Concepts like testimonial injustice (Fricker, 2007) and testimonial violence (Dotson, 2011) articulate that marginalized epistemic agents are unjustly undermined as testifiers when dominant agents cannot or will not hear, understand, or believe their testimony. This paper turns attention away from these constraints on uptake, and towards pragmatic, social, and political constraints on how dominant audiences receive and react to testimony. I argue that these constraints can also be sources of testimonial injustice and epistemic violence. Specifically, I explore a kind of (...) injustice that I call testimonial withdrawal, which occurs when a would-be speaker chooses to remain silent because they know or reasonably expect that there is pragmatic risk associated with speaking, given their unjust marginalization. I argue that this unjustly undermines epistemic agency, and that expanding Fricker and Dotson’s umbrella concepts to accommodate this idea results in a better understanding of the moral and epistemic contours of both testimonial withdrawal and these broader categories. (shrink)

While agreeing with the main conclusion of Dominic Wilkinson and colleagues (Wilkinson, Butcherine, and Savulescu 2019), namely, that there is no moral difference between treatment withholding and withdrawal as such, we wish to criticize their approach on the basis that it treats the widespread acceptance of withdrawal aversion (WA) as a cognitive bias. Wilkinson and colleagues understand WA as “a nonrational preference for withholding (WH) treatment over withdrawal (WD) of treatment” (22). They treat WA as a manifestation of loss aversion (...) and refer to Kahneman and colleagues (1991), which defined this effect as follows: “the disutility of giving up an object is greater that the utility associated with acquiring it” (194). In a previous work, Wilkinson and Savulescu understood nonequivalence between treatment withholding and withdrawal as a reflection of slightly different, although related, phenomena: status quo bias or omission bias (Wilkinson and Savulescu 2012, 130–131). In neither of these two papers do they describe precisely the relation between these well-known psychological effects and WA, nor do they explain why they treat these effects as examples of nonrational preferences, despite the fact that these issues have been the subject of wide-ranging discussions on the intersection of psychology, economy, and philosophy. (shrink)

If a doctor is trying to decide whether or not to provide a medical treatment, does it matter ethically whether that treatment has already been started? Health professionals sometimes find it harder to stop a treatment (withdraw) than to refrain from starting the treatment (withhold). But does that feeling correspond to an ethical difference? In this article, we defend equivalence—the view that withholding and withdrawal of treatment are ethically equivalent when all other factors are equal. We argue that preference (...) for withholding over withdrawal could represent a form of cognitive bias—withdrawal aversion. Nevertheless, we consider whether there could be circumstances in which there is a moral difference. We identify four examples of conditional nonequivalence. Finally, we reflect on the moral significance of diverging intuitions and the implications for policy. We propose a set of practical strategies for helping to reduce bias in end-of-life decision making, including the equivalence test. (shrink)

The Zhuangzi, a 4th century BCE Daoist text, is sceptical about the political culture of its time. Those who debated conceptions of a good life were hostile to the views of others. They were intolerant and at times contemptuous of others who did not embody their values. In contrast to such negativity, the Zhuangzi promotes equanimity. The equanimity of the sagely person is grounded in a balance she maintains between engagement and withdrawal. Engaging critically, she problematises the lack of diversity (...) in their options for a good life. By withdrawing, she refuses to be party to the squabbles that perpetuate intolerance. The paper aims to show how equanimity is possible, thereby articulating a new angle on emotions in the Zhuangzi. (shrink)

The problem of how to remove information from an agent's stock of beliefs is of paramount concern in the belief change literature. An inquiring agent may remove beliefs for a variety of reasons: a belief may be called into doubt or the agent may simply wish to entertain other possibilities. In the prominent AGM framework for belief change, upon which the work here is based, one of the three central operations, contraction, addresses this concern (the other two deal with the (...) incorporation of new information). Makinson has generalised this work by introducing the notion of a withdrawal operation. Underlying the account proffered by AGM is the idea of rational belief change. A belief change operation should be guided by certain principles or integrity constraints in order to characterise change by a rational agent. One of the most noted principles within the context of AGM is the Principle of Informational Economy. However, adoption of this principle in its purest form has been rejected by AGM leading to a more relaxed interpretation. In this paper, we argue that this weakening of the Principle of Informational Economy suggests that it is only one of a number of principles which should be taken into account. Furthermore, this weakening points toward a Principle of Indifference. This motivates the introduction of a belief removal operation that we call severe withdrawal. We provide rationality postulates for severe withdrawal and explore its relationship with AGM contraction. Moreover, we furnish possible worlds and epistemic entrenchment semantics for severe withdrawals. (shrink)

There is a concern that as a result of COVID-19 there will be a shortage of ventilators for patients requiring respiratory support. This concern has resulted in significant debate about whether it is appropriate to withdraw ventilation from one patient in order to provide it to another patient who may benefit more. The current advice available to doctors appears to be inconsistent, with some suggesting withdrawal of treatment is more serious than withholding, while others suggest that this distinction should (...) not be made. We argue that there is no ethically relevant difference between withdrawing and withholding treatment and that suggesting otherwise may have problematic consequences. If doctors are discouraged from withdrawing treatment, concern about a future shortage may make them reluctant to provide ventilation to patients who are unlikely to have a successful outcome. This may result in underutilisation of available resources. A national policy is urgently required to provide doctors with guidance about how patients should be prioritised to ensure the maximum benefit is derived from limited resources. (shrink)

Is it a stronger interference with people's freedom to withdraw options they currently have than to withhold similar options they do not have? Drawing on recent theorizing about sociopolitical freedom, this article identifies considerations that often make this the case for public policy. However, when applied to tobacco control, these considerations are shown to give us at best only very weak freedom-based reason to prioritize the status quo. This supports a popular argument for so-called “endgame” tobacco control measures: If (...) we believe that cigarettes would and should be withheld from entering markets in hypothetical scenarios in which they do not yet exist, then we also have reason to seek their abolition in situations, such as ours, in which cigarettes do exist—if necessary by banning their sale. The same considerations are then used to disarm objections that have recently been raised to using nudges in public policy. (shrink)

When can or should citizenship be granted to prospective members of states? When can or should states withdraw citizenship from their existing members? In recent decades, political philosophers have paid considerable attention to the first question, but have generally neglected the second. There are of course good practical reasons for prioritizing the question of when citizenship should be granted—many individuals have a strong interest in acquiring citizenship in particular political communities, while many fewer are at risk of denationalization. Still, (...) loss of membership in a political community is a practice with a long history that continues to take place today. -/- Concerns about national security have recently led several liberal democratic states to pass, strengthen or consider legislation that would empower their governments to denationalize certain persons.] At the international level, formal norms governing denationalization are vague and generally toothless, and there are no international legal norms that restrict denationalization to citizens who hold another citizenship or wish to take up citizenship elsewhere (Worster, 2009). So it is important to determine whether there are conditions under which denationalization can be morally justified and, if so, what those conditions are. We shall argue that while denationalization is ordinarily impermissible, there is a class of crime committed by citizens that may render it not only permissible, but a fitting response on the part of the state. (shrink)

End-of-life decision making is fraught with ethical challenges. Withholding or withdrawing life support therapy is widely considered ethical in patients with high treatment burden, poor premorbid status, or significant projected disability even when such treatment is not “futile.” Whether such withdrawal of therapy in the aftermath of attempted suicide is ethical is not well established in the literature. We provide a clinical vignette and propose criteria under which such withdrawal would be ethical. We suggest that it is appropriate to (...) class='Hi'>withdraw life support, regardless of the cause of the critical illness or disability, when the following criteria are met: Surrogates request withdrawal of care and the adequacy of surrogates is confirmed, an external reasonability standard is met, passage of time, perhaps 72 hours, to allow certainty regarding the patient's wishes, and psychiatric morbidity should be considered as grounds for withdrawal only in truly treatment-refractory cases. Fundamentally, we believe the question to ask is, “If this were not an attempted suicide, would a request to withdraw care be reasonable?” We believe that under these circumstances, such withdrawal of life support, even in an individual who has attempted suicide, does not constitute physician assistance with suicide and is distinct from physician aid-in-dying in several important respects. (shrink)

End-of-life decision making is fraught with ethical challenges. Withholding or withdrawing life support therapy is widely considered ethical in patients with high treatment burden, poor premorbid status, or significant projected disability even when such treatment is not ?futile.? Whether such withdrawal of therapy in the aftermath of attempted suicide is ethical is not well established in the literature. We provide a clinical vignette and propose criteria under which such withdrawal would be ethical. We suggest that it is appropriate to (...) class='Hi'>withdraw life support, regardless of the cause of the critical illness or disability, when the following criteria are met: (1) Surrogates request withdrawal of care and the adequacy of surrogates is confirmed, (2) an external reasonability standard is met, (3) passage of time, perhaps 72 hours, to allow certainty regarding the patient's wishes, and (4) psychiatric morbidity should be considered as grounds for withdrawal only in truly treatment-refractory cases. Fundamentally, we believe the question to ask is, ?If this were not an attempted suicide, would a request to withdraw care be reasonable?? We believe that under these circumstances, such withdrawal of life support, even in an individual who has attempted suicide, does not constitute physician assistance with suicide and is distinct from physician aid-in-dying in several important respects. (shrink)

In 2011 the English Court of Protection ruled that it would be unlawful to withdraw artificial nutrition and hydration from a woman, M, who had been in a minimally conscious state for 8 years. It was reported as the first English legal case concerning withdrawal of artificial nutrition and hydration from a patient in a minimally conscious state who was otherwise stable. In the absence of a valid and applicable advance decision refusing treatment, of other life-limiting pathology or excessively (...) burdensome suffering, the judgement makes it clear that the obligation on health professionals falls strongly in favour of preserving life. Although the Court sought to limit the judgement as closely as possible to the facts of the case, it is likely to have a significant impact on life-sustaining treatment decisions for people in states of low awareness. This paper outlines the main legal features of the judgement. (shrink)

With recent guidance from the BMA and RCP on the withdrawal of nutrition from patients, and how the cause of death is being recorded (1), and the case of Vincent Lambert (2), the debate surrounding withdrawal of care and treatment has been rekindled in Catholic circles. In this article, I wish to highlight some of traditional principles that form the basis of such decision-making. I discuss these within the context of the withdrawal of nutrition and hydration (NaH), as well as (...) ventilation, to elucidate the key points. (shrink)

The Royal College of Physicians of London published the 2013 national clinical guidelines on prolonged disorders of consciousness in vegetative and minimally conscious states. The guidelines acknowledge the rapidly advancing neuroscientific research and evolving therapeutic modalities in PDOC. However, the guidelines state that end-of-life decisions should be made for patients who do not improve with neurorehabilitation within a finite period, and they recommend withdrawal of clinically assisted nutrition and hydration . This withdrawal is deemed necessary because patients in PDOC can (...) survive for years with continuation of CANH, even when a ceiling on medical care has been imposed, i.e., withholding new treatment such as cardiopulmonary resuscitation for acute life-threatening illness. The end-of-life care pathway is centered on a staged escalation of medications, including sedatives, opioids, barbiturates, and general anesthesia, concurrent with withdrawal of CANH. Agitation and distress may last from several days to weeks because of the slow dying process from starvation and dehydration. The potential problems of this end-of-life care pathway are similar to those of the Liverpool Care Pathway. After an independent review in 2013, the Department of Health discontinued the Liverpool Care pathway in England. The guidelines assert that clinicians, supported by court decisions, have become the final authority in nonconsensual withdrawal of CANH on the basis of “best interests” rationale. We posit that these guidelines lack high-quality evidence supporting: 1) treatment futility of CANH, 2) reliability of distress assessment from starvation and dehydration, 3) efficacy of pharmacologic control of this distress, and 4) proximate causation of death. Finally, we express concerns about the utilitarian-based assessment of what constitutes a person’s best interests. We are disturbed by the level and the role of medical authoritarianism institutionalized by these national guidelines when deciding on the worthiness of life in PDOC. We conclude that these guidelines are not only harmful to patients and families, but they represent the means of nonconsensual euthanasia. The latter would constitute a gross violation of the public’s trust in the integrity of the medical profession. (shrink)

Unfortunately, there is broad confusion regarding the justification for healthcare professionals unilaterally limiting or withdrawing life-prolonging interventions. Many mistakenly believe that suc...

The question a judge has to ask in deciding whether or not life-sustaining treatment should be withdrawn is whether the continued treatment is lawful. It will be lawful if it is in the patient’s best interests. Identifying this question gives no guidance about how to approach the assessment of best interests. It merely identifies the judge’s job. The presumption in favour of the maintenance of life is part of the job that follows the identification of the question.The presumption is best (...) regarded as a presumption of law. It has long been recognised as part of the way in which the English law discharges its obligations under Article 2 of the European Convention on Human Rights. But even if it is a ‘mere’ evidential presumption it cannot, on the facts of most cases involving applications for the withdrawal of life-sustaining treatment from patients in prolonged disorders of consciousness, be rebutted. (shrink)

Although AGM theory contraction (Alchourrón et al., 1985; Alchourrón and Makinson, 1985) occupies a central position in the literature on belief change, there is one aspect about it that has created a fair amount of controversy. It involves the inclusion of the postulate known as Recovery. As a result, a number of alternatives to AGM theory contraction have been proposed that do not always satisfy the Recovery postulate (Levi, 1991, 1998; Hansson and Olsson, 1995; Fermé, 1998; Fermé and Rodriguez, 1998; (...) Rott and Pagnucco, 1999). In this paper we present a new addition, systematic withdrawal, to the family of withdrawal operations, as they have become known. We define systematic withdrawal semantically, in terms of a set of preorders, and show that it can be characterised by a set of postulates. In a comparison of withdrawal operations we show that AGM contraction, systematic withdrawal and the severe withdrawal of Rott and Pagnucco (1999) are intimately connected by virtue of their definition in terms of sets of preorders. In a future paper it will be shown that this connection can be extended to include the epistemic entrenchment orderings of Gärdenfors (1988) and Gärdenfors and Makinson (1988) and the refined entrenchment orderings of Meyer et al. (2000). (shrink)

We reject the concept of a default option of withdrawal as proposed by Syltern and colleagues, and will outline here potential consequences on parental trust, particularly in historically marginali...

This article, prompted by an extended essay published in the Journal of Medical Ethics by Charles Foster, and the current controversy surrounding the case of Vincent Lambert, analyses the legal and ethical arguments in relation to the withdrawal of life-sustaining treatment from patients with prolonged disorders of consciousness. The article analyses the legal framework through the prism of domestic law, case-law of the European Court of Human Rights and the Convention on the Rights of Persons with Disabilities, and examines the (...) challenge to the ethical consensus made by Foster. It concludes that the right approach remains a version of the approach that has prevailed for the last 25 years since the decision in Airedale NHS Trust v Bland[1993] AC 789, refined to reflect that that there is now, and rightly, a much more limited place for judgments made about the ‘burden’ of treatment or the quality of life enjoyed by the person made on the basis of assumptions about that person as a category as opposed to investigation of that person as an individual human being. (shrink)

In the United States, the decision of whether to withdraw or continue to provide artificial nutrition and hydration (ANH) for patients in a permanent vegetative state (PVS) is placed largely in the hands of surrogate decision-makers, such as spouses and immediate family members. This practice would seem to be consistent with a strong national emphasis on autonomy and patient-centered healthcare. When there is ambiguity as to the patient's advanced wishes, the presumption has been that decisions should weigh in favor (...) of maintaining life, and therefore, that it is the withdrawal rather than the continuation of ANH that requires particular justification. I will argue that this default position should be reversed. Instead, I will argue that the burden of justification lies with those who would continue artificial nutrition and hydration (ANH), and in the absence of knowledge as to the patient's advanced wishes, it is better to discontinue ANH. In particular, I will argue that among patients in PVS, there is not a compelling interest in being kept alive; that in general, we commit a worse violation of autonomy by continuing ANH when the patient's wishes are unknown; and that more likely than not, the maintenance of ANH as a bridge to a theoretical future time of recovery goes against the best interests of the patient. (shrink)

In a recent paper, Charles Foster argued that the epistemic uncertainties surrounding prolonged disorders of consciousness make it impossible to prove that the withdrawal of life-sustaining treatment can be in a patient’s best interests and, therefore, the presumption in favour of the maintenance of life cannot be rebutted. In the present response, I argue that, from a legal perspective, Foster has reached the wrong conclusion because he is asking the wrong question. According to the reasoning in two leading cases —Bland (...) and James —the principle of respect for autonomy creates a persuasive presumption against treatment without consent. Therefore, it is the continuation of treatment that requires justification, rather than its withdrawal. This presumption also works as the tiebreaker determining that treatment should stop if there is no persuasive evidence that its continuation is in the best interests of the patient. The presumption in favour of the maintenance of life, on the other hand, should be understood as an evidential presumption on a factual issue that is assumed to be true if unchallenged. However, the uncertainties regarding PDOC actually give reasons for displacing this evidential presumption. Consequently, decision-makers will have to weigh up the pros and cons of treatment having the presumption against treatment without consent as the tiebreaker if the evidence is inconclusive. In conclusion, when the right question is asked, Foster’s argument can be turned on its head and uncertainties surrounding PDOC weigh in to justify the interruption of treatment in the absence of compelling contrary evidence. (shrink)

I reject the traditional picture of philosophical withdrawal in the Hellenistic Age by showing how both Epicureans and Stoics oppose, in different ways, the Platonic and Aristotelian assumption that contemplative activity is the greatest good for a human being. Chrysippus the Stoic agrees with Plato and Aristotle that the greatest good for a human being is virtuous activity, but he denies that contemplation exercises virtue. Epicurus more thoroughly rejects the assumption that the greatest good for a human being is virtuous (...) activity. He maintains that the greatest good for a human being is the tranquility that virtuous activity always and contemplative activity sometimes brings about. (shrink)

The right to withdraw from participation in research is recognized in virtually all national and international guidelines for research on human subjects. It is therefore surprising that there has been little justification for that right in the literature. We argue that the right to withdraw should protect research participants from information imbalance, inability to hedge, inherent uncertainty, and untoward bodily invasion, and it serves to bolster public trust in the research enterprise. Although this argument is not radical, it (...) provides a useful way to determine how the right should be applied in various cases. (shrink)

Withdrawing Artificial Nutrition and Hydration in the neonatal intensive care units has long been controversial. In France, the practice has become a legal option since 2005. But even though, the question remains as to what the stakeholders’ experience is, and whether they consider it ethically appropriate. In order to contribute to the debate, we initiated a study in 2009 to evaluate parental and health care professionals perspectives, after they experienced WAHN for a newborn. The study included 25 cases from 5 (...) different clinical neonatology departments. We interviewed both the parents and some of the HCP who cared for the baby, at least 6 months after this latter deceased. We proceeded through in-depth individual qualitative interviews. Content was analyzed for themes and patterns that emerged from the data. Some parents expressed that WANH offered an opportunity to the family to spend a few demedicalized days with the baby before she dies, without any tubes and machines, and to be well supported by the HCP during this palliative stage. But others evaluated the practice in retrospect as a terrible ordeal. All said that, at least, the time of waiting for death to ensue should not last too long. After a few days, it becomes unbearable because of the transformation of the baby’s appearance and because they, as parents, began to wonder if she was not dying from starvation rather than from her initial disease. An important proportion of HCP also expressed some kind of ethical unease. This was due to the psychological violence involved in the decision for a human being to stop feeding a little one, and also to the difficulty to deal with the fundamental intention behind the decision of WANH: indeed, could it be claim that it does not presuppose the intention of provoking the infant’s death? The discussion focuses on the point to know if WANH can be considered as a source of progress from an ethical point of view, particularly in comparison with earlier practices—that in France could involve active euthanasia by lethal injection. We argue that when HCP are merely focused on avoiding that WAHN could be construed as a way of intending to hasten the baby’s death, the practice is at risk to be implemented in a way that becomes ethically counterproductive. Focusing on this intention easily distract the clinical teams from what should be their ultimate concern, namely the baby’s comfort during the dying process, as well as the support owned to her parents. To conclude, we suggest that the ethical priorities, when WANH is decided, should be the support due to the patient and her family on the one hand, and, on the other hand to implement it in such a way that at least the baby seems to have died of her initial disease and never of starvation. This means that HCP have a duty to control the timing of death, even though this might be incompatible with the worry to avoid the intention of hastening the baby’s death. (shrink)

Representatives from eight European countries compared the legal, ethical and professional settings within which decision making for neonates takes place. When it comes to limiting treatment there is general agreement across all countries that overly aggressive treatment is to be discouraged. Nevertheless, strong emphasis has been placed on the need for compassionate care even where cure is not possible. Where a child will die irrespective of medical intervention, there is widespread acceptance of the practice of limiting aggressive treatment or alleviating (...) suffering even if death may be hastened as a result. Where the infant could be saved but the future outlook is bleak there is more debate, but only two countries have tested the courts with such cases. When it comes to the active intentional ending of life, the legal position is standard across Europe; it is prohibited. However, recognising those intractable situations where death may be lingering and unpleasant, Dutch paediatricians have reported that they do sometimes assist babies to die with parental consent. Two cases have been tried through the courts and recent official recommendations have set out standards by which such actions may be assessed. (shrink)

I argue that the arguments brought by Counsel for M to the English Court of Protection are morally problematic in prioritising subjective interests that are the result of ‘consistent autonomous thought’ over subjective interests that are the result of a more limited cognitive perspective.

Many countries have adopted new triage recommendations for use in the event that intensive care beds become scarce during the COVID‐19 pandemic. In addition to establishing the exact criteria regarding whether treatment for a newly arriving patient shows a sufficient likelihood of success, it is also necessary to ask whether patients already undergoing treatment whose prospects are low should be moved into palliative care if new patients with better prospects arrive. This question has led to divergent ethical guidelines. This paper (...) explores the distinction between withholding and withdrawing medical treatment during times of scarcity. As a first central point, the paper argues that a revival of the ethical distinction between doing and allowing would have a revisionary impact on cases of voluntary treatment withdrawal. A second systematic focus lies in the concern that withdrawal due to scarcity might be considered a physical transgression and therefore more problematic than not treating someone in the first place. In light of the persistent disagreement, especially concerning the second issue, the paper concludes with two pragmatic proposals for how to handle the ethical uncertainty: (1) triage protocols should explicitly require that intensive care attempts are designed as time‐limited trials based on specified treatment goals, and this intent should be documented very clearly at the beginning of each treatment; and (2) lower survival prospects can be accepted for treatments that have already begun, compared with the respective triage rules for the initial access of patients to intensive care. (shrink)

One way to help ensure the future of human life on the planet is to reduce the total number of people alive, as a hedge against dangers to the environment. One commentator has proposed withdrawing government and insurance subsidies from all fertile people, to help reduce the number of births. Any proposal of this kind does not, however, offer a solution commensurate with current problems of resource use and carbon emissions. Closing off fertility medicine to some people – or even (...) to all – would have only negligible effects in environmental protection. Moreover, the proposal to withdraw financial subsidies from fertile people would have prejudicial effects on lesbian and gay people, who must always reach beyond their same-sex relationships for help in having children. It is, moreover, entirely unclear why some people turning to fertility medicine for help in having children should have to pay their own way even though they contribute to the pool of money available for government and insurance subsidies. Entitlements based on an alleged moral difference between the ‘fertile’ and the ‘infertile’ cannot support such a conclusion. (shrink)

RD, a 32-year-old male, was admitted to the hospital with hypoxic COVID pneumonia–a potentially life-threatening condition characterized by dangerously low levels of oxygen in the body- during one of the pandemic’s surges. While RD’s age gave the clinical team hope for his prognosis, his ability to recover was complicated by his being unvaccinated and having multiple comorbidities, including diabetes and obesity. His condition worsened to the point that he required extracorporeal membrane oxygenation (ECMO), a machine that maintains the functioning of (...) a person’s heart and lungs. -/- Given its scarcity–only 264 of the over 6,000 hospitals in the United States offer ECMO, according to the Extracorporeal Life Support Organization–as well as its high cost and the inadequate supply of staff required to maintain it, ECMO primarily serves as a bridge to support critically ill patients until they can receive an organ transplant or implanted medical device. For RD, ECMO was started to support him until he could be evaluated for, and possibly receive, a bilateral lung transplant. Despite its intended use as a treatment of last resort, some patients can remain on ECMO for weeks or months. And some are awake, alert, and capable of medical decision-making. -/- RD was one such patient. However, the transplant evaluation committee ruled out RD’s candidacy for bilateral lung transplantation, based on his poor potential for recovery and a lack of family and friends to provide post-transplant support. This determination raised the prospect of continued ECMO treatment being a bridge to nowhere. But RD was comfortable on ECMO and wanted to remain in the ICU. The ICU intensivist contacted the ethics consult service with questions about whether continued ECMO support was medically and ethically inappropriate. (shrink)

The debate between Ursin (2019) and Wilkinson and colleagues (2019) in this issue of The American Journal of Bioethics underscores the long-standing theoretical controversy about the equivalence of...

Ethical questions surrounding withdrawal of life support can be complex. When life support therapies are the result of a suicide attempt, the potential ethical issues take on another dimension. Duties and principles that normally guide clinicians’ actions as caregivers may not apply as easily. We present a case of attempted suicide in which decisions surrounding withdrawal of life support provoked conflict between a patient’s family and the medical team caring for him. We highlight the major unresolved philosophical questions and contradictory (...) normative values about suicide that underlie this conflict. Finally, we show how these considerations were practically applied to this particular case. (shrink)

This article explores the taxing legal questions that are raised in the context of withdrawing life sustaining treatment from patients who are in a minimally conscious state. The Court of Protection, for the first time in England, was recently asked to rule on this issue. This paper analyses the legal and ethical implications of this decision moving forward.

The right to withdraw from research without penalty is well established around the world. However, it has been challenged in some corners of bioethics based on concerns about various harms—to participants, to scientific integrity, and to research bystanders—that may stem from withdrawal. These concerns have become particularly salient in emerging debates about the ethics of controlled human infection (CHI) studies in which participants are intentionally infected with pathogens, often in inpatient settings with extensive follow‐up. In this article, I provide (...) support for preserving the right to withdraw from research without penalty and demonstrate that it is also typically justified in the specific context of CHI studies. The right is well aligned with individual freedoms outside the research setting, where autonomous individuals are permitted to engage in behaviors that will foreseeably cause them harm; where they cannot be compelled to satisfy contracts for their services, nor penalized for failure to do so; and where their behavior is not constrained by public health authorities except in extreme circumstances. These freedoms are supported by U.S. law, as well as by ethical analysis that is more globally relevant. The problems associated with the right to withdraw, however, remain. The best approach to addressing them is not to restrict the right but rather to avoid initiating research when withdrawal would be especially problematic. If research proceeds, steps can still be taken to minimize participant withdrawal without infringing the right. Investigators can avoid participant surprise through informed consent focused on a study’s most burdensome aspects and promote study completion through financial incentives. Should participants nonetheless seek to withdraw, investigators may attempt to persuade them not to do so by encouraging consideration of the range of potential harms that may result. Researchers conducting CHI studies and other research from which withdrawal might be especially problematic should prepare for the possibility of participant withdrawal, respect participant requests to withdraw without penalty, and incorporate various measures to avoid such requests. (shrink)

BackgroundPublished data and practice recommendations on end-of-life care generally reflect Western practice frameworks; there are limited data on withdrawal of treatment for children in China.MethodsWithdrawal of treatment for children in the pediatric intensive care unit of a regional children’s hospital in eastern China from 2006 to 2017 was studied retrospectively. Withdrawal of treatment was categorized as medical withdrawal or premature withdrawal. The guardian’s self-reported reasons for abandoning the child’s treatment were recorded from 2011.ResultsThe incidence of withdrawal of treatment for children (...) in the PICU decreased significantly; for premature withdrawal the 3-year average of 15.1% in 2006–2008 decreased to 1.9% in 2015–2017. The overall incidence of withdrawal of care reduced over the time period, and withdrawal of therapy by guardians was the main contributor to the overall reduction. The median age of children for whom treatment was withdrawn increased from 14.5 months in 2006 to 40.5 months in 2017. Among the reasons given by guardians of children whose treatment was withdrawn in 2011–2017, “illness is too severe” ranked first, accounting for 66.3%, followed by “condition has been improved”. Only a few guardians ascribed treatment withdrawal to economic reasons.ConclusionsThe frequency of withdrawal of medical therapy has changed over time in this children’s hospital PICU, and parental decision-making has been a large part of the change. (shrink)

BackgroundWhen rationing health care, a commonly held view among ethicists is that there is no ethical difference between withdrawing or withholding medical treatments. In reality, this view does not generally seem to be supported by practicians nor in legislation practices, by for example adding a ‘grandfather clause’ when rejecting a new treatment for lacking cost-effectiveness. Due to this discrepancy, our objective was to explore physicians’ and patient organization representatives’ experiences- and perceptions of withdrawing and withholding treatments in rationing situations of (...) relative scarcity.MethodsFourteen semi-structured interviews were conducted in Sweden with physicians and patient organization representatives, thematic analysis was used.ResultsParticipants commonly express internally inconsistent views regarding if withdrawing or withholding medical treatments should be deemed as ethically equivalent. Participants express that in terms of patients’ need for treatment withholding and withdrawing should be deemed ethically equivalent. However, in terms of prognostic differences, and the patient-physician relation and communication, there is a clear discrepancy which carry a moral significance and ultimately makes withdrawing psychologically difficult for both physicians and patients, and politically difficult for policy makers.ConclusionsWe conclude that the distinction between withdrawing and withholding treatment as unified concepts is a simplification of a more complex situation, where different factors related differently to these two concepts. Following this, possible policy solutions are discussed for how to resolve this experienced moral difference by practitioners and ease withdrawing treatments due to health care rationing. Such solutions could be to have agreements between the physician and patient about potential future treatment withdrawals, to evaluate the treatment’s effect, and to provide guidelines on a national level. (shrink)

In their target article, Childress et al provide a detailed analysis of dilemmas arising from disagreement between an ICU team and a competent patient (Mr J) about dis/continuation of extra-corpore...

The advent of COVID-19 has been the occasion for a renewed interest in the principles governing triage when the number of critically ill patients exceeds the healthcare infrastructure’s capacity in a given location. Some scholars advocate that it would be morally acceptable in a crisis to withdraw resources like life support and ICU beds from one patient in favor of another, if, in the judgment of medical personnel, the other patient has a significantly better prognosis. The paper examines the (...) arguments for and against this approach from the point of view of natural law theory, especially using the principle of double effect. We conclude that it is inadmissible to withdraw life-saving medical interventions from patients who are still benefiting from them, on the sole grounds that other patients might benefit more. Those who are currently using such technology should only interrupt their treatment if, in the judgment of medical personnel and, if possible, taking into account the wishes and needs of the patient and his family, the treatment is deemed futile, burdensome, or disproportionate. (shrink)

Withholding and withdrawing treatment are widely regarded as ethically equivalent in medical guidelines and ethics literature. Health care personnel, however, widely perceive moral differences between withholding and withdrawing. The proponents of equivalence argue that any perceived difference can be explained in terms of cognitive biases and flawed reasoning. Thus, policymakers should clear away any resistance to accept the equivalence stance by moral education. To embark on such a campaign of changing attitudes, we need to be convinced that the ethical analysis (...) is correct. Is it? In this article, I take a closer look at the moral relation between withholding and withdrawing. My conclusion is that withholding and withdrawing are not in general ethically equivalent. Thus, medical guidelines should be rewritten, and rather than being “educated” away from their sound judgments, medical professionals and patients should have nuanced medico-ethical discussions regarding withholding and withdrawing treatment. (shrink)

ObjectiveA form of pathological social withdrawal which is also called hikikomori has been proved its existence in China. But the prevalence and characteristics of hikikomori in China remain unknown. Past studies had investigated the hikikomori phenomenon in three cities of China. The purpose of this study is to discover the prevalence of hikikomori in a convenient online sample in China as well as the difference in demographic characteristics and other possible traits between hikikomori sufferers and the general population.MethodsA total of (...) 1,066 youths in China completed the online questionnaire, which consisted of questions about demographics, the 25-item Hikikomori Questionnaire, the Internet Addiction Test, the Loneliness Scale, and the General Health Questionnaire. SPSS is used to evaluate the data.ResultsOf the 1,066 youths, 980 were identified as belonging to group A, 46 to group B, and 40 to group C. The hikikomori group accounted for 8.1%. The present data suggest that residence and loneliness are related to the occurrence of hikikomori. HQ-25 score of the hikikomori group was significantly higher than the comparison group. The UCLA score showed that those in the hikikomori group felt lonelier than those in the comparison. The regression model predicted hikikomori risk, the Hosmer-Lemeshow test value is 7.114 and P = 0.524 > 0.05.ConclusionThe grouping criterion in our present study is reasonable and such a grouping criterion can screen out potential populations of hikikomori. When people develop into hikikomori sufferers in the present, their social withdrawal behaviors and feeling of loneliness are both much more severe than in the past. The possible relationships between hikikomori and loneliness reflect the need to give the youths more social support, to help them connect with society. (shrink)

Confucius lived in a society he found morally wanting. The rituals were distorted, the government was corrupt, and the rulers lacked a Heavenly mandate. Our limited historical knowledge makes it difficult today to imagine Confucius' situation in all its rich context and detail; however, we may be able to imagine something like it, at least something like it in certain ways. We can probably imagine living in a state led by officials of questionable integrity, and many of us may feel (...) that we in fact do live in a society that suffers some kind of serious moral deficiency.What should a person do when she finds herself in a morally compromised society? Should she try to avoid moral contamination by withdrawing into .. (shrink)

This study aimed to elucidate the withdrawal behaviors syndrome (lateness, absence, and intent to leave work) among nurses by examining interrelations between these behaviors and the mediating effect of organizational commitment upon ethical perceptions (caring climate, formal climate, and distributive justice) and withdrawal behaviors. Two-hundred and one nurses from one hospital in northern Israel participated. Data collection was based on questionnaires and hospital records using a two-phase design. The analyses are based on Hierarchical Multiple Regressions and on Structural Equation Modeling (...) with AMOS. Affective commitment was found to mediate the relationship between different dimensions of nurses’ ethical perceptions (caring climate, formal climate, and distributive justice) and their intent to leave work. Lateness was found to be positively related to absence frequency which was found negatively related to intent to leave. Males were late more frequently than females, while seniority was related only to absence frequency. The findings indicated that each withdrawal behavior exhibits unique relationships. The results may help policy makers to focus on improving the ethical environment in order to increase nurses’ commitment and reduce their intent to leave. Improving the ethical environment may be achieved through ethical education for nurses which may promote ethical considerations becoming an integral part of nurses’ work. (shrink)

Background According to some medical ethicists and professional guidelines, there is no ethical difference between withholding and withdrawing life-sustaining treatment. However, medical professionals do not always agree with this notion. Patients and their families may also not regard these decisions as equivalent. Perspectives on life-sustaining treatment potentially differ between cultures and countries. This study compares Japanese physicians’ and citizens’ attitudes toward hypothetical cases of withholding and withdrawing life-sustaining treatment.Methods Ten vignette cases were developed. A web-based questionnaire was administered to 457 (...) citizens and 284 physicians to determine whether they supported withholding or withdrawing treatment.Results In a case where a patient had an advance directive refusing ventilation, 77% of the physicians and 68% of the citizens chose to withhold treatment. In a case where there was an advance directive but the patient’s family requested treatment, 55% of the physicians and 45% of the citizens chose to withhold the ventilator. When a family requested withdrawal of the ventilator but patient wishes were unknown, 19% of the physicians and 48% of the citizens chose to withdraw the ventilator. However, when the patient had also indicated their wishes in writing, 49% of the physicians and 66% of the citizens chose to withdraw treatment. More physicians were prepared to withdraw dialysis (84%) and artificial nutrition (81%) at a patient’s request than mechanical ventilation (49%).Conclusions A significant proportion of Japanese physicians and citizens were reluctant to withhold or withdraw life-sustaining treatment, even in cases where the patient had indicated their wishes in writing. They were more likely to withhold than withdraw treatment, and more likely to withdraw artificial nutrition than mechanical ventilation. Japanese physicians gave significant weight to family views about treatment but were less likely to agree to withdraw treatment than citizens, indicating a potential source of conflict in clinical settings. (shrink)

In healthcare priority settings, early access to treatment before reimbursement decisions gives rise to problems of whether negative decisions for cost‐effectiveness reasons should result in withdrawing treatment, already accessed by patients. Among professionals there seems to be a strong attitude to distinguish between withdrawing and withholding treatment, viewing the former as ethically worse. In this article the distinction between withdrawing and withholding treatment for reasons of cost effectiveness is explored by analysing the doing/allowing distinction, different theories of justice, consequentialist and (...) virtue perspectives. The authors do not find any strong reasons for an intrinsic difference, but do find some reasons for a consequentialist difference, given present attitudes. However, overall, such a difference does not, all things considered, provide a convincing reason against withdrawal, given the greater consequentialist gain of using cost‐effective treatment. As a result, patients should be properly informed when given early access to treatment, that such treatment can be later withdrawn following a negative reimbursement decision. (shrink)

It is generally assumed in research ethics that research participants have an unconditional right to withdraw from research without any detriment or reprisal. This paper analyses this right in the context of biobank research and argues that the traditional shape of the right in clinical research can be modified in biobank research without incurring significant ethical cost. The paper falls in three parts. The first part is a brief explication of the philosophical justification of the right to withdraw. (...) The second part presents a number of extant criticisms of the right. And the third and final part argues that although a right to withdraw is crucial in relation to biobank research, such a right has to be specified in a different way to the similar right in relation to clinical research. (shrink)