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Terminating Treatment:

Grounds For and Against 

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A.    Consent Elements 

1.    Patient's informed consent/refusal of treatment/demand for treatment/demand to die.

2.    Substituted judgment: decision made by another, but based upon an attempt to determine what the patient himself/herself would choose if competent.

3.    Proxy consent/refusal demand: decision made on behalf of the patient by a designated agent, ideally based upon the agent's judgment as to what is in the patient's best interests.

4.    Family's or friends' wishes in the matter: decision based upon the best interests, values, etc. of the family and/or friends themselves.

5.    Consensus judgment: of any or all of the following: patient, family, friends, health-care professionals, hospital ethics committee.

B.    Quality of Life Judgments

6.    Patient's quality of life: determined wholly from the perspective of the patient himself/herself.

7.    Evaluation of the patient's quality of life from the perspective of an observer: e.g., "I don't know what that state of life feels like from the inside, but I consider it unacceptable."

8.    Disvalues for treatment: Pain, risks, indignities, uncertainties, displacement, disruption of relationships.

9.    To prevent the patient from "losing hope"

10.    Family's quality of life

C.    Medical Judgments

11.    Determination that death has already occurred

12.    Efficacy of treatment: "Treatment wouldn't do any good anyway."

13.    Reversibility of illness

14.    Imminence of death: "She doesn't have long to live no matter how much we do."

15.    Standard-medical-care policy: assumes that a given procedure is obligatory if its use is "standard medical care" in cases of this clinical type.

16.    Medical-indications policy (Ramsey 1978): assumes that a given procedure is obligatory as long as there exist "medical indications" or "biological indices" for its use.

17.    Implications of the patient/professional relationship: "Patients expect their physicians to ..."

18.    Principles of professional ethics

19.    Goals of medicine: e.g., to extend life, to relieve suffering, to restore health, etc.

20.    Educational values: "To attempt to extend this patient's life for a short period could teach me how to save lives of future patients."

21.    Research values: "Medical science could learn something from this patient which would save lives of future patients."

D. Other-Regarding Judgments

22.    Patient's obligations to others: "The patient owes it to his children to allow them some time to adjust to the prospect of his death," or "The patent owes it to his family to spare them the agony of a prolonged death watch."

23.    Family's obligations to patient: "The family owes it to the patient to spare her this suffering," or "The family owes it to the patient to see that everything is done that can possibly be done.

24.    Family's obligations to its members and others: "The family members owe it to themselves not to prolong their agony in a protracted death-watch," or "They  owe it to his friends to allow them time to adjust to the prospect of his death."

25.    Societal obligations to patient: e.g., to provide treatment resources, to spare the patient from pain and indignity.

26.    Societal needs: e.g., for the resources required to sustain this patient, for the moral example the patient could provide.

27.    Public health issues

28.    Allocation of resources issues: e.g., effects of denying resources to others, issues of equity, social worth of patient, expenses of treatment.

29.    Effects on health services personnel who must work with the patient.

E.    Conceptual Elements

30.    Ordinary/extraordinary measures distinction

31.    Natural/artificial support distinction

32.    Killing/allowing-to-die distinction

33.    Active/passive measures distinction

34.    An "act of mercy"

35.    Providing "a good death"

36.    To avoid "playing God"

37.    To avoid acting "contrary to Nature"

38.    To avoid "prolonging dying"

39.    To satisfy the precept "do no harm"

40.    Deontological religious standards: accordance with God's will, the Ten Commandments, other biblical dictates, etc.

F. Moral Principles

42.    The Golden Rule: "because this is what I would want done if I were in the patient's shoes (or bed)."

43.    Principle of sanctity of life

44.    Principle of right to life

45.    Principle of value of life

46.    Slippery slope objections: even though this act may not be wrong in itself, undertaking it may incline us in the future to perform acts that are clearly objectionable.

47.    Appeal to the "symbolic meaning" of treatment (or nontreatment)

48.    Appeal to the long-term consequences of this decision: e.g., disabilities become intolerable; the infirm may feel social pressure to refuse treatment.

G. Factual Appeals

49.    "A miracle cure might come along."

50.    Appeal to uncertainty of diagnosis, prognosis: "We cannot know for certain that death is near."