The Ethics of Foregoing Treatment at the End of Life

Dr Paulina Taboada
Profesor Centro de Bioetica
Pontificia Universidad Catolica de Chile
Alameda 340 Correo Central 1
Santiago, Chile

A basic ethical intuition tells us that we have an moral obligation to preserve life and health. Nevertheless, it is evident that nobody is obliged use all available medical interventions, but rather only those offering a reasonable benefit/risk ratio. A more difficult question is whether one can refuse medical interventions that may entail potential benefits. The care for patients at the end of life frequently confronts us with this kind of questions. In an attempt to distinguish morally obligatory from morally non-obligatory medical interventions, a conceptual distinction between ‘proportionate’ and ‘disproportionate’ medical interventions has been proposed (also known as ‘ordinary’ and ‘extraordinary’ means). The ‘principle of therapeutic proportionality’ states the moral obligation to provide patients with those treatments that fulfill a relation of due proportion between the means employed and the end pursued. Medical interventions in situations in which this relation does not hold, are considered ‘disproportionate’ (previously referred to as ‘extraordinary’) and regarded as morally non-obligatory.

To verify whether there this relation of due proportion exists in a particular case, one has to evaluate the type of therapy, the difficulties and risks involved, the necessary expenses, and the actual possibility of its application, and confront this with the result that can be realistically expected. Also the physical and moral strength of the individual patient need to be taken into account. In other words, in order to be ethically legitimate, proportionality judgments need to be grounded on objective state of affairs regarding both the concrete clinical condition of the patient and the present state of the medical art. The main clinical aspects that need to be considered are the certainty of the diagnosis, the evidence-based utility/futility of the intervention, the benefits and risks presently known for the different courses of action, the accuracy of the prognosis and the ‘costs’, understood in the wide sense of this expression, i.e., including not only financial aspects, but also other kind of burdens to patients, families or health care workers (burdens of physical, psychological, or even spiritual nature).

Although both quantitative and qualitative aspects are tightly interconnected in proportionality judgments and cannot be easily isolated, it might be methodologically helpful both for physicians and patients (or their surrogates) to consider these aspects separately. It is important to establish which aspects of the decision belong mainly to physicians – in virtue of their technical expertise – and which to patients and their proxies, in virtue of their autonomy. Since proportionality judgments refer always to particular clinical situations, it is not possible to establish universal standards for decisions to forgo medical interventions. Hence, the way in which the different elements involved in proportionality judgments have to be weighted in a given situation needs to be guided by the virtue of prudence.

The moral relevance of proportionality judgments is that forgoing a treatment that would have been objectively proportionate would be morally equivalent to an act of euthanasia (by omission). Thus, well interpreted, this principle does not just state the need for proportionality between the means to be employed and the expected results, but rather the absolute moral imperative that the medical professional never ought to intentionally hasten the patient’s death – even when this maysubjectively appear to be a ‘compassionate’ response to the patient’s condition (as some argue to defend euthanasia). Hence, the ethical principle of non-maleficence (primum non nocere), jointly with the principle of proportionality, demand – among others – that before forgoing treatments at the end of life, sufficient scientific evidence is collected as to be certain that our attempt not to harm the patient with ‘disproportionate’ treatments will not actually hasten his death.

Dr. Paulina Taboada, MD, PhD
Palliative Care and Bioethics