Families will struggle with these choices, regardless of whether withholding or withdrawing treatment is being considered. For the ethics consultant, it's good to begin with the understanding that withholding and withdrawing are moral and ethical equivalents. That clears the playing field.
It seems likely that family members who are guilt-ridden - for all the things they did to and for the dying relative and all the things they didn't do - will have great difficulty with any of these choices. As they're losing their relative permanently, all the past can now never be made right. So there's a strong tendency to hold on regardless of the medical circumstances.
Such individuals could never be "responsible" for any proactive choice that would result in their relative's demise. As long as the relative lives, the family member's fantasy of resolving the guilt can continue. And, in no way could they be able to pile on more imagined guilt than they already have.
Withholding treatment might be more palatable, as the family member is only agreeing to the status quo. Withdrawing treatment would require taking action that would change the present circumstances. The family member cannot take on that responsibility in the face of the unresolved issues.
For the most likely small minority of families who are able to let their loved ones go in a humane and medically responsible manner, such questions might not arise.
Matters of withholding or withdrawing treatment depend on the specifics of the case. If there are reasonable expectations regarding quality and length of life, then beginning treatment with targeted reevaluation is appropriate. Withdrawal might be considered at a later date.
If the prognosis is poor from all points of view, and lifesaving measures would only keep the body alive with no other prospects, then withholding treatment seems most appropriate.
Of course, these are hypotheticals and necessarily sketchy.
A fresh perspective may be obtained by considering that our current medical expertise is only a modest upgrade from the days of leeches and bleeding patients. If the human race lasts another 300 years, future physicians and concerned citizens will look back on the 21st century with much of the same horror and bemusement with which we view early 18th-century medicine.
Cancer treatment provides a bracing context. Chemotherapy, ablative surgery, and radiation may be eventually viewed as barbaric rather than "heroic". From another viewpoint, these methods may be the best we have right now. But that doesn't suggest they should be used in all cases. Case-by-case evaluation and treatment would be the most humane approach.
Similarly with percutaneous endoscopic gastrostomy (PEG)tubing. Whereas these may be useful in the ICU in cases in which survival and quality of life are real considerations, such methods of artificial nutrition/hydration are not appropriate merely for ensuring continued life. What's the value of being alive when you're mostly dead?
In clinical bioethics, nothing is straightforward. It is critically important to have an open mind and leave one's prejudices and preconceptions at the hospital entranceway.
David Lemberg, M.S. in Bioethics, Albany Medical College, May 2010
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