Withholding and withdrawing treatment

I have heard that there is a consensus on the equivalence of the actions of withholding medical treatment and withdrawing it, even when the withdrawal requires a positive action from the medical professional (e.g., disconnecting a machine).

Here is a reason to doubt this consensus.

Consider first this pair of cases. In both, the following facts hold. A patient will die within hours without a ventilator, and competently requests that they be on a ventilator. However, an enemy of the patient has very credibly threatened the doctor with death if the patient is on a ventilator tomorrow. The only way the enemy can get at the patient is through the doctor, and there is no way to protect the doctor from the enemy. The difference between the two cases, however, is that in one case, the patient is already on a ventilator and in the other the patient is not yet on it.

If the patient is already on the ventilator, the doctor should refuse to disconnect the patient because of the enemy’s threat. Disconnecting the patient would be a wrongful cooperation in murder, and one should die rather than do that. Disconnecting the patient would be tantamount to murder. On the other hand, if the patient is not yet on the ventilator, then it would be supererogatory for the doctor to ventilate the patient at the expense of the doctor’s life. The doctor does not have the duty to save the patient’s life at the nearly certain expense of their own life. And even if one thinks it is a duty, failure in this duty is far below the wickedness of murder.

But disconnecting is withdrawal and failure to connect is withholding. Thus the two are not equivalent actions, because they can differ in moral evaluation even when done for the same reason (avoidance of the threat).

One might think the two become equivalent when the patient refuses to consent to the treatment (whether its continuation or initiation). It seems odd to think that the patient’s refusal somehow turns both actions equivalent.

But anyway, consider a reversal of the threat case. A “friend” of the refusing patient informs the doctor that they will cut off the doctor’s thumbs unless the patient is on a ventilator tomorrow, and suppose that the ventilation in question is invasive. It seems pretty plausible that in the case where the patient is not yet on the ventilator, the doctor should refuse to invasively ventilate them. For to invasively ventilate the patient would be an assault on the patient’s bodily integrity, and one should suffer a greater loss to one’s own bodily integrity rather than impose a lesser loss on another.

But in the case where the patient is already on the ventilator, it seems that the doctor has no obligation to suffer a greater loss themselves in order to respect the patient’s wish to be disconnected from the ventilator.

Thus, even in the case where the patient refuses consent, withholding and withdrawing are not equivalent.

Medical recommendations and informed consent

It is widely accepted that medical treatments require informed consent from the patient. This requires medical professionals to educate patients, to a reasonable degree, on the relevant scientific aspects of the treatment.

Interestingly, I have been told by a medical ethicist that it is not widely accepted that medical recommendations, whether from one’s individual physician or from a government body, are governed by similar informed consent standards. Thus, before giving you an injection, the physician is required to give you both the medical pros and cons of the injection, but if the physician recommends exercise to you, there is no such education requirement (e.g., the physician is not required to tell a clueless patient that exercise can result in joint pain).

This view seems wrong to me. The main reason for requiring informed consent is patient autonomy. But autonomy can be compromised just as much by recommendations omitting salient information as by actual treatment. Let’s say that Jeeves is annoyed by Wooster’s ugly mustache, and recommends to a Wooster the deliciousness of a particular brand of chocolate, having heard from the factory owner's valet that this brand has been contaminated with a chemical that makes one’s facial hair fall out. Jeeves has violated Wooster’s bodily autonomy through the recommendation almost as much as if Jeeves had shaved Wooster in the night.

Forcing and threatening

Suppose the state thought it had good reason to force me to undergo a medical procedure that I believed to be immoral. The state would have two kinds of options:

1. Threaten me with a variety of serious threats such as deprivation of employment and educational opportunities, fines or imprisonment if I refused to cooperate with the procedure.

2. Force me to undergo the procedure by physically holding me down and performing the procedure.

Intuitively, the threat option seems like the “nicer” option, at least if the threats fall short of imprisonment. And the force option clearly violates standard principles of consent in medical ethics.

But what has struck me was this interesting fact: depending on the details of the case, I might well prefer being forced to being threatened. For if I am threatened, there are two possibilities: either I resist the threat or I give in. If I resist, then I have to suffer the serious losses that were threatened. And if I give in, then I have to live with the knowledge that I have violated my conscience. But if I am forced, then my conscience is clear, I do not suffer any of the threatened losses, and if the procedure is one that is in fact medically beneficial, I get the benefits of the procedure. (And note that it is quite possible to believe a procedure to be immoral while knowing that it is medically beneficial. For instance, one might reasonably think that it is immoral to accept an organ transplant from a prisoner who was compelled by an evil state to yield the organ, even though one knows that the transplant would be beneficial.)

Of course, if asked, I couldn’t very well say: “Please force me.” For that would be consent to a procedure I believed to be immoral. But nonetheless I might prefer the force option. In such a case, it’s hard to say that the threat option is “nicer”. Indeed, it might impose much greater hardship than the force option.

So from the point of view of a state that thinks the procedure is intrinsically permissible and necessary for the public good, it seems that there is good reason to prefer the force option, in that it might impose much less hardship. But this seems paradoxical. It seems obvious that the threat option is better, especially for non-punitive threats that are “naturally” tied to the refusal (“We won’t employ anyone who medically could be vaccinated but refuses to be”), even though the force option seems the better one for both the person being forced and for the rest of society (since it’s more effective).

Perhaps the way out of the paradox is that it is so important for us as a society to maintain the requirement of consent for medical procedures that forcing people to undergo a medical procedure should be avoided except in the most extreme of cases (such as when the very existence of society is at stake), and hence even though the short-term consequences of forcing are better than those of threatening—including morally better for the person being forced who isn’t tempted to violate conscience—forcing should be avoided. But this isn’t a complete solution. For normally we think threats also vitiate consent. But perhaps they vitiate it less?