Response to: The College of Physicians & Surgeons of Manitoba

Response to: The College of Physicians & Surgeons of Manitoba
Statement on "Withholding and Withdrawing Life-Sustaining Treatment"

By: Alex Schadenberg,
Euthanasia Prevention Coalition, February 8, 2008

The Euthanasia Prevention Coalition is a national coalition of groups and individuals who support measures that will create an effective social barrier to euthanasia and assisted suicide.

The College of Physicians and Surgeons of Manitoba announced on January 30, 2008 a Statement on Withholding and Withdrawing Life-Sustaining Treatment [henceforth referred to as the Statement. see www.cpsm.mb.ca/statements/1602.pdf]. The Statement came into effect on February 1, 2008 , and is binding on all Manitoba physicians.

The Euthanasia Prevention Coalition is concerned that the Statement will result in patients having basic medical care, including fluids, food and the respirator, withheld or withdrawn against a patient’s consent or personal values.

Euthanasia by omission includes the intentional withholding or withdrawal of fluids and food from a person who is not otherwise dying.

Post-modern bioethicists have falsely redefined fluids and food as medical treatment even though the provision of fluids and food do not constitute a treatment of a medical condition, but rather provide a basic necessity of life. Medical treatment is always optional whereas basic care is a necessity that must be provided based on need.

The Statement claims to: "assist physicians, their patients and others involved with decisions to withhold or withdraw life-sustaining treatment by establishing a process for physicians to follow when withholding or withdrawing life-sustaining treatment is being considered. It stipulates the ethical obligations of physicians, open communications aimed at achieving consensus and provides for conflict resolution in circumstances consensus cannot be reached." [No. 1602, 15-S1]

In reality, the Statement establishes that the physician has the final decision pertaining to the withholding or withdrawal of Life-Sustaining Medical Treatment. When the family disagrees with the physician, the physician must attempt to achieve consensus, but when consensus is not reached, the family will receive notice before Life-Sustaining Medical Treatment is withheld or withdrawn.

The Statement does not promote open communication between families and physicians, but rather defines the rights of the physician and informs the family that whether they agree with the physician or not, the final decision on withholding and withdrawing life-sustaining treatment is made by the physician.

Definitions are paramount:

Life-Sustaining Treatment is defined as: "Any treatment that is undertaken for the purpose of prolonging the patient’s life and that is not intended to reverse the underlying medical condition." [No. 1602, 15-S3]

This definition of Life-Sustaining Treatment includes basic care provisions such as fluids and food (provided by any and all means) and respiration.
Traditionally, fluids and food were considered basic care and not medical treatment. Fluids and food provide a basic human need and should be considered basic care and obligatory until the point when the patient is imminently dying and unable to physiologically benefit from its provision or until the burden of its provision exceeds the benefit.

It is important to note that the definition of Life-Sustaining Treatment in the Statement is not the withholding and withdrawal of medical treatment in general but rather treatments that are not intended to reverse the underlying medical condition. Medical treatment that is intended to reverse the underlying medical condition, most likely, will have already been withheld or withdrawn.

Therefore, the Statement is not based on withholding or withdrawing futile medical treatment but rather decisions concerning patients that are deemed to be futile.

"Minimum goal of life-sustaining treatment is clinically defined as the maintenance of or recovery to a level of cerebral function that enables the patient to:
• achieve awareness of self; and
• achieve awareness of environment; and
• experience his/her own existence.
For pediatric patients, the potential for neurological development must be factored into the assessment." [No. 1602, 15-S6]

The Statement says that: "Where a Physician concludes that the minimum goal is not realistically achievable and that life-sustaining treatment should be withheld or withdrawn and there is no consensus with the patient/proxy/representative, the physician is not obligated to continue to reach a consensus before withholding or withdrawing treatment, but must meet the implementation requirements ... before treatment can be withheld or withdrawn." [No. 1602, 15-S11]

Therefore, the physician is not obligated to reach a consensus before withholding or withdrawing fluids and food which may result in the person dying of dehydration. To intentionally cause the death of another person is a very serious decision. It is even more serious when it is done without the consent of the patient.

The Statement also says that: "Where the physician concludes that the minimum goal is realistically achievable but that treatment should be withheld or withdrawn, and the patient/proxy/representative does not agree and/or demands life-sustaining treatment." that a second physician must be consulted. If the second physician agrees that "treatment should be withheld or withdrawn and there is no consensus reached with the patient/proxy/ representative then the physician must provide at least 96 hours advance notice to the patient or proxy. [No. 1602, 15-S12]

Therefore, even in cases where the person is expected to reach the "minimum goal of life-sustaining treatment" as described above, the person can still be dehydrated to death, if two physicians agree that the patients life is futile or lacks a subjective quality of life.

The authors of the Statement must have understood that this part of the Statement would be criticized and therefore it states under the heading of communication that: "the concerns in these circumstances may not relate to clinical assessment or care and may involve values and judgements regarding quality of life."(emphasis is ours) [No. 1602, 15-S12]. By admitting to the reality of subjective quality of life assessments they are trying to deflect criticism by acknowledged these concerns ahead of time. When did doctors become the arbiters of who has the right to live and who must die?

Once again, the Statement is not about withholding surgery or cancer treatment from someone who is unconscious or nearing death. This is about withholding and withdrawing basic care measures.

It is interesting to note that when the "Physician offers life-sustaining treatment but the patient/proxy declines treatment or the representative advocates withholding or withdrawing treatment" the Statement says:
• "If the physician has satisfied him/herself of the matters referred to in the Communications section ... he/she must withhold or withdraw treatment in accordance with the patient/proxy’s wishes." [No. 1602, 15-S10]

In other words, the physician cannot provide life-sustaining treatment, when it is of benefit to the patient, against the expressed wishes of the patient or the consent of the proxy/representative. But it doesn’t work both ways. The physician can withhold or withdraw life-sustaining treatment/care against the expressed wishes of the patient and without the consent of the proxy/representative.

In Ontario, the Consent to Treatment Act recognizes that consent is paramount. The same Consent to Treatment Act defines a ‘Plan of Treatment’ as being comprised of various treatments or courses of treatment and may provide for the withholding or withdrawal of treatment. In both cases consent is necessary.

The Ontario model recognizes that a plan of treatment includes a consent for treatment and non-treatment.

In conclusion the Euthanasia Prevention Coalition opposes the College of Physicians & Surgeons of Manitoba Statement on Withholding and Withdrawing Life-Sustaining Medical Treatment because it directly threatens the lives of vulnerable persons and approves acts which may result in euthanasia by omission.

We recognize that medical treatment may become futile and may need to be withheld or withdrawn under certain conditions. Futile treatments are those that offer little to no benefit based on the condition of the person or where the burden of the treatment exceeds its possible benefit. We do not approve of decisions to remove basic care provisions, such as fluids, food and respiration because the patient has been deemed as futile.

There is a difference between letting a person die and intentionally causing a person’s death by action or omission. The Statement equates omissions that lead to the death of people who are not otherwise dying, with that of omissions that allow a natural death for those who are dying.

Patients depend on physicians who are willing to protect them and give them basic care, as deemed by their human need. Medical decisions must not be made based on supposed "quality of life" arguments that threaten the rights of people with disabilities and demean the value of each individual person.

In Canada medical professionals must be very concerned about safeguarding the trust relationship that exists with their patients. Canadians have a right to quality end-of-life care. Due to our medical system, patients are not free to purchase medical care. Therefore, there needs to be a recognition that the values of individuals should be upheld and protected.

The future of medical care and the confidence Canadians have in our medical system depend on rejecting policies such as the Statement on Withholding and Withdrawing Life-Sustaining Medical Treatment by The College of Physicians and Surgeons of Manitoba.