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 lifesaving 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.

Knowledge and attitudes about end-of-life decisions, good death and principles of medical ethics among doctors in tertiary care hospitals in Sri Lanka: a cross-sectional study

“…Although there is consensus in the medical, ethical, and legal communities that the withholding and withdrawing of life-sustaining treatment at the end-of-life are morally equivalent, there is a growing body of arguments challenging this assertion [16,17]. However, withdrawal remains more emotionally challenging than withholding life-sustaining treatment as was also seen in our study.…”

Patient termination of a life‐sustaining medical device: Suicide or natural death?

“…Likewise, the international community of medical ethicists has overwhelmingly supported the exclusion of withholding or withdrawing life-sustaining therapy at the patient's request from the definition of suicide or homicide. For example, Emmerich & Gordijn [7] cite…”

“…Likewise, the international community of medical ethicists has overwhelmingly supported the exclusion of withholding or withdrawing life‐sustaining therapy at the patient's request from the definition of suicide or homicide. For example, Emmerich & Gordijn [7] cite McGee [8] in stating:

Consider the fact that neither the withdrawal nor the withholding of life‐saving treatment constitutes killing [McGee]. While the withdrawal of treatment might involve some kind of action—the removal of a ventilator, say—it does not amount to killing per se.

…”

Withholding Versus Withdrawing Treatment: Why Medical Guidelines Should Omit “Theoretical Equivalence”

“…(Wightman andDiekema, 2019, Char andHollander, 2019) Here, the question is what is right at the different stages of the treatment and caring relation, and how decisions made influence what is right, most often explicitly regardless of rationing concerns. Indeed, as recently argued (Emmerich and Gordijn, 2019), withholding and withdrawing are not just different decisions, but are part of quite different medical practices. 6 By contrast, the point of ET is to say that there is no difference between withholding and withdrawing treatment, because we at all times just choose to act in the situation we are currently confronted with.…”