Critical care decisions in fetal and neonatal medicine: ethical issues
Withholding and withdrawing treatment
2.33 The Working Party examined whether there was any case to say that withholding or withdrawing treatment are morally equivalent.22In our view, when healthcare professionals withhold or withdraw treatment in the context of critical care decisions, when guided by the best interests of a baby, they substitute one form of care for another. They may refuse to start or continue a particular treatment when they know that doing so can bring about no benefit to patients or may actively harm them. In these cases, other forms of care or palliative care would routinely be substituted. For example, when mechanical ventilation to support breathing is withdrawn in a patient whose quality of life is described as intolerable (see paragraph 2.16), the medical staff implement palliative care to minimise any discomfort associated with any ensuing difficulty in breathing. Although many people, including clinicians, perceive a moral difference between withholding and withdrawing treatment, the Working Party concludes that there are no good reasons to draw a moral distinction between them, provided these actions are motivated in each case by an assessment of the best interests of the baby. Either withholding or withdrawing treatment
would be an acceptable course of action depending on the circumstances of each case. We note that the RCPCH has reached the same conclusion (see Box2.1).23
| Box 2.1: Royal College of Paediatrics and Child Health framework on withholding or withdrawing life-sustaining treatment
The Royal College of Paediatrics and Child Health first published guidance on withholding or withdrawing treatment in 1997, recognising that there was a need for guidance in dealing with these difficult decisions. A revised edition was published in 2004.*
In a situation where the conditions for one of these categories are not met, where there is disagreement, or where there is uncertainty over the degree of future impairment, the RCPCH advises that the child’s life should always be safeguarded until these issues are resolved. The guidance notes that withdrawal or withholding of life-sustaining treatment “does not imply that the child will receive no care”, and highlights the need for provision of palliative care in order to ensure that the remainder of the child’s life is as comfortable as possible.‡ |
2.34 It is important to clarify that the observations above have no bearing on when to make the decision that it would be appropriate to withhold or withdraw treatment. In practice, in many cases it will be preferable to continue to treat until healthcare professionals can decide
with a reasonable degree of certainty that withholding or withdrawing treatment would be preferable.
22 Some commentators might think discussions of ‘acts and omissions’ could be relevant to the discussions on end-of-life decision making in this Report. However, the Working Party takes the view that when medical staff withhold or withdraw treatment, they do not fail to act, they substitute one form of care for another. The classic critique of the acts and omissions doctrine in the context of taking life is Rachels J (1975) Active and passive euthanasia N Engl J Med292: 78–80.
23 The RCPCH notes that “Ethically the withholding and the withdrawal of life sustaining treatment are equivalent but emotionally they are sometimes poles apart.” Royal College of Paediatrics and Child Health (2004) Witholding or Withdrawing Life Sustaining Treatment in Children: A framework for practice, 2nd Edition (London: RCPCH). See Appendix 9.