Withdrawal of "futile" life-sustaining treatment over family objection.

The Baby Miller case discussed here on Sept. 30, involved the resuscitation of a newborn over the objections of parents who wanted no heroic measures. That dispute represents the classic "right to die" scenario. The "reverse right to die" case -- sometimes called the "duty to die" case -- reverses the roles of family and caregiver, with the latter claiming that further aggressive treatment will not benefit the patient. These so-called "futility" disputes can be difficult to resolve. If the patient doesn't die first, and if the family doesn't change its mind about continuing aggressive treatment, the physicians and the hospital staff are in a tough predicament: (a) keep providing therapy they believe to be unethical to continue or (b) unilaterally remove life-support over the objections of family. Texas is one of the few states in the country with a statute that provides legal protection for the health care professionals and institutions that take the latter course. (See Health & Safety Code § 166.046.) A case reported in an article in today's Independent (London) illustrates the problem:

An elderly woman, whose feeding tube was withdrawn by doctors against the wishes of her family, died in hospital yesterday.

Olive Nockels, 91, became the focus of a legal battle about treating the elderly after being admitted to the Norfolk and Norwich Hospital more than two weeks ago. She was unconscious and doctors suspected she had suffered a stroke after an operation to pin a broken hip.

They advised her relatives last week that there was no chance of recovery. They said using drips and tubes to feed and hydrate her would unnecessarily prolong her suffering and the tubes were withdrawn on Friday 3 October.

But Mrs Nockels' family objected and obtained an interim court order on Monday compelling the doctors to restart feeding and hydration until a full hearing could be held. Ivy West, 60, Mrs Nockels' daughter, said: "We think she would still be here now if they had not taken her drip away for three days before they were forced to put it back."

It will, of course, be a very difficult case in which to prove causation. There is no doubt, however, that the peremptory action taken by the hospital exacerbated the family's distrust. The ethics rules that govern these types of disputes appear to be about the same in Great Britain as they are in the States:

The British Medical Association says the "active and intentional" termination of a patient's life is illegal but adds that medical treatment, including artificial feeding and hydration by tube, can be withdrawn when it is "futile, when it would not be in the patient's best interest ... or when the patient has refused further treatment".

Experience with the Texas law since its enactment 4 years ago suggests that having legal authority for withdrawals of futile treatment actually helps families accept the ethical principle that there are limits to the duty to treat.

Where do disagreements over end-of-life care come from? Michael Wilks, chairman of the BMA ethics committee, said it well:

"If doctors decide a treatment is not providing benefit, it is unethical to continue to provide it. The commonest reason for a breakdown between a health team and relatives is a failure of communication."