Is it ethical to forgo treatment?
CMAJ 1997;157:1740
See response from: P.A. Singer
In their article "The 'Supremes' decide on assisted suicide: What should a doctor do?" (CMAJ 1997;157[4]:405-6 [full text]), James Lavery and Dr. Peter Singer write: "There are 3 practices along the spectrum of end-of-life care: palliative care, decisions to forgo treatment, and euthanasia and assisted suicide. The first 2 are ethically uncontroversial, legally permissible and part of quality medical care."
The second half of this statement is incorrect, for although palliative care is undeniably and always "ethically uncontroversial," the same cannot be said about decisions to forgo treatment. The ethical character of these decisions depends largely on what is meant by "treatment." Is it "medical treatment" or is it "treatment" that involves not only the administration of remedies by a physician but also the provision of minimal care such as nutrition?
Furthermore, it makes a considerable difference whether the medical treatment being withheld or withdrawn is considered ordinary (proportionate) or extraordinary (disproportionate). A medical treatment is disproportionate if its complexity, cost or risk or the degree of suffering it entails is out of proportion with the potential benefits.
Even committed pro-lifers recognize that proportionate medical treatment can be withheld or withdrawn under certain circumstances, such as at an advanced stage of a terminal illness. In their view this does not constitute passive euthanasia but simply good medical practice.
As for disproportionate treatment, it should never be imposed upon a patient, and it can be legally discontinued at any time. There can be disagreement, of course, as to whether a medical treatment is disproportionate.
It is generally held that if "treatment" includes basic (or minimal) care and if such treatment is stopped at any time in a patient's illness other than in the phase of imminent death, this constitutes passive euthanasia because the patient will die as a result of the treatment being withheld or withdrawn.
If they are to make a meaningful and useful contribution to the euthanasia debate, physicians who talk or write about "decisions to forgo treatment" should be very clear about what they mean.
W. André Lafrance, MD
Ottawa, Ont.
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