A costly separation between withdrawing and withholding treatment in intensive care

Bioethics

Volumn 28, Issue 3, 2014, Pages 127-137

  Wilkinson, Dominic ^a   Savulescu, Julian ^b  

^a WOMEN S AND CHILDREN S HOSPITAL   (Australia)

^b UNIVERSITY OF OXFORD   (United Kingdom)

Author keywords

Health care rationing; Intensive care; Medical ethics; Resource allocation; Withholding treatment

Indexed keywords

CONFLICT OF INTEREST; ETHICS; HEALTH CARE ORGANIZATION; HOSPITAL ADMISSION; HUMAN; INFORMED CONSENT; INTENSIVE CARE; MEDICAL ETHICS; MORALITY; MORTALITY; PASSIVE EUTHANASIA; TIME; TREATMENT WITHDRAWAL; UNITED KINGDOM; VULNERABLE POPULATION;

CONFLICT OF INTEREST; ETHICAL ANALYSIS; ETHICS, MEDICAL; EUTHANASIA, PASSIVE; GREAT BRITAIN; HEALTH CARE RATIONING; HOSPITAL MORTALITY; HUMANS; INFORMED CONSENT; INTENSIVE CARE; MORALS; PATIENT ADMISSION; TIME FACTORS; VULNERABLE POPULATIONS; WEDGE ARGUMENT; WITHHOLDING TREATMENT;

EID: 84894250410     PISSN: 02699702     EISSN: 14678519     Source Type: Journal    
DOI: 10.1111/j.1467-8519.2012.01981.x     Document Type: Article

References (67)

1. This case is fictional, though based on real cases that we have encountered.
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9. discussion 223-224. Some might distinguish between strong forms of ET ('Other things being equal, it is always permissible to withdraw etc.) and weaker forms ('Other things being equal, it is usually permissible etc.). In this paper we refer to and defend the former, strong form of ET. The other way of expressing the ET is that the 'bare difference' between withdrawal and withholding makes no moral difference to the question of whether or not treatment should be provided.
10. This statement of Non-equivalence is based on the idea that it is less morally troublesome to withhold treatment than it is to withdraw treatment. An alternative Non-equivalence thesis might endorse the opposite view (that treatment withdrawal is preferable to treatment withholding). See below.
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53. This sort of mechanism might also resolve residual concerns about intensive care doctors' greater duty of care to existing patients in the ICU. This higher-level triage officer would not have a duty of care to specific patients.
54. There is a separate concern about counselling and consent. Although currently treatment withdrawal decisions are rarely, if ever, primarily motivated by a shortage of intensive care beds, patients' families often cite this concern as one reason for refusing to believe the prognosis offered by doctors, or for refusing to agree to treatment withdrawal. Currently it is possible for doctors to claim sincerely that their treatment withdrawal decisions are only ever motivated by the interests of the patient. However, if resource allocation were allowed to play a significant role in withdrawal decisions in intensive care, this would no longer be the case. Families might be more likely to insist on treatment continuing, even in those cases where doctors are genuinely motivated solely by the patient's interests.
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58. Indeed, this paper might be cited in support of a claim that the standard of care is not to include resource considerations in treatment withdrawal decisions. However, our aim (below) will be to argue that the standard of care should change.
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61. Embracing ET in intensive care does not mean that treatment should be withdrawn whenever there is a patient with a slightly better prognosis in need of a bed. There is often considerable uncertainty about prognosis for critically ill patients; it is rarely possible to quantify survival chances in the way that we have outlined in the cases above, and it may be extremely difficult to compare prognosis between patients with very different illnesses. Furthermore, it may compromise the care of critically ill patients in intensive care if their physicians were constantly attempting to establish their prognosis and to compare them with other patients every time that they were faced with a new admission.
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67. The other significance of long-stay patients in intensive care is that they have a disproportionate impact on bed availability. Queuing models of intensive care admission highlight an exquisite sensitivity of the system to bed crises when there are staff shortages or long-staying patients. M.L. McManus et al. Queuing Theory Accurately Models the Need for Critical Care Resources. Anesthesiology 2004; 100: 1271-1276.