Is it ethical to forgo treatment?
CMAJ 1997;157:1741
Re: "The 'Supremes' decide on assisted suicide: What should a doctor do?" (CMAJ 1997;157[4]:405-6 [full text]), by James Lavery and Dr. Peter Singer
In response to: W.A. Lafrance
Dr. Lafrance is correct that in a detailed discussion of consent to treatment (which was not the purpose of our "Supremes" article) "treatment" should be defined, as it is in consent legislation in some jurisdictions.
In terms of nutrition and hydration, "treatment" includes feedings administered by a nurse through a tube, but not chicken soup lovingly administered by a family member. Although I acknowledge that there is a longstanding ethical and legal debate on nutrition and hydration, most courts and commentators have concluded that tube feeding constitutes medical treatment.
Regarding the distinction between terminally and nonterminally ill people, these terms can be arbitrary, prognostication is sometimes inaccurate, and even nonterminally ill people have the legal right to refuse medical treatment.
The extraordinaryordinary distinction has deep religious roots that deserve respect but may not resonate sufficiently across cultures to serve as a basis for public policy in our multicultural society. Nevertheless, one of our greatest ethical challenges is to ensure that health care providers and institutions treat the cultural and religious values of patients, family and staff with the utmost care and respect. My colleagues and I have argued, for instance, that health care facility missions, including those based on religion, should be protected and respected.1
At the heart of our article was the notion that Canada still has too many patients dying in pain or connected to life-support machines they do not want. We must draw clear distinctions between palliative care and decisions to forgo treatment, which are ethical and legal under appropriate circumstances, and euthanasia and assisted suicide, which are ethically controversial but clearly illegal. Any muddying of these waters will lead to another patient dying in pain or hooked up to unwanted life-support equipment. With palliative care and decisions to forgo treatment, it is time to move beyond ethical and legal hair-splitting to focus on improving Canadians' quality of life as they approach death.
Peter A. Singer, MD, MPH
Sun Life Chair in Bioethics
Director
University of Toronto Joint Centre for Bioethics
Toronto, Ont.
Reference
- Miles SH, Singer PA, Siegler M. Conflicts between patients' requests to forgo treatment and the policies of health care facilities. N Engl J Med 1989;321:48-50.
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