Withholding and withdrawing treatment, once again

Consider one more pair of cases to challenge the standard view that there is no significant moral difference between withholding and withdrawing treatment.

A patient’s knee became inflexible with age. The only treatment available is an artificial replacement. The patient is competent, informed, free, but eccentric. Consider two cases:

1. The patient doesn’t agree to an artificial replacement, because the patient thinks that if their leg is flexible, they will be expected to do half of the chores in their two-person household, whereas right now they are getting away with doing only a quarter on account of their bad knee.

2. The patient has already received an artificial replacement, but is dismayed by the fact that they are now expected to do half of the chores, so they demand that a physician inject epoxy into the artificial knee to restore the inflexibility they enjoyed prior to the replacement.

In case 1, it is clear that it is a violation of the patient’s bodily integrity and autonomy to force the knee replacement on them, even if one thinks that the patient’s reason for refusal is terrible.

But in case 2, it would be reasonable for a physician to refuse to inject the epoxy, as this would violate the do-no-harm principle which forbids performing medical procedures, even ones requested by the patient, that on balance harm the patient.

Refraining from implanting an artificial knee is an instance of withholding medical treatment. Refraining from injecting epoxy into the artificial knee is an instance of withdrawing medical treatment by disabling a medical device. It’s a different way of disabling than just by throwing a switch, but it is the least damaging way to disable the artificial knee (removing the artificial knee would be tantamount to amputating the leg above the knee).

The judgment that in case 1, acceding to the patient’s refusal is clearly right, while in case 2, refusing the patient’s request for discontinuation of the artificial knee treatment for joint inflexibility at the very least can be right. Hence withholding and withdrawing are not morally equivalent.

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.

Treatment versus enhancement

I don't think you have much hope of having a distinction between treatment and enhancement unless you have the notion of the normal state or proper function of the human body. I previously thought we want a distinction between treatment and enhancement for such purposes as figuring out what the task of the physician as such is and what requests from the patient the physician has a right to turn down flat. For instance, a physician who receives a request to remove a cancer, and who judges that removal of the cancer is feasible, safe and ethically permissible, has a medical duty to either remove the cancer or refer to someone else. On the other hand, a physician who receives a request to pierce a patient's ears for earrings, even though she no doubt judges this to be feasible and ethically permissible, has no medical duty to perform the procedure or refer to someone else, since it is not a medical treatment.

But a new kind of case seems to me to make the distinction even more pressing, and this is cases where it is not possible to ask the patient's consent. Suppose that in the middle of heart surgery, the surgeon notices an old bullet lodged near the heart. The bullet does not impair the heart's functioning, so the patient's consent to the heart operation does not extend to the bullet. But it is intrinsically morally permissible for the surgeon to remove the bullet if she reasonably judges that doing so is good for the patient (of course, there may be laws and regulations that prohibit this, in which case it will be extrinsically impermissible). On the other hand, if a brain surgeon removing a cancer from someone's brain reasonably judges, on the basis of the latest research, that moving a few neurons around will make the subject super-fast at arithmetic with large numbers, that is unacceptable. Likewise, if in the course of a Caesarian the physician notes that the tubes could be tied and judges that the patient would be better off not getting pregnant, that too is unacceptable, whether or not consensual sterilization is permissible (this is, alas, not a hypothetical case).

One can try to handle this with "presumed consent", but that's kludgy, and probably doesn't work. Presumed consent from an unconscious suicidal patient for emergency treatment following the attempted suicide is going to involve dubious counterfactuals, like asking what the patient would want if the patient were fully sane (there might be no fact of the matter about this), and, besides, you probably can't make sense of "sane" without the concept of normalcy. Moreover, we can imagine cases where one can presume that the patient would consent if asked, but the action is still wrong. For instance, one may well know of many patients that they would agree to have a gift of diamonds worth millions sewed into them as a part of surgery, if they were going to be later notified and could have the diamonds safely removed through another surgery and if there was no other way for them to be given the diamonds. But to sew in the diamonds as part of heart surgery, without having sought the patient's consent, is morally impermissible--or at least it's bad medicine.