Who Should Make Medical Decisions When a Patient Lacks an Advance Directive?

Patients admitted to the hospital with neurological problems are sometimes incapacitated and unable to make end-of-life decisions. In these instances, without an advanced directive from the patient, clinicians and family members must make critical medical decisions without input from the patient. This paper looks at two cases - one child and one adult – in which neuroprognosis was uncertain, and physician and family members’ beliefs on end-of-life care clash. We provide insight into these disagreements and reflect on how best to manage them. We argue that when considering withdrawing treatment, respecting autonomy is of paramount importance, while decision-making about continuing life-sustaining treatment requires clinicians to ensure surrogates are adequately educated about the principle of beneficence.

THE CONCEPT OF HAPPINESS IN BIOETHICAL RESEARCH (QUALITY OF LIFE CONCEPTION)

The topic of happiness is one of the oldest in philosophical researches. Now it is the subject of interest, in particular, for bioethicists, scientists who are looking for the principles of proper treatment of human life, health, and death. The concept of happiness acquires special significance in the quality of life bioethical conception. The author of the article outlines the origins of the understanding of happiness adopted by the supporters of this conception, as well as gives examples of its application by them (above all by P. Singer, L. Nordenfelt, and J. McMahan). The quality of life bioethical conception adopted utilitarian vision of happiness, developed mainly by J. Bentham and J. S. Mill. According to it, happiness is identified with benefit or pleasure, which can be measured and maximized. In the XX century utilitarians began to consider autonomy – the ability of a person to manage his or her own life and death – as an important element of happiness. The influence of the preference utilitarianism is also noticeable. In obedience to it they see happiness in the ability of person to realize his or her rational and autonomous desires. The medical conditions that does not allow it are interpreted as lack of happiness. Thus, they justify not only the admissibility of withdrawing treatment that doesn’t give the expected result, but also of euthanasia. Killing a person, in terms of the quality of life conception, may not be a lack of happiness if the other alternative is to continue living in conditions that do not allow a person to realize his or her preferences, or does not coincide with his or her ideas of a decent life. The lives of persons who do not manifest rationality and autonomy are interpreted as inhuman, as wrongful, and the person as deprived of the right to happiness. Critics of the quality of life conception point to the subjectivity of the criteria by which happiness is measured. The second reproach is the reference to the absence of a hierarchy of values. That is why they give pleasure and absence of suffering too much importance.

Withdrawal of Treatment in a Pediatric Intensive Care Unit at a Children’s Hospital in China: A 10-year Retrospective Study

Background: Published data and practice recommendations on end-of-life care generally reflect Western practice frameworks; there are limited data that refer to withdrawing treatment of children in China. Methods: Withdrawing treatment of children in the pediatric intensive care unit (PICU) of a regional children’s hospital in eastern China from 2006 to 2017 was studied retrospectively. Withdrawing treatment was divided into medical withdrawal and premature withdrawal as defined. The guardian’s self-reported reasons for abandoning the child’s treatment were recorded from 2011.Results: The incidence of withdrawing treatment from children in the PICU decreased significantly, for premature withdrawal, from a 3-year average of 15.1% in 2006–2008 to 1.9% in 2015–2017 (87.4% reduction). The overall incidence of withdrawal of care reduced over the time period, and withdrawal of therapy by guardians was the main contributor to the overall reduction. The median age of children from whom treatment was withdrawn increased from 14.5 (interquartile range: 4.0–72.0) months in 2006 to 40.5 (interquartile range: 8.0–99.0) months in 2017. Among the reasons given by guardians of children whose treatments were withdrawn in 2011–2017, “illness is too severe” ranked first, accounting for 66.3%, followed by “condition has been improved” (20.9%). Only a few of the guardians ascribed withdrawing treatment to economic reasons.Conclusions: The frequency of withdrawal of medical therapy has changed over time in this children’s hospital PICU, and parental decision-making has been a large part of the change.

Is withdrawing treatment really more problematic than withholding treatment?

There is a concern that as a result of COVID-19 there will be a shortage of ventilators for patients requiring respiratory support. This concern has resulted in significant debate about whether it is appropriate to withdraw ventilation from one patient in order to provide it to another patient who may benefit more. The current advice available to doctors appears to be inconsistent, with some suggesting withdrawal of treatment is more serious than withholding, while others suggest that this distinction should not be made. We argue that there is no ethically relevant difference between withdrawing and withholding treatment and that suggesting otherwise may have problematic consequences. If doctors are discouraged from withdrawing treatment, concern about a future shortage may make them reluctant to provide ventilation to patients who are unlikely to have a successful outcome. This may result in underutilisation of available resources. A national policy is urgently required to provide doctors with guidance about how patients should be prioritised to ensure the maximum benefit is derived from limited resources.

Withdrawing treatment from patients with prolonged disorders of consciousness: the presumption in favour of the maintenance of life is legally robust

The question a judge has to ask in deciding whether or not life-sustaining treatment should be withdrawn is whether the continued treatment is lawful. It will be lawful if it is in the patient’s best interests. Identifying this question gives no guidance about how to approach the assessment of best interests. It merely identifies the judge’s job. The presumption in favour of the maintenance of life is part of the job that follows the identification of the question.The presumption is best regarded as a presumption of law. It has long been recognised as part of the way in which the English law discharges its obligations under Article 2 of the European Convention on Human Rights (the right to life). But even if it is a ‘mere’ evidential presumption it cannot, on the facts of most cases involving applications for the withdrawal of life-sustaining treatment from patients in prolonged disorders of consciousness, be rebutted.