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

Abstract

I am grateful for all the comments on my target article «Withholding and Withdrawing Life-Sustaining Treatment: Ethically Equivalent? » The comments provide useful contributions to the important debate on this topic. In this paper, I will discuss some of the interesting points raised by the commentators, and the notable challenges raised to my position in the target article. This allows me to clarify and improve the reflections and my position in the target article, to further advance the discussion.What is going on in this debate? My starting point was that while medical guidelines tend to state that withdrawing life-saving treatment is ethically indifferent from withholding life-saving treatment, surveyed health care personnel (HCP) are sceptical to this assertion. Thus, there seems to be a contradiction between the views of practitioners and the guidelines set for their practice.This inconsistency lead to the questions: why the disagreement, and who is right? My answer was that the disagreement is the result of attempts to question certain HCP attitudes, but in the attempt, the guidelines unfortunately make use of flawed ethical reasoning. Thus, regarding the purported equivalence, the practitioners are right. The main problem does not lie with medical guidelines questioning the appropriateness of general HCP attitudes in certain specific situations, but in eschewing these attitudes as generally unsound altogether.In short, my diagnosis was that simplistic ethical theory is used to navigate the complex ethical realities of health care practices. In this paper, I will start by describing the theoretical imaginary of ethical equivalence. My point will be that the "ethical analyses" referred to in medical guidelines is a misnomer. The purported philosophical backing of equivalence referred to in these guidelines is not based on comprehensive ethical analyses, rather on narrow ethical activism.Subsequently, I will move on to discuss the relation between withholding and withdrawing treatment in light of the comments received. This relation is complex and calls for nuanced descriptions. A central question is whether any assertion of ethical equivalence is fruitful for guiding medical practice, and moreover if the assertion misses the target and is redundant in making the points of concern in these guidelines. My answer is that the points of concernmost notably cases of illegitimate persistence of upholding life-sustaining treatmentshould be addressed directly, without invoking an equivalence with withholding that rests on a number of questionable premises. The conclusion of this paper is that this calls for a rewriting of medical guidelines on this point.