Chapter XXVI: Staying to the Very End at the Patient's Side

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Letting Die. Obviously, this concept spans a wide range of decisions. Many such decisions are medically and morally sound. At the other end of the spectrum are criminal decisions such as deliberately causing death of a diabetic child by denying him insulin treatment. (447) The moral arguments tend to focus on that crucial moment in the course of an illness when the patient's death becomes imminent and unavoidable. Quite rightly it is stated that since then all therapy becomes futile, all burdensome interventions must stop, and the doctor's duty is to stay at the patient's side, to care, and bring relief.

However, such a distinct turning point occurs only in some cases, more often in patients dying of cancer than in other persons. The death of every living being is unavoidable, but death at a particular time is often due to a coincidence of avoidable causes.

It would be a most unfortunate result of the moral debate if it were to discourage all doctors who fight for their patients' lives to the very end. Therapeutic obstinacy when the patient is clearly dying is a failure of professional skills and of common sense. The opposite error, allowing the death of patients who could stay alive, is a moral failure, often due to ideological indoctrination.

Refraining from Treatment. Such decisions should not be taken arbitrarily by physicians or hospital officials against the wishes of the patient and the family It is a good and wise rule that the usefulness or futility of a treatment can only be determined together by the physician and the patient: the doctor is best equipped to determine effectiveness, the patient is the authority on benefits, and the two share the assessment of burdens.448

Respect for autonomy must be balanced with beneficence, otherwise it may lead to unnecessary and untimely deaths. A competent person's refusal of treatment must be respected even when the proposed therapy would probably be beneficial; but the doctor should try to persuade. Doctors who refrain from such attempt fail in their duty.

There are very few, quite exceptional situations when the treatment is life-saving, the patient's refusal ill-informed, and there is no way of explaining this to him. The two examples I know from personal experience are: a patient who lost consciousness due to massive bleeding from duodenal ulcer, having first refused to be operated on; and a relapse of ventricular fibrillation in a still conscious patient 409 who had already been defibrillated once and refuses to undergo the electric shock again. In such situations most doctors act against the will of the patient and assume the responsibility We would rather be sued by a living person than take the patient at his word and allow his totally unnecessary death.

A conflict between the patient's stated wish and the doctor's duty may arise in connection with an advance directive or "living will." (450) It is often questionable whether the patient's clinical situation is indeed what the patient had foreseen in the advance directive. Moreover, for treatment-refusing provisos of advance directives to be valid, we have to assume that the now incompetent, gravely ill person would stand by the decision he made when he still was in good health. This is doubtful. Well-documented studies have shown that the opinions of healthy people on life, death, and medical treatments differ from the views of gravely ill patients. The healthy persons tend to display a "cavalier attitude" toward their own lives while the majority of seriously ill patients choose life-prolonging treatments. (451)

A case reported by Dr. A. Dees from Ikazia Hospital in Rotterdam illustrates how a previously stated patient's wish may lead to tragic misinterpretation:

   Mrs. S., 78, was admitted on Friday evening. ... In the last few
   years she had been several times hospitalized because of
   breathlessness. ... She was also diabetic and injected herself
   insulin twice a day. … 

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