Withdrawal Life Support and Let Dying Ill Patients: Right or Wrong Decision

Health care decision making is characterized by uncertainty. In the clinical practice one never knows in advance that whether one has made the right decision, or has opted for the right or the best option. Even if, medical decisions may result in serious harms and burdens, the ethical principles all in all are not applicable to health care. These principles hold one accountable that no harms will result from the actions or policy. However, in clinical practice it is an obligation to do well for the patient and have to weigh the beneficences against possible harms. The purpose of this paper is to identify certain ethical issues in the given scenario and critically analyze them by using different ethical approaches, and to reach the best possible practical solution. Journal of Clinical Research Bioethics J o u r n a l o f C lin ical Resrch& Bioe t h i c s


Case Scenario
In my nursing profession I came across a clinical case in one of the private hospital, where a thirty years old male patient, with multi organ failure, who was on ventilator support for ten days, went through the withdrawal of life support. This withdrawal was made on the basis of family request due to their personal issues. When the support was withdrawn, the patient was fully conscious, with GCS 10/10 and the clinical reports were showing 20% survival chance. Later on, it was identified that the main issue of the family was financial burdens for the patient treatment. As the patient was on continue treatment since last two years and family did not have such resources to continue his treatment. In this case, the patient was left to die, although, he was still having chance of survival [1].

Critical Analysis
Looking at the nature of above clinical case, it is clear that because of some prominent ethical concerns related to the decision made by the health care professionals. As human life is very precious and as Muslims we know that it has been declared absolutely inviolable by God. Now looking at such inviolability and preciousness of life, it is very clear that nobody has the right to destroy it so easily and especially in cases like this, where the patient was fully oriented and had 20% chances of survival. In this case, the health care professionals might misused the concept of autonomy and may argue that patients and family are ethically autonomous to select appropriate treatment for themselves and to refuse treatment at any point. But the questions arise: Is autonomy superior to life? Or can autonomy override the sanctity of life? Obviously the autonomy cannot be superior to the sanctity of life; however, in this case, it seems that autonomy has overridden the sanctity of life, which is really beyond the limits of ethics. It is true that patient's or family rights should be respected but in the limits of ethics, where it is said that if a situation occurs, where the patient does not have any chance of recovery, and has no hopes for quality life, then in such situations the withdrawal of the life support might be thought. Looking at the decision in this case seems as beyond the boundary of ethics because in this case, there are still 20% chances of remission towards the recovery, which shows that enough respect was not given to the life and the professional obligations. Moreover, a clash between the ethical principles has been created by respecting one that is, autonomy and ignoring the importance of other basic principles such as justice, beneficence and non-beneficence. In this case the financial constraints and physical burdens of the family members appears as one of the strongest influencing factors for withdrawal of life support, because of which the family and the patient were agreed to let him die. If we see it from ethical point of view, this decision cannot be justified because any ethical law never permit to let someone die, rather to search the financial support if needed, maximize the physical and medical support to preserve the life.

Ethical Approaches
The patient did not deserve the withdrawn of life support, rather he deserved the appropriate interventions for treatment and minimization of pain and ultimately to gain justice, but here the preference was given to patient's autonomy and life support was withdrawn, but there is no literature through which the withdrawal of life support on patients' wishes can be proved in conditions, where there are still some hopes and chances of survival. Gratton [2] argued that if the death process is long and painful, then the health care professionals might have the ability to think about the withdrawal of life support to let the patient die with peace and dignity. However, in the above scenario, the patient condition did not follow the need for withdrawal from life support, and hence it cannot be justified. Furthermore, obligation for autonomy is in conflict with justice due to allocation of scarce resources. But, if it is not possible to continue life support due to lack of resources, then how could it possible to respect his autonomous request of withdrawal. This is an instance of the way in which obligations to respect autonomy can clash with justice.
History of human kind from the beginning till to date shows a very clear continuation of inequalities in different aspects of life such as social, political, cultural and economic aspects. Worldwide the standard of needs and facilities is unequal and differ from region to region, country to country, and even from culture to culture. This whole story of inequality is revolving around the concept that how much a country or region is developed and wealthy. This system of unequal distribution of needs and benefits based on development of a country is not only limited to social, political, cultural and economic inequalities but also gives rises to an unequal health care system worldwide. It means that the people of developed countries enjoy their lives because they are equipped with a best approved quality standard of care while on the other hand people in the developing counties face the miseries of health problems. According to Wendler et al. [3], that people who lives in the developing countries, experiencing far greater disease burdens and shorter lives than people lives in developed countries. These disparities in health care compel the developing countries to adopt a poor standard of care. In the scenario, the patient was withdrawn from life support due to scarce resources and hence, obligation for justice was not taken care. Here one can think about the patient's and family worries about financial constraints and coercions, which compel them to choose death for the patient, therefore, we can assume that the decision was of the autonomous but not voluntary decision.
Moreover, the proponents of the withdrawal of life support may also argue that in case, where the patient does not have quality life anymore, but the life is a misery for him, then there is no need to keep him alive in such misery [4]. However, in our case, there were still signs of life because till the withdrawal, the patient could perform nonverbal communication very well, he was having a good orientation and understanding, the patient was calm and fully aware of everything around him, therefore it was against the principle of justice. The decision made was based on patient's autonomy, therefore, the decision could be analyze through Kant perspective as well, because Kant has done a marvelous discussion on the concept of human autonomy. Kant's concept of autonomy is such that the individuals are free from the external forces but it does not mean that the individual is absolute free or autonomous because this individuals is also bound by the internal rational will [5]. Therefore, it seems that the autonomy is not absolute and the individual does not have the full right on his own life. It is very clear from Kant's point of views that the individual's autonomy cannot qualify self-determination [6]. Therefore, in the above scenario, that even the decision was made by the patient and family about the withdrawal of life support is not correct.
In a clinical setting, the idea of autonomy according to a Kantian account requires that the practitioner has a well-grounded knowledge and sense of what leads his or her own decision making. This requirement of self-recognition as a rational agent and self-reflection is independent of the values and outcomes that may also influence the exchange of communication [7]. So, from this perspective, respecting the autonomy of patient in a clinical setting requires respecting the patient as an equal, in the ability to self-reflect and make choices. According to Mill, actions and choices are to be judged as 'right' or 'wrong' in terms of their promotion of happiness [7]. Therefore, in the above scenario, the health care providers could counsel the patient and family, continue the treatment and solve their issues, rather than follow the request of the family and let the patient die. According to Black [8] that international code of medical ethics by declaration of Geneva says, that the doctor owes to his patient complete loyalty and all the available resources of his/her science. The oath suggested for the physician that the health of patient will be his/her first concern. These ethics extend to the consent never to harm the patient, and include decision making about health and death, and also extends to political and social advocacy on the patient's behalf. However, these medical ethics were totally missing in the above case.
Bailey [9] introduced the best interest principle. This principle is a guiding principle for decision making in health care, in order to promote the good of patient to maximize. This principle is usually referred to decision making about intensive care treatment, as a mean of justifying, withholding or provision of care. Advances in medical sciences allow health care providers to prolong human life through extra ordinary efforts fostering debate regarding what is considered medically appropriate as opposed to that what is medically useless. Health care professional are expected to practice in an ethical manner, and when working in situation to respect patient autonomy due to lack of resources and resulting harm, may experience ethical distress. Although, availability of high tech measures by implementing may be postponing death or may decrease suffering prior to death.

Conclusion
In conclusion I would say that while making important decisions such as decisions about the life and death, one needs to consider the value of life, because if we see from any angle, nothing can be compared with the sanctity and preciousness of life. Being a health care professional, before making decision we need to balance our decision in the light of ethical principles, theories, and human rights, before letting someone to die. We also need to measure the consequences of our decision and should avoid bad consequences. In this case the value of life was lost because of financial and physical burdens of the family. Moreover the basic professional obligations were ignored, patients and family autonomy was given preferences on other principles and even on the value of life as well. In the above situation, the patient treatment should be continued and family should be counsel, and as healthcare providers, we should advocated for the right of the patient, and explore financial resources to avoid such cases in clinical practices. The decision should be based with the obligation of respect for autonomy, as well as respect for beneficence and non-beneficence. However, it is important to justify the decision within moral boundaries, including respect for beneficence and non-beneficence. So, as a health care providers, we should adopt those steps which are beneficial for the patients, not harming them, and well justifiable in moral boundaries.