Ethically withholding and refusing treatment

Ethical Reasons to Withhold and Refuse Medical Treatmentrefuse withhold forgo medical treatment ethics bioethics

One might agree that a doctor should withhold medical treatment in certain situations. But should a patient refuse medical treatment?

Anthony Fisher in his essay Bioethics After Finnis, in a festschrift¹ in honour of Professor John Finnis,² comments on Finnis’s four situations when it would be appropriate to forgo or withhold medical treatment. Two situations where treatment should not be applied are:

1. Where the treatment proposed does not in fact contribute to participation in life or health (e.g. ineffective or at most marginal tests or therapies, substance abuse, and most sterilization, abortion, IVF and “sex change” surgery.)

2. Where the healthcare proposed does indeed contribute to participation in life or health but only in ways that are morally unreasonable (e.g. killing patients to obtain organs, using stem cells taken from human embryos, other ethically dubious therapies, or research).

Reasons to forgo treatment are as follows:

3. Where it is judged by the patient (or other appropriate decision-maker where the patient is incompetent) to be disproportionately burdensome in terms of the pain, physical side effects, indignity, disruption, confinement, risk or cost to that individual or others.

4. Where a patient judges that a particular proposed treatment would be inconsistent with his/her responsibilities. While harmonizing one’s healthcare with other elements of one’s life plan will not justify neglecting life and health entirely, it may be appropriate to forgo certain healthcare opportunities for the sake of rival personal goals or the needs of others. Thus a man might reasonably decide to receive simpler treatments at home, rather than leaving and bankrupting his family to receive a more expensive and experimental therapy.

Worsening Medico-Ethics and Bioethics

The philosophy behind Finnis’s philosophy of law, of which this is a precis of Fisher’s essay on one aspect of it, is that there are basic goods (seven) of which we partake and we realise these goods through practical reasoning. These basic goods exist in and of themselves and are not just a means to an end. For example, health is a good which we enjoy because it is a good and not because it, say, helps us go to work. If something is a good for me; it is a good for you. Goods enable us to flourish, be happy.

Fisher explains that medicine has become a service for a fee or a tool of ideologies without reference to its internal goals and without a coherent ethic. Ethics in medicine has worsened as a result. First, medicine has a poor understanding of the common good and practical reason. Second, thin conceptions of the good (a buffet bioethics where autonomous subjects choose from a range of principles to achieve their prior preferences and a ledger bioethics that purports to balance various debits and credits, usually in favour of prior preferences) are matched by a failure to attend to the kind of character appropriate to medical research and healthcare. Third, a thin conception of the common good, of profession and community  leaves bioethics with little to say about the place of traditions of practice or about social responsibility for provision. Fourth, liberal and utilitarian ethics are ultimately incompatible with and can offer no reasoned basis for the Hippocratic tradition carried forward in the post-war codes of the international and local medical associations. Finally, says Fisher, though providing rhetorical justifications for the preferences of the medical and research establishments, much contemporary bioethics fails to offer ordinary practitioners or patients any clear direction.

To be more than a boon to the medibusiness and the bioethics industry itself, bioethics must follow the best recent moral philosophy into the richly textured terrain of human goods, norms and commitments, natural and supernatural values, narratives, communities and traditions; it must also have a sound understanding of the science, history and craft of healthcare.

In his comment on Fisher’s essay, Finnis also comments on the poor state of medical ethics since the war. This is felt most acutely by those who began their philosophical reflections on ethics in the fifteen years after the war. “In those days, revulsion at the abuses which the Nazis perpetrated – in some fields developing them in seamless continuity with advanced medico-ethical thinking of the 1920s – seemed capable of reversing the slide, accelerating from the late nineteenth century into medico- and bioethical laissez-faire or totalitarian appropriation of utilitarian rationalizations. Oaths and declarations were drafted to affirm, for example, that –

I.5…Concern for the interests of the subject of biomedical research must always prevail over the interests of science and society.

III.4 In research on man, the interest of science and society should never take precedence over considerations related to the well-being of the subject. (Both quotes are from World Medical Association, Declaration of Helsinki. The declaration, drafted in 1964 achieved this form in 1975)

By the turn of the millennium, Finnis says, the World Medical Association had replaced those clauses with –

21. Medical research involving human subjects may only be conducted if the importance of the objective outweighs the inherent risks and burdens to the research subjects. (WMA Declaration of Helsinki revised through October 2008.)

Fisher examines the virtues of healthcare professionals and patients, according to Finnis’s philosophy.

Virtues of Healthcare Professionals and Patients

Virtues traditionally constitutive of good character in health professionals and patients include:

  • respectfulness and fellow-feeling, which ensure an inclination always to treat one’s patients and carers as one’s moral equals and to seek their good, especially life and health;
  • practical wisdom, which enables quick, morally reasonable treatment decisions;
  • courage and patience, including both stretching oneself and coming to terms with finitude;
  • temperance, including taking responsibility for health and moderating healthcare expectations;
  • justice which considers the demands of the common good and prioritizes allocations according to need;
  • mercy or active compassion in the face of “crying need”;
  • fidelity to those with whom one has a special relationship of care;
  • truthfulness and confidentiality towards patients.

Notes
¹Reason, Morality, and Law: The Philosophy of John Finnis, edited by John Keown and Robert P. George (link). A review is available here.
²John Mitchell Finnis (born 28 July 1940) is an Australian legal scholar and philosopher specialising in the philosophy of law. He is professor of law at University College, Oxford and at the University of Notre Dame, teaching jurisprudence, political theory, and constitutional law. He is admitted to the English Bar as a member of Gray’s Inn. He was appointed an honorary Queen’s Counsel in 2017 (source; Wikipedia)

John Finnis featured in the Nobel Peace Prize acceptance speech by Aung San Suu Kyi who noted it was Finnis who nominated her (link).

Further Reading
Hugh McCarthy’s ASC Blog provides A Summary of John Finnis’s Theory of Natural Law
See also: How not to Read Finnis
Much of Fisher’s essay is based on Finnis’s book: Natural Law and Natural Rights
The Nazis believed in medical ethics. But they were a twisted, depraved version, by Prof Reville, Irish Times

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