When autonomy trumps sense: the costs of refusal to allow withdrawal of life support.

In Canada this week, an 84 year old man died after 9 months of treatment
in an intensive care unit. He had severe brain damage and multi-organ
failure, but his family sought a legal injunction to prevent doctors in
the intensive care unit from withdrawing life-support. Over the course
of his long intensive care stay, intensive care beds at a major trauma
centre were closed
so that nurses could used instead to support his
care, and three doctors resigned from the hospital in protest at being
required to provide what they felt was ‘unethical’ treatment.

Samuel Golubchuk had suffered severe brain damage 5 years ago after a head injury, and was subsequently in a long term care facility. He developed a life-threatening chest infection and was admitted to the intensive care unit in late October 2007. He had multiple complications, and appeared to be in what his doctors described as a ‘minimal conscious state’. One month later doctors in the intensive care unit communicated to his family that they believed continuing intensive care was futile, and that consequently they intended to remove Mr Golubchuk’s breathing machine and other life supports. However Mr Goluchuk was an orthodox Jew, and his family argued that to withdraw life support was contrary to his religious beliefs.

There are various contested issues in this case. Doctors involved in this case argued that treatment was ‘futile’, that continuing to provide treatment to Mr Golubchuk was inhumane, and could only prolong his suffering. The family denied medical claims about his limited state of consciousness, maintaining that he remained aware of those around him.

However the fundamental question in this case relates to whether patients or their families can demand treatment at the expense of others. If there were unlimited resources to provide treatment this case would never have arisen.

Although questions of resource allocation are present throughout healthcare, in intensive care such issues are played out every day, and with life-or-death consequences. Like the UK and Australia, Canada has a public health system that provides inpatient hospital care. There are finite medical resources. When a patient occupies an intensive care bed, that bed, and the staff required to care for the patient are not available for others. Many intensive care units operate at close to their capacity most of the time. When they are full patients who are critically ill needing admission must be transferred to another hospital (which is a risky process when you are seriously unwell). Elective surgery must be cancelled, and sick patients on the wards who might benefit from intensive care (but who are perhaps on the borderline of needing that support) are refused an intensive care bed. The pressure to make space so that patients can be admitted often leads to compromises in clinical care. Some patients who are approaching the point where they can be discharged from intensive care are sent to the ward precipitously. Sometimes they cope. At other times their health can be seriously compromised. Samuel Golubchuk’s intensive care stay has certainly cost Canadian tax payers hundreds of thousands of dollars. It may have cost other patients their lives.

But what about the wishes and religious beliefs of patients? Autonomy is often held up as a first order principle in medical ethics. One ethicist in Canada has roundly criticised the doctors in this case for opposing the family’s requests.

“If the doctors’ actions go unchallenged, it will amount to saying that patients and their families are free to choose – as long as they choose what a physician approves. That, alas, is no choice at all.”

In the UK and Australia competent patients and their surrogates have a legal right to refuse medical treatment. For example the requests of a Jehovah’s witness not to receive a blood transfusion is usually respected, even when that request will lead to the patient’s death. However patients generally do not have a legal right to demand treatment from doctors. One way of justifying this asymmetry would be to appeal to Mill’s harm principle. We are justified in infringing someone’s liberty to prevent harm to others. Allowing patients to demand treatment when it is not medically indicated, and/or when there are other patients who are in greater need of a limited resource, will harm others.

It is not clear whether the courts in Canada would have supported the doctors’ decision in this case, or whether they would have upheld the family’s right to insist on the continuation of treatment. In the event, legal prevarication meant that the family prevailed. Mr Golubchuk died in intensive care despite maximal treatment. However this type of question will recur. We could maintain the pre-eminence of patient choice. But that would mean that some will be denied life-saving treatment who genuinely need it, or it will require a vast increase in spending on healthcare to provide for the demands of the few. Neither are palatable options. There are costs to patient autonomy and religious freedom. If there is to be just distribution of precious medical resources there must be limits to those freedoms.

Links

Doctor cites ethical turmoil in decision not to treat terminally ill man
Canada.com 17/6/08

Winnipeg hospitals divert key resources to care for dying man Canada.com 20/6/08

Doctors, religion and the law Globe and Mail 19/6/08

Nature should take its course Calgary Herald 21/6/08

When doctors say no Winnipeg free press 21/6/08

Man at centre of life support controversy in Winnipeg dies
The Chronicle Herald 25/6/08

Why doctors can say no Winnipeg free press 13/2/08

Court of Queen’s Bench of Manitoba ruling 13/2/08

Blogs

Medical Futility 18/6/08

The Mound of Sound 25/6/08

Euthanasia Prevention Coalition 25/6/8

Secondhand smoke 25/6/8

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2 Responses to When autonomy trumps sense: the costs of refusal to allow withdrawal of life support.

  • Dennis Tuchler says:

    The relevant Autonomy is that of Samuel Golubchuk, and he’s not talking. I don’t see how respecting his autonomy is relevant to the decision whether to remove life support. Would Sam want support removed under these circumstances? How does one know? Of course, if Sam is conscious of what is going on around him, there’s no choice. But the physicians and the family don’t really know whether he is conscious.

    There is another way to look at this — dignity — which works better if one is not a thoroughgoing believer in free will. I wonder if dignity isn’t a better way to determine whether to terminate the life of a person like Sam.

  • Dom says:

    Dennis,

    Although Mr Golubchuk’s wishes are unknown, it seems plausible given his religious beliefs that he would have wanted life-sustaining treatment to continue. Even if we accept that, even if, for example he had made a valid advanced directive indicating that he wished intensive care to be continued regardless of his prognosis or clinical state, the key ethical question is whether such desires should trump all other considerations. Unless we believe that autonomy is of absolute and incommensurable value, the questions that I raise still need to be answered.

    Dignity does not resolve the central questions here. Although some (you, and I for example) may feel that it is undignified to die in the way that Mr Golubchuk did, dignity can be interpreted in many different ways. Mr G’s family might well argue that it would be consistent with his human dignity to provide intensive care to him until the last possible moment, indeed that this is the only course of action that would be consistent with their understanding of what human ‘dignity’ requires.

    Finally, you imply that if he were conscious, the ethical issues would be settled. However it does not seem to me that this is necessarily the case. Although we might think that consciousness is valuable, it again is not an absolute. Intensive care may be withdrawn from individuals who are conscious (if for example that is their express wish), or treatment may be denied from individuals who are conscious (if there are others who need that treatment more). Indeed for Mr G’s sake I sincerely hope that he has not been conscious over the last 9 months. If he were conscious he would certainly have suffered from the multiple painful and invasive procedures that would have been required to keep him alive. Yet he was unable to communicate or to undertake any purposeful action. To be trapped in a dying body in intensive care for 9 months, unable to move or to speak might be thought to be one of the worst forms of torture imaginable.

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