1. Withholding and refusing optional treatment

2. Cases Withholding treatment Karen Ann Quinlan -Right to die controversy in US -Valium and alcohol  unconscious  persistent vegetative state -Parent’s request of withdrawal of active care Refusing treatment Dennis Lindberg 14y.o. (“mature minor”) Leukemia patient Jehovah’s witness Refused blood transfusion

3. On withholding and refusing treatment Does the therapy offer hope or benefit insofar as helping the person strive for the goods and goals of life? – Can it restore the cognitive-affective function of the person

4. Will the burden resulting from the therapy impede significantly the person’s quest to fulfill the goods and goals of life? – Prolongation of life should be in accordance to the main spiritual purpose of our life -- to love and serve God and neighbors

5. Following the principles No class of persons should be refused therapy Decision to withhold/remove life support should not be made unless fatal pathology is present and giving further treatment is of no additional benefit to the patient.

6. Ethical reasons for withholding and withdrawing medical treatments Principle of autonomy – implies respecting the wishes of a competent patient who refuses medical interventions – Decisions can be made at the time treatment is offered (competent patient) or at some prior time (now incapacitated ) – Alternatively, a decision may be made by others who claim to represent the wishes of the now incompetent patient Living will & durable power of attorney for healthcare – ensure patient’s wishes are followed & future conflicts avoided

7. Principles of beneficence and nonmaleficence – a surrogate decision maker (usually patient’s family member) may decide to forgo medical interventions because this is considered to be in the patient’s best interest – benefit is also at stake when treatment is forgone because the health care team judges that treatment is futile and provides no medical benefit to the patient

8. Factors that can influence autonomy and mental competence of patient Pain Depression Effects of medication Mental illness Setting (at home/at hospital; with or without presence of family members / support system)

9. Mental competence Patient who refuses a recommended medical procedure cannot be assumed as incompetent (doctor and patient may have different sets of goals and values) Determinations of competence cannot be made simply by determining whether the patient is mentally ill Ask patient to explain how he/she arrived at the decision (in relation to his/her goals and values)

10. Refusing treatment Patients have right to refuse treatment Refusing additional medical efforts is not to reject life itself, or the God who gave it; Not equivalent to suicide The right to refuse treatment might be limited, however, in court by appeal to parental obligations or in extreme cases suicide laws or in case the autonomy interest at stake is weak in comparison to the benefit to the patient: raising bed rails against a competent patient's wishes – This sort of exception would not work for a Jehovah's Witness refusing blood transfusion since his or her autonomy interest would be strong