Legal and Ethical Considerations for Withdrawal of Life-Sustaining Treatment
Discuss who has the legal authority to make the decision about withdrawal of life-sustaining treatment, in this case, identifying and explaining relevant ethical and legal considerations.
In Australia, the laws dealing with the patient at end of life are unambiguous and complex to understand, since laws are different in distinct states and territories (QUT, 2016). In a situation to decide whether to withhold lifesaving treatment when the situation seems hopeless or to withdraw life-sustaining treatment when there is less or no chance of recovery attracts numerous questions on both medical and ethical grounds. Decision-making in such situations is very complicated. It questions both logic and emotions simultaneously. It also raises complex questions relating to the relationship of legal and medical ethics and principles; and rights associated with it (Douglas, 2013). Simply put, various complex legal, clinical, and ethical issues are identified when deciding whether to withdraw or withhold the life support of a dying patient.
Consideration of the medical condition of the patient and the wishes of patients or their families holds the weightage in the decision-making process. Other factors like goals and values of the patient, the balance of burden and benefit from the treatment, and the patient’s best interests are considered. The duty of clinicians’ is to manage discussions and decisions taken by the patient or their families, respecting patients’ autonomy (Kerckhoffs, 2019). If legal concerns relating to the proposed medical decision arise then hospitals may seek court or tribunal opinion and family members may seek judicial intervention. Issues related to withdrawing life-sustaining treatment came up in front of the Australian Supreme Court. Generally, such cases are heard in parens patriae jurisdiction where the test of “best interest of the patient” is applied is. However, the meaning and scope of the “best interest” test still lacks clarity and appears vague. As a result, courts mostly consider patient and family wish even if they have deferred views about treatment decisions than medical practitioners (Long, 2019).
The most vulnerable patients require life support and are usually near or at the end of their life. In the majority of cases, patients even lack decision-making capacity and the decision is made by their closest person or legal documents (Willmott, White, Smith, & Wilkilson, 2014). Every adult has the right to take a decision for their well-being. So, consent of the patient is essential for medical treatment to become lawful. However, such consent is only valid if the patient concerned has the capacity or is competent enough to give consent for his betterment. Patients without competency, due to being physically unwell or unconscious, or mental inability, cannot make the decision for their medical treatment. In such cases, the legal authority to make decisions can be by:
- Advance directive- The patient has decided in advance which medical treatment to be used. It can be used for specific instructions on treatment, including refusal of treatment.
- Substitute decision-maker- Closest person to the patient can make the decision, keeping in mind what would the patient have wanted and their best interests. In the absence of an Advance Directive, substitute decision-maker decides for patients. Guardianship legislation in each territory and state, allow someone else, for example, a family member or friend, or a public guardian appointed by the statutory body to take medical treatment decision on the patient’s behalf.
- A Tribunal or the Australian Supreme Court can decide for the patient.
In Australia, it is lawful for an adult with competence to make their own medical treatment decisions. Refusing medical treatment is also allowed, even if such a decision may result in their death (ACSQHC, 2019). The autonomy of the Patient is respected in such cases. If directed, doctors can legally withhold i.e., not start treatment or withdraw i.e., stop the ongoing treatment. Even in the case of life-sustaining treatments. The substitute decision-maker can also make such a request for withdrawal of life support. However, Patients, substitute decision-makers, and Tribunals cannot demand treatment which contradicts the ‘best interest’ test laid by the apex court of Australia. By application of the following four ethical principles, a patient at the end of life can have dignity (Queensland Health, 2018).
- All decision-making must involve respect for the patient’s life and right to choose.
- All decision-making must be per the standards of good medical practice.
- Efforts for a collaborative approach must be taken to obtain consent.
- Decision-making must involve accountability and transparency.
Decision-Making Process for Withdrawal of Life-Sustaining Treatment
Decisions of life-sustaining measures are mostly based on the standards of good medical practice, which involves obtaining patient’s consent when there’s time to do it, or consent, by their substitute keeping patient’s best interests in mind (Luce & Alpers, 2015).
In the case of Ms. Heyer, who is on life support is incompetent to make medical treatment decisions for herself. Her wife Alison and father John can decide on her behalf keeping the best interest of Ms. Heyer and her goals and values of life. The suggestion given by the clinical team is to withdraw life-sustaining treatment i.e., Artificial ventilator support after observing for a few days. Alison is adamant to keep Ms. Heyer alive through life support. But Ms. Heyer’s father is in favor of withdrawing ventilator support since he was aware of his daughter’s life goals and values. He wants her to go peacefully. The dilemma in such a difficult situation is to address the question of whether to choose quantity or quality of life with the help of science, technology, and medicine that preserves life in terms of quantity with little quality. Being alive by any means is not living. Respect for life does not only mean being preserved at all costs. For patients in critical condition, the benefits of life preservation must be weighed against its subsequence, which includes suffering, pain, compromise of dignity and freedom, and monetary expense. Everyone regardless of gender, race, age, culture, or lifestyle, is entitled to empathy and dignity at the end of life.
Other countries have taken various approaches while making dealing with a sensitive issue overlapping ethics, health, and legal spheres. Under UK legislation, physicians are entitled to decide the suitability of life-sustaining treatment. However, only by the decision of the tribunal life support can be withdrawn for patients in a minimally conscious or permanent vegetative state.
Canadian laws make it legal for competent patients to refuse life-saving or life-sustaining treatment. Even their substitute decision-makers (SDM) can also make such decisions on the incapable patients’ behalf. The law also provides clarity that patients or SDMs can refuse the life-sustaining treatment while keeping the best interest in mind. Similarly, in Australia legislation requires consent either from a competent patient himself or SDM in case of an incapable person. Withholding of CPR in “acute emergencies” is also allowed under certain conditions.
References (APA Sixth Edition)
ACSQHC. (2019). National Consensus Statement: Essential elements for safe and high-quality end-of-life care. Retrieved from Australian Commision on Safety and Quality in Health Care:
https://www.safetyandquality.gov.au/publications-and-resources/resource-library/national-consensus-statement-essential-elements-safe-and-high-quality-end-life-care
Douglas, B. W. (2013). The right to choose an assisted death: time for legislation? ACT, 11.
Kerckhoffs, M. C. (2019). Selecting and evaluating decision-making strategies in the intensive care unit: A systematic review. . Journal of critical care, 39-45.
Long, A. C. (2019). Agreement with consensus statements on end-of-life care. Critical Care Medicine.
Luce, J. M., & Alpers, A. (2015). Legal Aspects of Withholding and Withdrawing Life Support from Critically Ill Patients. ATS .
Queensland Health. (2018, January). End-of-life care: Guidelines fordecision-making about withholding and withdrawing life-sustaining measures from adult patients. Retrieved from Clinical Excellence Division: https://www.health.qld.gov.au/clinical-practice/guidelines-procedures/patient-safety/end-of-life
QUT. (2016). Australian law at the end of life: An overview. Australian Centre for Health Law Research.
Willmott, L., White, B., Smith, M. K., & Wilkilson, D. J. (2014). Withholding and withdrawing life-sustaining treatment in a patient’s best interests: Australian judicial deliberations. Medical Journal of Australia, 545-547.
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