Health professionals have an ethical duty

The British Medical Association (BMA) recently published guidance from its medical ethics committee on decision making concerning the withholding and withdrawing of life-prolonging medical treatment. It is a very thoughtful and thought-provoking document, the ramifications of which go far beyond the immediate situation it is addressing. The authors are clearly well aware of this.When considering a doctor’s ethical response to “contemporaneous requests for life-prolonging treatment” made by competent patients, the committee observes: “Although patients’ wishes should always be discussed with them, the fact that a patient has requested a particular treatment does not mean that it must always be provided.” They advance four propositions in support of this conclusion, namely: “(a) Health professionals are not obliged to provide any treatment which cannot produce the desired benefit”. “(b) There is no obligation to provide any treatment which is clearly contrary to an individual’s health interests. A life-prolonging treatment may, for example, prolong life but result in severe pain or loss of function so that overall it produces severe harm to the patient”. “(c) Except in an emergency situation, doctors are not obliged to treat contrary to their conscience (though they may be obliged to make an appropriate referral)”. “(d) Where resources are limited, it is inevitable that some patients will not receive all of the treatment they request even though such treatment could be potentially beneficial to them”. Towards the end of their commentary on the last of these propositions, they observe: “Health professionals have an ethical duty to make the best use of the available resources and this means that hard decisions must be made. Whilst this is a much broader issue than can be discussed thoroughly in this document, it is clear that doctors are not obliged to comply with patients’ requests for treatment when they make inequitable demands on scarce resources”. Later they come back to this issue in the context of patients who have lost or never attained competence. In that connection they observe: “Existing guidelines and court judgments have insisted that non-treatment decisions for people who lack the ability to make or communicate decisions should be based on considerations of benefit to the patient and not cost. It is obvious, however, that money spent caring for irreversibly and severely brain-damaged patients is money which cannot be used to treat other patients. This is an issue which needs to be acknowledged and addressed on a national scale as part of the debate on rationing and prioritising resources”.