Dying too soon or living too long? Withdrawing treatment from patients with prolonged disorders of consciousness after Re Y

Abstract

BackgroundIn the ruling in Y [2018], the UK Supreme Court has confirmed that there is no general requirement for the courts in England and Wales to authorise the withdrawal of clinically assisted nutrition and hydration from patients with prolonged disorders of consciousness. The perceived requirement, which originated in a court ruling in 1993, encompassed those in the vegetative state and those in the minimally conscious state. The ruling in Y confirms that the court may still be approached to decide difficult or contested cases, but there is otherwise no routine requirement that the judges be approached.Main bodyThere is much to welcome in this ruling, particularly as it means that these decisions for these patients are no longer (unusually) singled out for a judicial decision, with all the financial and emotional costs that court proceedings can entail. However, there is also a risk that the ruling might have unwelcome consequences. First, there is the possibility that patients might die too soon, particularly if doctors should now adopt the courts’ previous reasoning, which has suggested that patients in the vegetative state lack interests, so treatment may – perhaps must – be withdrawn. Secondly, there is the converse possibility that patients might live too long, since empirical research suggests that – whether intentionally or not – patients’ families, clinicians, and the health system appear to promote treatment-by-default.ConclusionRather than adopt general positions, which may be contestable and potentially risky, this article argues, on a pluralistic basis, that the individual patient should be the focus of any decision made in his or her ‘best interests’. The existing legal framework in England and Wales, which is provided by the Mental Capacity Act 2005, already points in this direction, although more efforts may be needed to ensure that those involved in making these decisions are suitably educated and supported. Fortunately, new guidance from the British Medical Association could help clinicians and families to make decisions in the future, which are appropriate for the incapacitated individual patient in question.

¿Es proporcionado suspender la nutrición e hidratación artificial en pacientes con pronóstico incierto?

“…En el caso de que el paciente sea incompetente, su familia deberá expresar lo que se sabe acerca de sus deseos, y también se debe consultar al comité de ética, si bien el foco siempre debe ser el paciente individual, y cualquier decisión debe tener en consideración su mejor interés (50).…”

Well-Being After Severe Brain Injury: What Counts as Good Recovery?

“…Clinicians may have ethical or religious objections which shape their communication with families about treatment withdrawal, or may themselves lack adequate knowledge or training about the complexities of prolonged DOC. 22,23 The Value of Health Traditionally, the value of health has been understood in terms of its contribution to well-being, (i.e., how well a person's life is going, for them). Health matters insofar as it is good or bad for people, and it is good or bad for people based on the ways it influences and contributes to their well-being.…”

Analyzing the paradigmatic cases of two persons with a disorder of consciousness: reflections on the legal and ethical perspectives

“…Parents began to doubt about severity of the disease and they wondered if their infant would not rather die from starvation than from the disease, which was perceived as unbearable from parents. We found this information important for our discussion, although it is referred to infant patients with terminal pathologies and not adult patients with a chronic condition like DOC, because it seems to underline that the administration of a "time interval" before the death of a patient is crucial for those who care the patient [44][45][46].…”