Life Prolonging Treatment : The Right to Refuse?

(Legal and Ethical considerations)

In medical parlance, a life prolonging treatment refers to all treatments which have the potential to postpone the death of patients suffering from incurable and terminal illnesses.  These conditions may include advanced cancers, failures of organs such as the lungs, heart, kidneys, liver or others and progressive, end stage neurological illnesses.  Advancements in modern technology have made it possible to sustain lives of such patients for several days, weeks or sometimes years with treatments involving cardiopulmonary resuscitation, artificial respiration, cancer chemotherapy, dialysis, artificial nutrition, hydration and other multiple drugs.

The subject has raised a whole lot of new questions and dilemmas in not only the medical and legal  circles but among the general public all over the world.  Media has often extensively covered and discussed such examples.  Legal and medical literature is replete with opinions and judgments on such questions and cases involving legal interventions.  Most such examples have emanated from the West, although there have been a few instances in India.  With a rapid expansion of techno-medical scenario promising almost moon to every individual, the demands of people to live long have also increased. But the costs are tremendous and there are wider gaps in availability of resources, expertise and manpower, infrastructure, awareness and knowledge in providing life prolonged treatment.  This has posed a huge burden on the shoulders of medical practitioners, health professionals and policy makers.

Even more basic than all other considerations is the core issue of medical judgement and its legal sanctity to provide life prolonging treatment.  It is a curious turn of events that medical practitioners tend to look to law for each of their action.  No citizen, much more so a medical doctor can afford to ignore law.  But medical judgements cannot always be surrogated to legal justifications especially since the law is other silent or ambiguous on most of the issues related to prolongation of life.

I give below two real case examples for you all to consider:

The legal considerations as well as the medical opinions guiding the judgements and actions of doctors are yet in an evolving phase in this country on the issue under discussion.  It is therefore, worthwhile to look into examples available elsewhere.  Most of the Western medical associations have come up with more clear guidelines to help doctors to decide action.  The British Medical Association has laid quite comprehensive recommendations on several issues with respect to decision making on ‘withholding’ or ‘withdrawing’ life prolonging treatment.  Needless to say that the guidelines can only act as an aid in the process of decision-making rather than form a protocol of action.  A doctor is essentially guided in his action by the primary goal of medicine i.e. to benefit the patient by restoring or maintaining the patient’s health.

One of the most contentious subject is related to the decision of patients to refuse a life prolonging treatment.  The law generally gives the right to an individual to decide and choose an option.  One is however faced with two different scenarios i.e. in case of a dying patient who may have the capacity to make and communicate decision vis a vis a patient who does not have this capacity (for example because of altered or impaired consciousness).  In other words, a patient may be either competent or may have lost the competence to decide.  Our discussion here refers to only the adults since babies, children and several other groups may not legally possess this competence at all.

Legally speaking, an adult has the full competence to make decisions unless there are doubts on grounds of mental incapability or misconception of reality.  In a famous trial in U.K. (reg. MB (Medical Treatment), in 1997), the Court has rejected the decision of a patient since he believed that his blood was poisoned because it was red.  The mere observation that individual’s decision appears irrational or unjustified to others cannot be taken as evidence of lack of mental capacity.  But doubts may arise if the decision is contrary to the previously expressed wishes.

The right to refuse treatment is firmly established in British Law.  This had been reasserted in other cases including St. George’s Health Care, National Health Service Trust vs S (etc.).  Interestingly, the right of refusal was upheld even in a psychotic patient who held erroneous views on several matters but was considered as correct with respect to refuse amputation of his gangrenous foot.  In the United States too, the Supreme Court in the Cruzan case as well as several other cases had cleared expressed the principle that an individual has the constitutional right to refuse treatment even if this may result in his/her death.  This right has been reiterated in several other judgements even where the patients did not have life threatening illnesses.

Another important issue which has emerged in terminal care is the concept of ‘advanced directives’.  Several sick patient like to leave written (or even verbal) directives expressing their wishes and desires regarding resuscitation and terminal care.  A ‘Do Not Resuscitate (DNR)’ directive by a terminally ill patient is not an uncommon practice in Western medicine.

Most ‘advanced directives’ have got legal sanctions and several judgements of the courts are available on the issue.  In U.S.A., the courts and legislatures have recognized this  legal tool of “advance care planning”.  Following the patient self-determination Act (1990), the hospitals are required to inform patients of their right to refuse medical treatment and to make advance directives.  These directives can be considered at par with the expressed desires of people for example the will regarding inheritance of their properties, wishes to donate eyes and body organs after death, or the method of their funerals and last rites.

The real dilemma is for the doctor looking after a patient who has left a DNR or ‘refusal to get treatment’ order.  The competence of such an advance directive is always challengeable.  On the other hand, providing treatment against the expressed wishes of a patient may also land the doctor in trouble.  The Medical Associations would therefore, recommend that wherever genuine doubts exist about the validity of an advance refusal, the doctor should act in favour of giving at least emergency treatment and buy more time to decide in consultation with the family and the colleagues.

Undoubtedly, the debate on the issue and the dilemma faced by the caring doctors are bound to continue.  No final protocol can be made for the doctors to act.  They need to follow the existing cultural and medical practices of the land.  Nonetheless, more individuals are likely to assert their rights in refusing life prolonging treatments.  The core philosophy in terminal care remains – Exit with Dignity.

Resource References

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Dr Surinder K. Jindal, MD, FCCP, FAMS, FNCCP

(Ex-Professor & Head, Department of Pulmonary Medicine

Postgrad Instt of Med Edu & Res, Chandigarh, India)

Medical Director, Jindal Clinics, SCO 21, Dakshin Marg, Sector 20 D,

Near Guru Ravi Das Bhawan, Chandigarh, India 160020.

Email: dr.skjindal@gmail.com

Website: jindalchest.com

Ph.  Clincis: +91 172 4911000,  Res.  +91 172 2712030/ 31