Withholding, withdrawing, and the magic of medicine

Consider two cases where a patient ended up with an implanted device D that benefits the patient by ameliorating an otherwise fatal medical condition.

1. Alice got in a fight with Carl the hospital janitor. The janitor grabbed the first weapon at hand—an injector for device D—and stabbed Alice with it, thereby ensuring that Alice now has D implanted in her.

2. Alice’s twin sister Brenda got D duly implanted by Carl’s sister Dr. Diana, a physician at the hospital.

Now suppose that Alice and Brenda both demand a physician to remove D.

It seems that Alice’s demand is completely on par with the demand to remove a bullet or a kidney stone. But normally a physician needs to make a judgment that a procedure requested by a patient is likely to on-balance benefit the patient, and ought to refuse otherwise. If a physician is asked to remove a bullet or a kidney stone, but professionally judges that the patient will die without the bullet or kidney stone, they must refuse the request. It thus appears that the physician ought to refuse to remove D from Alice, unless there are significant burdens from D to Alice (maybe D is not a burden at all, but Alice just wants to die).

But in the case of Brenda, removing D is not just “a procedure”, but it constitutes the withdrawing of a medical treatment. On a standard view, just as one must withhold a medical treatment when a patient competently demands withholding it, even if the treatment would save the patient’s life, a demand for withdrawing is exactly on par, and hence must be honored, even if D does not impose any significant burden on Brenda.

Suppose the standard view is right. Then the above shows you can have two patients who are in exactly the same physical state, and are making exactly the same demand, but the demands are treated differently by standard medical ethics. The reason they are being treated differently is that in Alice’s case, D’s presence does not constitute a medical treatment because D was injected by the janitor in the course of a fight, while in Brenda’s case, D;’s presence does constitute a medical treatment because D was duly injected by a physician.

I find this troubling. It seems to be taking medicine as something magical, as if the status of D inside Alice’s and Bob’s became different when D came to be present “medically”.

Maybe one way to avoid the “magical” thinking is to think that consensual medical implantations come with an explicit or implicit agreement between the patient and the provider (the medical professional or maybe the medical institution) to withdraw the item should one so demand it? Then the magic is not due to medicine but due to promising. (I don’t think this completely resolves the questions, because not all promises need to be kept.)