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CMF Ethics: Cloning Submission from the CHRISTIAN MEDICAL FELLOWSHIP to the Medical Ethics Committee of the BRITISH MEDICAL ASSOCIATION on WITHDRAWING AND WITHHOLDING TREATMENT Introduction Christian Medical Fellowship is interdenominational and has as members more than 4, 500 British doctors and 1, 000 British medical students who are Christians and who desire their professional and personal lives to be governed by the Christian faith as revealed in the Bible. We have members in all branches of the profession, and through the International Christian Medical and Dental Association are linked with like-minded colleagues in over 60 other countries. We regularly make submissions on ethical matters to Governmental and other bodies and, for example, commented at length[ 1 ] to the House of Lords Select Committee on Medical Ethics in 1993 on matters which include those covered in this Submission. We are grateful for the opportunity to comment on the issues involved in the Bma's Consultation Paper Withdrawing and Withholding Treatment and would be willing to help further if requested. Positional Statements The following concepts in our Affirmation on Christian Ethics in Medical Practice are relevant to this Submission: In Relation to Human Life Acknowledging that God is the Creator, the Sustainer and the Lord of all life. Recognising that human beings are unique, being made in the image of God...
Maintaining the deepest respect for individual human life from its beginning to its end, including the unborn, the helpless, the handicapped, and those advanced in age. In Relation to Patients Giving effective service to those seeking our medical care irrespective of age, race, creed, politics, social status or the circumstances which may have contributed to their illness. Serving each patient according to their need... Respecting the privacy, opinions and personal feelings of patients and safeguarding their confidences.
Speaking truth to patients as they are able to accept it, bearing in mind our own fallibility. Doing no harm to patients, using only those drugs and procedures which we believe will be of benefit to them. Maintaining as a principle that the first duty of doctors is to their patients, whilst fully accepting our duty to promote preventive medicine and public health. We hold the Bible to be the revealed Word of God and find this helpful in giving us principles such as the above to guide decision-making in the ever more complex areas of ethics and practice. General Comments We regret the tight timetable allowed for the production of Submissions on such a vital matter. To circulate a long and complex consultation document in July, just before the holiday season, with a deadline of mid-October has meant that we have not been able to hold as wide a consultation within our own extensive constituency as we would have wished.
Although some of us felt the document meandered, it is certainly comprehensive and we find much to commend in the content. We would particularly commend a presumption in favour of prolonging life in cases of doubt (2. 1), the introduction (a-c) to Basic Moral Principles (2. 8), the refusal to categorise patients on the grounds of disability (eg 2. 8. 4) and the concept of Best Interests (2. 9. 4). Specific Comments Before attempting answers to the specific questions posed in the consultation document, we make a number of comments of a compare and contrast nature: Curing and caring not killing Although we acknowledge that this consultation is not about euthanasia, that subject can never be far away from the issues involved. We hold that intentional medical killing is always unnecessary and always wrong[ 1 ] and has no place in the practice of medicine.
Caring not curing always Medicine has two traditional obligations to prevent death and to relieve suffering. One (cure) deals with the quantity of life, the other (care) with its quality. At the heart of the discussion of withdrawing and withholding treatment is the shifting of the balance from the obligation to prevent death or preserve life to the obligation to prevent suffering and maximise quality of the increasingly precious time that remains. Associated with this, it is essential for the public and the profession to recognise that life has a natural end. For reasons perhaps connected with general loss of commitment to the Christian faith and ethic, death has become a taboo in our society. Rising patient expectations of wonder cure after wonder cure add to the trend for many patients and their families to deny the reality of imminent death.
In addition, many doctors overheat dying patients or treat them inappropriately. This may be partly for the general societal reasons given above, for reasons of defensive medicine, or for more personal reasons. Facing dying patients may raise uncomfortable suggestions of the doctors own mortality, doctors may enjoy giving treatments, or perhaps they need more patients in their trials. One of our members has written movingly of these phenomena in the profession in a recent BMJ Personal View [ 2 ]. Whatever the explanations in general and in individual cases, we are convinced that the medical profession has caused much of the present drive for euthanasia amongst some in our society because of over treatment. It is not necessarily a failure for medicine when the time comes that we can no longer cure; we then change the goals of medicine towards concentrating on caring, a philosophy so well demonstrated by the palliative care movement.
The public needs ongoing education about the limitations of curative medicine. Real not rare It is well said that hard cases make bad law, and whilst we recognise the specific and difficult issue of withdrawing tube feeding in PVS patients, for example, we must acknowledge that such cases are thankfully rare, and not allow principles for decision-making to be driven by hard cases alone. As one of our geriatrician members put it in his evidence to us, most people who die are old. The principles for arriving at ethical answers in withdrawing and withholding treatment situations must work out in practice with those much larger patient groups with, for example, severe stroke. Principled guidance not prescriptive guidelines We believe a key mistake in the generally excellent thinking in the consultation document is that guidelines will solve the problems. Two very recent BMJ articles [ 3, 4 ] have noted that doctors are being flooded with guidelines.
Why is this? The answer probably lies in the current cultural situation of fear and blame. As the consultation document says so well [ 5 ]: how widespread is the impression that when a person dies someone else must be responsible rather than simply illness or human mortality being the cause of death. Perhaps the individual health professional thinks unconsciously: If a patient dies, someone is to blame.
That someone mustnt be me. I must cover myself. If I have followed the guidelines they cant pin anything on me. And in an increasingly litigious society, employers will be anxious to prove that everything was done by the book. However, prescriptive rulebook's dont apply well to medicine. It isnt like that.
It is imprecise, and uncertain. Perhaps prescriptive guidelines of the If A, do B sort may work for a few well-specified surgical conditions, but they are too rigid for ethical application in the vast majority of serious illnesses. Clinical conditions wax and wane, and therapies are iterative, tried on an empirical basis and perhaps withdrawn on grounds which are more often clinical than moral. We call below for more objective research on treatment outcomes and doubtless more knowledge will be gathered, but medicine will always remain an art as much as a science.
We believe it would be a great mistake for the BMA or others to seek narrowly prescriptive ethical guidelines. Each patient, each illness, each situation is unique. The profession needs a set of principles, ethical guidance along the lines we set out here, but not more guidelines of the type swamping the profession. Seniors at the bedside not slaves to bureaucracy Acknowledging that much of medicine is an art, clinical experience is a great help. Difficult treatment decisions of the type being considered by the BMA deserve the presence of the most clinically experienced doctors and nurses at the bedside.
Patients deserve the best. Yet inappropriate management culture within the NHS may mean that those experienced senior professionals cannot give the time they would like to helping make the best decisions at the bedside, incidentally modelling best practice to colleagues in training. We also commend multidisciplinary team approaches with shared information inputs. Often decisions are taken by inexperienced juniors, as isolated individuals, and not by experienced teams together.
Perhaps there need to be cultural changes and restructuring within some parts of the NHS so that patients and paperwork both have the priorities they deserve. Carers and clinicians not committees and courts We favour ethics decisions in healthcare being taken according to the partnership of two experts the health professionals who have their technical areas of expertise and the patient who is an expert in two things: how he or she feels and what he or she wants. Ideally, appropriate professional paternalism and appropriate patient autonomy should be balanced in such a dialogue between experts, to the benefit of both. Decisions would ordinarily best be taken with the patient by carers and clinicians. We do not favour the development of clinical ethics committees most of the ethics committees currently in existence are research ethics committees and many new structures would need to be set up, with dubious benefit. Most of the difficult treatment decisions under consideration are relatively acute and committees would be too slow to respond.
Nor do we in general favour extending the involvement of the courts. Whilst we believe decisions about withdrawal of tube feeding in PVS patients should still go to court, and that there should be no areas in medical practice that the law cannot examine, we do not favour further involvement of law in ethics decision-making. Research not rhetoric Whilst many aspects of caring for a patient with a final illness will always remain to some extent intuitive, we advocate objective research into factors determining treatment outcomes. For example, multivariate analysis of clinical findings can assist in making predictions (eg APACHE scoring in the ITU). Advice and decision-taking can thus be as evidence based as possible, and continuously updated as new techniques make their impact. All the healthcare disciplines should be committed to continuing education and the propagation of proven best practice.
Many of these comments endorse sections of the consultation document, and we make them all in the most constructive spirit. Individual decisions will never be easy and we counsel against any approach that makes them seem so. However, a reliable set of ethical boundaries such as we have tried to indicate within these seven sets of specific comments should set helpful limits for the difficult decisions in each unique case. Answers to Section 3 Specific questions on which the BMA is seeking views 1.
Are there gaps which need filling in current UK ethical / legal guidance about withdrawing or withholding life-prolonging treatments? Are there other legal and ethical problems associated with withdrawing or withholding treatment which are not mentioned in this paper? As outlined above, we dont believe there is currently the right kind of guidance that takes adequate account of the natural history of the illnesses in question or of their responses to therapy. Our own conceptual framework indicates the way we view the legal and ethical issues. 2. Are international consensus documents such as the 1992 Appleton International Consensus used in practice when decisions need to be made? If so, is review of such guidelines necessary?
Few of us are aware of the Appleton Consensus. We doubt this approach is much used by clinicians. 3. If guidance were to be produced, are there good reasons for distinguishing between withdrawing and withholding treatment? If so, what are they? In principle, and from a moral philosophy perspective, we agree with the Bma's position that there is no ethical difference between withdrawing treatment which has become futile and not introducing that treatment at an earlier stage. However, in practice the two may well feel very different to professional and family carers and this must be taken into account at the bedside. 4.
Are there good reasons for distinguishing between the treatment of adults and children when drawing up guidance? If so, what are they? We do not believe there are valid moral differences, though it seems to be a (well-documented [ 6 ]) human instinct to try harder for children. On clinical grounds, children in many situations will tend to do better than adults and prognosis is even more difficult.
For physiological but not moral reasons, guidance about treatment of children may need to be distinguished from treatment of adults in some clinical situations, since their resilience greatly exceeds that of adults. 5. When patients lack the ability to make decisions for themselves, will not recover sentience, and there is no clear indication of their wishes, should withdrawing or withholding treatment be an issue to be decided by health professionals and families alone? We presume from its phrasing that this question addresses issues including the withdrawal of tube feeding in PVS patients. Because to stop giving food and fluid to a patient will inevitably and certainly cause their life to end, we believe this decision, if it has to be considered, should continue to come before the courts. Other treatment decisions which are more clearly clinical, such as considering withholding antibiotics for life-threatening infection, could ethically be taken by professionals and family together. If so, should the decision-making process conform to strict criteria?
N/A What kind of criteria would be appropriate? N/A Are the ones discussed in this paper sufficient? N/A 6. Is there a foreseeable stage at which withdrawing nutrition and hydration from patients who have irrevocably lost sentience would no longer need to go to court? No.
See (5) 7. Is there a role for ethics committees to be involved in making decisions about withdrawing or withholding treatment from patients who cannot express their own views? No (see our Specific Comments above). Most current committees are research ethics ones. New structures of unproven benefit would be needed. Many such decisions are too acute to await the next meeting of the committee. 8.
Are there particularly problematic decisions of this type which should be made only by the courts? As stated, we believe decisions about withdrawing food and fluid from patients in PVS should come to court. Whilst equally sincere doctors disagree about the intention of withdrawing food and fluid from such patients, the fact that the patients death is the inevitable consequence means this decision is different from others. If so, can clear parameters be defined to differentiate those cases sufficiently problematic to require legal overview from those which could legitimately be decided jointly by families and health professionals? It is the certainty of death following the withdrawal of food and fluid from patients not otherwise at the end of their natural lives which leads to this ethical dilemma. For many professionals such action represents a breach of duty of care, and is outside the clinical decision to stop attempts at cure.
There would be particular pressures on nurses in such situations. Would ambiguity about the terms of a patients refusal of treatment or about competence to make valid refusal be the type of case where courts should be involved? Other examples of cases that should come to court might include major conflicts between parties that cannot be resolved after second opinions. However, we repeat our conviction that there should be as little legal involvement in medical decision-making as possible. 9. Does withdrawing or withholding artificial nutrition and hydration form a separate category of decision from any other type of treatment which might be withheld or withdrawn?
Yes. If so, why? The patient will inevitably die as a consequence of withdrawing food and fluids, though the time of death may be unpredictable. Most health professionals feel this is wrong in the five years since the death of Antony Bland a conservative estimate of 1 - 2, 000 patients have gone into PVS and died of it.
Only ten or so cases have come before the courts in that period to request permission to withdraw food and fluids. This suggests that whatever the difficult philosophical issues, the intuitions of about 99 % of family and professional carers are that such an action is wrong. Does society need to agree clear and strict criteria for withdrawing or withholding artificial nutrition and hydration? No. If so, what kind of criteria? N/A Are the criteria and safeguards discussed in this paper (e.
g. a period of monitoring before a decision is made; an independent second medical opinion) sufficient? No. 10. When decisions about withdrawing or withholding have to be made, what are the main factors which health professionals currently take into account when discussing the matter with competent patients? Likely prognosis is the main issue, but the integrity of the health professional in question is important he or she can so bias the presentation of information as to obtain the decision they would prefer the patient made. When deciding how to proceed for patients who cannot express an opinion?
Communicating difficult and uncertain issues to the family, with the highest integrity. 11. How should best interests be defined for incapacitated people? What criteria should be taken into account? In general, we agree with the documents discussion at 2. 9. 4.
We would certainly see capacity for relationships as valuable, but the absence of such capacity where there appears no sentience does not reduce the intrinsic worth of that person in Gods eyes. They are always of value because they remain made in the image of God and He has a continuing relationship with them. 12. If a patient has left no indication of who should be consulted on his or her behalf, how widely should views be sought from people caring for an incapacitated adult? Although there are no legal rights involved, it would certainly be good practice to seek the views of those directly involved in care. However, caution is needed because of the emotional reactions of loved ones, and their other interests, which may or may not be ulterior motives. Should the views of blood relatives take precedence over others?
No. The social work concept of Most caring other is probably the best guide. 13. Is conflict common between different categories of health professionals or between health professionals and relatives? No, but it is not that unusual in most practices and departments. Could conflict between health professionals be avoided or is it a positive spur to well-rounded discussion? Conflict in the sense of adversarial discussion can be constructive and should not be avoided at all costs.
Are there good models for resolving disputes within and between health teams, carers and relatives? Prevention is better than cure. Good communication is important, and the time pressures on understaffed and overworked teams are therefore regrettable. The dialogue between the partnership of two experts is based on mutual respect and open communication, with the aim being to find consensus. 14.
Is there still place for separate sets of professional guidance, attempting to reflect the particular perspective of each profession or is it desirable that all guidelines attempt to reflect a wide multi-disciplinary approach? No. The different health disciplines should all be partners in the same enterprise, and guidance must reflect commonly accepted principles. 15. Should there be more research into how decisions about withdrawing or withholding treatment are made? Yes, but rather than subjective research on the behaviour of health professionals who may not know why they are doing what they are doing, we would favour objective research on outcomes to allow the best clinical evidence base possible. These decisions are often more clinical ones than ethical ones. 16.
Do you consider that there is broad concern about the use of the double effect argument concerning treatment at the end of life? No. We hold the principle of intention as critical in this whole area and have stated above that we believe intentional medical killing is always wrong. Once explained properly, our experience is that health professionals and the public readily understand and support the concept. Incidentally, we find the phraseology double effect unnecessary and unhelpful, seeming in itself to suggest double standards, ie hypocrisy.
We favour the single word intention. The doctors intention is the relief of pain or suffering even though this may very occasionally shorten by hours or days a life which it is not possible to save. Of course, there may in practice be hypocrisy, as doctors can pretend one intention while having another, or there may be unconscious self deception about motives. There are also issues about the knowledge gap we may intend one thing but because of limited foresight achieve another, the meaning well but doing badly situation.
However, despite these issues, intention is the most helpful concept we have in this area. It has legal standing, and there are safeguards. A safeguard to How do we know what the doctors intention actually was? would be to ensure that major decisions were taken out in the open with the widest possible discussion of foreseeable consequences and involving the patient as fully as possible. In addition, where the administration of treatments is concerned, there would be pharmacological safeguards in prescription records of drug dosage and frequency. If so, is the concern shared by health professionals and the public?
Such concern as there is partly reflects genuine confusion, which should be amenable to explanation and education. However, confusion is also encouraged by the euthanasia movement as a cynical campaign strategy. It is in their interests to try and convince professionals and patients that doctors are doing euthanasia already with these big doses of powerful painkillers and what we need now is a law to clarify the position. Would health professionals welcome more debate about the implications of double effect? Some need this helpful and very clear point explained more effectively. 17. Are there additions or amendments that should be made to the list of general points concerning withholding or withdrawing treatment mentioned in section 2. 11 of the discussion paper?
We would only emphasise that parts of this generally excellent summary seem to take too simplistic a view of the likely natural history of clinical conditions and of their responses to therapy. Patients can surprise us by getting better against the odds. 18. Do you know of any existing local or national guidelines which the BMA should take into account if it moves ahead to draw up new guidance? No. Do you know of any innovative ways of resolving problems connected with withdrawal or withholding of treatment? No, other than our approach which establishes the boundaries within which individual decisions are taken.
We do not believe that more prescriptive guidelines will ever give the best results. In these dilemmas, a decision-making framework is of more value than a formula. Ten key concepts in summary: 1. Intentional killing is always unnecessary and wrong. 2. Life has a natural end and there is not necessarily anyone to blame when a patient dies. 3. Doctors tend to overheat towards the end of life, causing demand for euthanasia. 4.
Society needs to break its current taboo about facing death. 5. Considering the Christian faith is essential for a healthy exploration of the concept of death. 6. When accepting that cure is either not possible or not sought by the patient, care continues. 7. The most senior clinicians should be central figures in these decisions. 8. Many of the difficult decisions are more clinical than ethical. 9. Medicine is a biological science with uncertain outcomes but research must improve its evidence base. 10.
Principles for guidance which define ethical boundaries are more helpful than prescriptive guidelines. References 1. Submission from the Christian Medical Fellowship to the House of Lords Select Committee on Medical Ethics. 1993 2. Personal view. Doctors fighting, fleeing or facing up to death. Goodall J.
British Medical Journal, 1 August 1998; 317: 355 - 6 3. Editorial. Wheres the chief knowledge officer? Muir Gray J A. British Medical Journal, 26 September 1998; 317: 832 4.
Guidelines in general practice: the new Tower of Babel? Bible A, Kansas D, Pencheon D, Poole's F. British Medical Journal, 26 September 1998; 317: 862 - 3 5. Withdrawing and Withholding Treatment: a consultation paper from the Bma's Medical Ethics Committee. 1998. p 5 6. Ibid.
p 14 Christian Medical Fellowship October 1998 Homepage About CMF Ethics homepage Site Index Copyright? 1998 Christian Medical Fellowship. Comments, suggestions, information: Email CMF is a registered charity (No 1039823)
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