Issue 8 / 10 March 2014

IS the distinction between euthanasia and withdrawing treatment to “let a patient die” really just a legal fiction?

The law and codes of medical ethics see the act of turning off a ventilator as fundamentally different from that of delivering a lethal injection. But should they?
Expatriate Australian philosopher Peter Singer is one of a number of philosophers to argue the distinction is a dubious one.

“If an incurably ill patient can refuse burdensome treatment, knowing that this refusal will mean his or her death, why should an incurably ill patient who is not being kept alive by any medical treatment, but finds that the illness itself makes life burdensome be unable to seek assistance in escaping that burden?” Singer asks.

Leaving aside the larger question of whether euthanasia should be legalised, should we consider the act of “letting someone die” and killing them to be effectively the same thing?

Legal scholar Dr Andrew McGee, from Queensland University of Technology’s Health Law Research Centre, challenges what he believes is now a “consensus in the academic legal and philosophical literature that there is no real difference between euthanasia and withdrawing life-sustaining measures”.

In an article in Medical Law Review, he cites medical ethicists Dr Franklin Miller and Professor Robert Truog who argue it is “patently false” to see withdrawal of treatment as anything other than causing the patient’s death.

They argue the distinction is a fiction we have invented to legitimise withdrawal of treatment by helping us to believe it does not “cause” death, but simply allows it to happen.

Dr McGee doesn’t agree, arguing that the distinction between withdrawal of treatment and causing death is a valid and useful one.

Doctors do not believe they are committing euthanasia when they withdraw life-sustaining treatment, he says, and the law and traditional medical ethics have supported them in this.

To do otherwise would mean doctors would “nonsensically be discouraged from initiating life-extending treatment” for fear they could be regarded as killers if they later withdrew it.

The act of turning off the ventilator, or removing the nasogastric tube, should be seen not as causing death but merely affecting the timing of it, he argues.

“By providing on-going life-prolonging treatment, we are preventing death only in the sense that we are staving it off or holding it at bay; we are not removing its threat completely by curing the patient”, he writes.

“For this reason, the provision and cessation of [life-sustaining treatment] can be regarded as controlling only the timing of death, rather than as causing death.”

I guess you could apply that argument to any medical treatment, if you consider life itself to be a terminal illness, but that wouldn’t invalidate Dr McGee’s point.

It’s easy to get caught up in semantics when discussing an issue like this.

Distinctions are often drawn between acts and omissions, for example, but it can all get pretty murky when you go down that path.

Removing a life-sustaining drip would clearly be an act. Not replacing the bags supplying the fluids to the drip might be seen as an omission.

It’s hard to see how you could make a clear legal or ethical case that the two were fundamentally different. The effect on the patient would certainly be the same.

Although Dr McGee believes the distinction between withdrawal of treatment and euthanasia is important, he acknowledges there are many grey areas.

What of a patient who asks to have their pacemaker removed, for example? Dr McGee sees this as “a genuine borderline case between a request to be killed and a request to be allowed to die”.

Removal of a pacemaker would be fundamentally different from the withdrawal of ongoing treatment such as ventilation, he argues, since consent cannot be withdrawn after a treatment is completed.

“It is, I believe, essential that we learn to be comfortable with the difficult or borderline cases that this and future forms of life-preserving technology might present, and regulate accordingly”, he writes.

One thing we can be sure of in this debate: drawing clear lines in the sand, and making laws about them, is never going to be easy.

Jane McCredie is a Sydney-based science and medicine writer.

3 thoughts on “Jane McCredie: Drawing the line

  1. Geoffrey Chu says:

    Clinical context, role of medical therapy, clinical course of the patient and prognosis are all important & relevant. In most cases, these factors, the primary intent of medical practitioner and patient is often known with a reasonable degree of confidence. Take for example 2 different clinical contexts. Case 1, healthy pt with severe community acquired pneumonia requiring mechanical ventilation for acute respiratory failure. Advanced life support is in anticipation of full recovery. Case 2, 85 year pt with inoperable pancreatic cancer with ongoing pain and acute pulmonary embolism. Life expectancy and prognosis are vastly different both cases. Goal of treatment in Case 1 is curative and in 2 is palliative. Early withdrawal of therapy in Case 1 would be mischievous and immoral. In Case 2 after informed discussion & consent, withdrawal of anticoagulation may be fatal but is jointly recognised between patient and practitioner that it is futile. It may marginally prolong life with no prospect of cure from an advanced malignancy with poor prognosis.

    Age-old questions of the meaning of life and what happens after we die remain controversial but are highly relevant to all because they ultimately influence and guide decisions. The right to actively end life well before the predicted time of death for the primary purpose of relieving suffering (i.e. euthanasia) can compromise the rights of others to reject euthanasia. The historical experience of abortion, euthanasia and embryonic stem cells supports the phenomenon of slippery slope as real. To advocates of euthanasia, do objective moral values exist and do you have an argument for their existence? What assurance do you provide that slippery slope will simply not happen?

  2. Randal williams says:

    This is not difficult. The key point is INTENT. If  medical intervention  is aimed at speeding up or initiating death then this is active euthanasia. If the aim is to make the patient more comfortable by withdrawing futile treatments and increasing analgesia, and a quicker death is a consequence of this, it is passive euthanasia which is acceptable ethically. The problem with active euthanasia is the ethical ‘slippery slope’ and potential for abuse by institutions or relatives..

  3. Helen Robertson says:

    In times gone past withdrawing a treatment was less contentious than it is now because treatments were less likely to markedly prolong life. However a patient can and should be able to ask for the cessation of a  treatment. 

    I don’t think withdrawing a treatment is the same as actively killing, even if withdrawing the treatment seems likely to hasten death. A treatment is commenced on the hope it will have a beneficial effect (comfort, cure, or prolongation of life, etc); if it is not producing a benefit, it is reasonable to cease it.  If the patient says the treatment (while perhaps prolonging their life) is not working, in that (e.g.) it is not producing comfort, then they should be allowed to have it ceased. 

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