholar
  36. 36.
    McGee, Andrew. 2015. Acting to let someone die. Bioethics 29: 74–81.CrossRefGoogle Scholar
  37. 37.
    Brody, Baruch. 1996. Withdrawal of treatment versus killing of patients. In Intending death: The ethics of assisted suicide and euthanasia, ed. Thomas L. Beauchamp, 90–103. Upper Saddle River, NJ: Prentice Hall.Google Scholar
  38. 38.
    Derse Arthur, R. 2005. Limitation of treatment at the end-of-life: Withholding and withdrawal. Clinics in Geriatric Medicine 21: 223–238.CrossRefGoogle Scholar
  39. 39.
    Huddle, Thomas S. 2013. Moral fiction or moral fact? The distinction between doing and allowing in medical ethics. Bioethics 27: 257–262.CrossRefGoogle Scholar
  40. 40.
    Jecker Nancy, S., and Linda Emanuel. 1995. Are acting and omitting morally equivalent? A reappraisal. Journal of the American Geriatrics Society 43: 696–701.CrossRefGoogle Scholar
  41. 41.
    Kuhse, Helga. 1998. Why killing is not always worse–and sometimes better–than letting die. Cambridge Quarterly of Healthcare Ethics 7: 371–374.CrossRefGoogle Scholar
  42. 42.
    Miller, Franklin G., Robert D. Truog, and Dan W. Brock. 2010. Moral fictions and medical ethics. Bioethics 24: 453–460.CrossRefGoogle Scholar
  43. 43.
    Steinbock, Bonnie (ed.). 1980. Killing and letting die. Englewood Cliffs, NJ: Prentice Hall.Google Scholar
  44. 44.
    Perrett, Roy W. 1996. Killing, letting die and the bare difference argument. Bioethics 10: 131–139.CrossRefGoogle Scholar
  45. 45.
    Rachels, James. 1981. Reasoning about killing and letting die. Southern Journal of Philosophy 19: 465–473.CrossRefGoogle Scholar
  46. 46.
    Rachels, James. 1979. Killing and starving to death. Philosophy 54: 159–171.CrossRefGoogle Scholar
  47. 47.
    Rachels, James. 1986. The end of life: Euthanasia and morality. Oxford: Oxford University Press.Google Scholar
  48. 48.
    Rachels, James. 2001. Killing and letting die. In Encyclopedia of ethics, 2nd ed, ed. Lawrence C. Becker, Mary Becker, and Charlotte Becker, 947–950. Abingdon: Routledge.Google Scholar
  49. 49.
    Zucker, Marjorie B., and Howard D. Zucker (eds.). 1997. Medical futility and the evaluation of life-sustaining interventions. Cambridge: Cambridge University Press.Google Scholar
  50. 50.
    Woollard, Fiona. 2015. Doing and allowing harm. Oxford: Oxford University Press.CrossRefGoogle Scholar
  51. 51.
    Gillett, G.R., S. Honeybul, K.M. Ho, and C.R.P. Lind. 2010. Neurotrauma and the RUB: Where tragedy meets ethics and science. Journal of Medical Ethics 36: 727–730.CrossRefGoogle Scholar
  52. 52.
    Christakis, Nicholas A. 2001. Death foretold: Prophecy and prognosis in medical care. Chicago: University of Chicago Press.Google Scholar
  53. 53.
    MacIntyre, Alasdair. 1988. After virtue: A study in moral theory. 2nd ed. Notre Dame: University of Notre Dame Press.Google Scholar
  54. 54.
    Christopher, Higgins. 2010. Worlds of practice: MacIntyre’s challenge to applied ethics. Journal of Philosophy of Education 44: 237–273.CrossRefGoogle Scholar
  55. 55.
    Lutz, Christopher Stephen. 2012. Reading Alasdair MacIntyre’s after virtue. London: Continuum.Google Scholar
  56. 56.
    Stern, David G. 2003. The practical turn. In The Blackwell guide to the philosophy of the social sciences, ed. Stephen P. Turner and Paul A. Roth, 185–206. Malden, MA: Blackwell.Google Scholar
  57. 57.
    Winch, Peter. 1990. The idea of a social science and its relation to philosophy. 2nd ed. London: Routledge.Google Scholar
  58. 58.
    Andre, Judith. 2004. Bioethics as practice. Chapel Hill: University of North Carolina Press.Google Scholar
  59. 59.
    Pleasants, Nigel. 2000. Winch, Wittgenstein and the idea of a critical social theory. History of the Human Sciences 13: 78–91.CrossRefGoogle Scholar
  60. 60.
    General Medical Council. 2013. Good medical practice. London: General Medical Council.Google Scholar
  61. 61.
    Frohock, Fred M. 1986. Special care: Medical decisions at the beginning of life. Chicago: University of Chicago Press.Google Scholar
  62. 62.
    Zussman, Robert. 1992. Intensive care: Medical ethics and the medical profession. Chicago: University of Chicago Press.Google Scholar
  63. 63.
    Anspach, Renée R. 1993. Deciding who lives: Fateful choices in the intensive-care nursery. Berkley: University of California Press.Google Scholar
  64. 64.
    Cassell, Joan. 2005. Life and death in intensive care. Philadelphia: Temple University Press.Google Scholar
  65. 65.
    Templeman, Jenni S. 2015. An ethnographic study of critical care nurses’ experiences following the decision to withdraw life-sustaining treatment from patients in a UK intensive care unit. Ph.D. dissertation, University of Salford. http://usir.salford.ac.uk/36188.
  66. 66.
    Jean-Louis, Vincent. 2005. Withdrawing may be preferable to withholding. Critical Care 9: 226–229.CrossRefGoogle Scholar
  67. 67.
    Solomon, Mildred. 1992. Health care professionals and treatment at the end of life. Presentation at the annual meeting of the American Society of Law and Medicine, Cambridge, MA, October 1992.Google Scholar
  68. 68.
    Somerville, Margaret. 2001. Death talk: The case against euthanasia and physician-assisted suicide. Montreal: McGill-Queen’s University Press.Google Scholar

Copyright information

© Springer Nature B.V. 2019

Authors and Affiliations

  1. 1.Medical School, Australian National UniversityCanberraAustralia
  2. 2.Institute of EthicsDublin City UniversityDublinIreland
  3. 3.School of History, Anthropology, Politics and PhilosophyQueen’s University BelfastBelfastUK

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