Læknablaðið - 15.10.1989, Blaðsíða 43

LÆKNABLAÐIÐ
305
Regarding requests for treatment, including
life-prolonging treatment
3. Physicians also have a strong prima facie
obligation to respect competent patients’ requests
for Iife-prolonging treatment. However, certain
qualifications are relevant:
(a) Physicians are not obliged to provide
physiologically futile treatments (i.e. treatments
that cannot produce the desired physiological
change). Where a physician considers a
life-prolonging treatment not to be
physiologically futile, but nonetheless »futile« in
the normal sense of the word because of the low
probability of success or because of the low
quality of life that would remain, then decisions
about the withholding or withdrawal of such
treatments should be made in the context of full
and open discussion of the nature and extent of
the »futility« of the treatment with the patient or
the patient’s representative;
(b) If a requested treatment entails, according to
the norms of medical practice, loss of function,
mutilation, or pain disproportionate to benefit,
the physician is not obliged to provide it;
(c) If a physician has a conscientious objection to
a requested treatment, that physician is not
obliged to provide it. The physician should
explain all treatment options and his or her
position regarding them. If the patient wishes, the
physician should arrange an orderly transition to
another physician of the patient’s choice;
(d) Scarcity of resources may sometimes require
over-riding a patient’s request for a
life-prolonging treatment (see Part IV).
4. Where an incompetent patient has previously
given a competent advance directive requesting
life-prolonging treatment(s) and/or appointed a
representative to make such requests, physicians
have a strong prima facie obligation to respect
such requests. The same qualifications apply here
as in 3 above.
Regarding requests for interventions intended to
terminate life (voluntary euthanasia)
5. Requests for euthanasia by competent patients
severely and irremediably suffering as a result of
incurable disease may be justified. It is a separate
question whether they should be honored.
Physicians have an obligation to try to provide a
peaceful, dignified, and humane death with
minimal suffering. However, statutory
legalization of the intentional killing of patients
by physicians is against the public interest
(*8 = indicates dissent. Dissents are located at the
end of the statement). Delegates disagreed as to
whether physicians should, as in Holland, be
protected from prosecution if euthanasia were
carried out according to agreed guidelines.
PART II: FOR DECISIONS INVOLVING
PATIENTS WHO WERE ONCE
COMPETENT, BUT ARE NOT NOW
COMPETENT, WHO HAVE NOT EXECUTED
AN ADVANCE DIRECTIVE
These guidelines pertain to situations involving
patients who once were but are no longer
competent, who left no advance directive, and
who have at least two potential future courses of
life depending upon a treatment choice. That
choice may be either: 1) whether to forgo rather
than use a particular treatment, or 2) which of
several possible alternative treatments should be
used.
Guidelines
1. Full medical prognosis. The physician has the
responsibility to discern, to the extent possible,
the patient’s current medical and social situation,
the likely future course of the disease or condition
in the absence of intervention, the full range of
potentially useful interventions, and the likely
course with each of these.
2. Patient’s values history. The physician also has
the obligation to ensure insofar as possible that
the patient’s own values and preferences in regard
to the current situation are ascertained.
3. Duty to inform. Information about all
alternatives that might be beneficial to the patient
should be shared with the patient’s family. The
term »family« should be understood to include
those persons who are available and competent,
have been involved with and concerned about the
patient, are knowledgeable about the patient’s
values and preferences, and are willing to apply
the patient’s values to making the decision. This
term might well include persons not related to the
patient and might exclude relatives.
4. »Substituted judgement« descisions. If the
physician can determine that a particular plan of
care, including the forgoing of particular
treatment, is clearly most in accord with the
patient’s values and if the patient’s family and
direct caregivers concur, then that plan of care
should be pursued.