Cloning Essay, Research Paper

CMF Ethics: CloningSubmission from the CHRISTIAN MEDICAL FELLOWSHIP to the

Medical Ethics Committee of the BRITISH MEDICAL ASSOCIATION on WITHDRAWING AND

WITHHOLDING TREATMENT

Introduction

Christian Medical Fellowship is interdenominational and has as members more than

4,500 British doctors and 1,000 British medical students who are Christians and

who desire their professional and personal lives to be governed by the Christian

faith as revealed in the Bible. We have members in all branches of the

profession, and through the International Christian Medical and Dental

Association are linked with like-minded colleagues in over 60 other countries.

We regularly make submissions on ethical matters to Governmental and other

bodies and, for example, commented at length[1] to the House of Lords Select

Committee on Medical Ethics in 1993 on matters which include those covered in

this Submission. We are grateful for the opportunity to comment on the issues

involved in the BMA’s Consultation Paper Withdrawing and Withholding Treatment

and would be willing to help further if requested.

Positional Statements

The following concepts in our Affirmation on Christian Ethics in Medical

Practice are relevant to this Submission:

In Relation to Human Life

Acknowledging that God is the Creator, the Sustainer and the Lord of all life.

Recognising that human beings are unique, being made in the ‘image of God’ . . .

Maintaining the deepest respect for individual human life from its beginning to

its end, including the unborn, the helpless, the handicapped, and those advanced

in age.

In Relation to Patients

Giving effective service to those seeking our medical care irrespective of age,

race, creed, politics, social status or the circumstances which may have

contributed to their illness.

Serving each patient according to their need . . .

Respecting the privacy, opinions and personal feelings of patients and

safeguarding their confidences.

Speaking truth to patients as they are able to accept it, bearing in mind our

own fallibility.

Doing no harm to patients, using only those drugs and procedures which we

believe will be of benefit to them.

Maintaining as a principle that the first duty of doctors is to their patients,

whilst fully accepting our duty to promote preventive medicine and public

health.

We hold the Bible to be the revealed Word of God and find this helpful in giving

us principles such as the above to guide decision-making in the ever more

complex areas of ethics and practice.

General Comments

We regret the tight timetable allowed for the production of Submissions on such

a vital matter. To circulate a long and complex consultation document in July,

just before the holiday season, with a deadline of mid-October has meant that we

have not been able to hold as wide a consultation within our own extensive

constituency as we would have wished.

Although some of us felt the document ‘meandered’, it is certainly comprehensive

and we find much to commend in the content. We would particularly commend ‘a

presumption in favour of prolonging life’ in cases of doubt (2.1), the

introduction (’a-c’) to Basic Moral Principles (2.8), the refusal to categorise

patients on the grounds of disability (eg 2.8.4) and the concept of ‘Best

Interests’ (2.9.4).

Specific Comments

Before attempting answers to the specific questions posed in the consultation

document, we make a number of comments of a ‘compare and contrast’ nature:

Curing and caring – not killing

Although we acknowledge that this consultation is not about euthanasia, that

subject can never be far away from the issues involved. We hold that intentional

medical killing is always unnecessary and always wrong[1] and has no place in

the practice of medicine.

Caring – not curing always

Medicine has two traditional obligations – to prevent death and to relieve

suffering. One (cure) deals with the quantity of life, the other (care) with its

quality. At the heart of the discussion of withdrawing and withholding treatment

is the shifting of the balance from the obligation to prevent death or preserve

life to the obligation to prevent suffering and maximise quality of the

increasingly precious time that remains.

Associated with this, it is essential for the public and the profession to

recognise that life has a natural end. For reasons perhaps connected with

general loss of commitment to the Christian faith and ethic, death has become a

taboo in our society. Rising patient expectations of wonder cure after wonder

cure add to the trend for many patients and their families to deny the reality

of imminent death.

In addition, many doctors overtreat dying patients or treat them

inappropriately. This may be partly for the general societal reasons given

above, for reasons of ‘defensive medicine’, or for more personal reasons. Facing

dying patients may raise uncomfortable suggestions of the doctor’s own

mortality, doctors may enjoy giving treatments, or perhaps they need more

patients in their trials. One of our members has written movingly of these

phenomena in the profession in a recent BMJ Personal View [2].

Whatever the explanations in general and in individual cases, we are convinced

that the medical profession has caused much of the present drive for euthanasia

amongst some in our society because of overtreatment.

It is not necessarily a failure for medicine when the time comes that we can no

longer cure; we then change the goals of medicine towards concentrating on

caring, a philosophy so well demonstrated by the palliative care movement. The

public needs ongoing education about the limitations of curative medicine.

Real – not rare

It is well said that ‘hard cases make bad law’, and whilst we recognise the

specific and difficult issue of withdrawing tube feeding in PVS patients, for

example, we must acknowledge that such cases are thankfully rare, and not allow

principles for decision-making to be driven by hard cases alone. As one of our

geriatrician members put it in his evidence to us, ‘most people who die are

old’. The principles for arriving at ethical answers in withdrawing and

withholding treatment situations must work out in practice with those much

larger patient groups with, for example, severe stroke.

Principled guidance – not prescriptive guidelines

We believe a key mistake in the generally excellent thinking in the consultation

document is that ‘guidelines’ will solve the problems. Two very recent BMJ

articles [3,4] have noted that doctors ‘are being flooded with guidelines’. Why

is this?

The answer probably lies in the current cultural situation of fear and blame. As

the consultation document says so well [5]: ‘how widespread is the impression

that when a person dies someone else must be responsible rather than simply

illness or human mortality being the cause of death’.

Perhaps the individual health professional thinks unconsciously: ‘If a patient

dies, someone is to blame. That someone mustn’t be me. I must cover myself. If I

have followed the guidelines they can’t pin anything on me.’ And in an

increasingly litigious society, employers will be anxious to prove that

everything was done by the book.

However, prescriptive rulebooks don’t apply well to medicine. It isn’t like

that. It is imprecise, and uncertain. Perhaps prescriptive guidelines of the ‘If

A, do B’ sort may work for a few well-specified surgical conditions, but they

are too rigid for ethical application in the vast majority of serious illnesses.

Clinical conditions wax and wane, and therapies are iterative, tried on an

empirical basis and perhaps withdrawn on grounds which are more often ‘clinical’

than ‘moral’. We call below for more objective research on treatment outcomes

and doubtless more knowledge will be gathered, but medicine will always remain

an art as much as a science.

We believe it would be a great mistake for the BMA or others to seek narrowly

prescriptive ethical guidelines. Each patient, each illness, each situation is

unique. The profession needs a set of principles, ethical guidance along the

lines we set out here, but not more guidelines of the type swamping the

profession.

Seniors at the bedside – not slaves to bureaucracy

Acknowledging that much of medicine is an art, clinical experience is a great

help. Difficult treatment decisions of the type being considered by the BMA

deserve the presence of the most clinically experienced doctors and nurses at

the bedside. Patients deserve the best. Yet inappropriate management culture

within the NHS may mean that those experienced senior professionals cannot give

the time they would like to helping make the best decisions at the bedside,

incidentally modelling best practice to colleagues in training.

We also commend multidisciplinary team approaches with shared information

inputs. Often decisions are taken by inexperienced juniors, as isolated

individuals, and not by experienced teams together. Perhaps there need to be

cultural changes and restructuring within some parts of the NHS so that patients

and paperwork both have the priorities they deserve.

Carers and clinicians – not committees and courts

We favour ethics decisions in healthcare being taken according to the

‘partnership of two experts’ – the health professionals who have their technical

areas of expertise and the patient who is an expert in two things: how he or she

feels and what he or she wants. Ideally, appropriate professional paternalism

and appropriate patient autonomy should be balanced in such a dialogue between

experts, to the benefit of both.

Decisions would ordinarily best be taken with the patient by carers and

clinicians. We do not favour the development of clinical ethics committees –

most of the ethics committees currently in existence are research ethics

committees and many new structures would need to be set up, with dubious

benefit. Most of the difficult treatment decisions under consideration are

relatively acute and committees would be too slow to respond.

Nor do we in general favour extending the involvement of the courts. Whilst we

believe decisions about withdrawal of tube feeding in PVS patients should still

go to court, and that there should be no areas in medical practice that the law

cannot examine, we do not favour further involvement of law in ethics

decision-making.

Research – not rhetoric

Whilst many aspects of caring for a patient with a final illness will always

remain to some extent intuitive, we advocate objective research into factors

determining treatment outcomes. For example, multivariate analysis of clinical

findings can assist in making predictions (eg APACHE scoring in the ITU). Advice

and decision-taking can thus be as evidence based as possible, and continuously

updated as new techniques make their impact. All the healthcare disciplines

should be committed to continuing education and the propagation of proven best

practice.

Many of these comments endorse sections of the consultation document, and we

make them all in the most constructive spirit. Individual decisions will never

be easy and we counsel against any approach that makes them seem so. However, a

reliable set of ethical boundaries such as we have tried to indicate within

these seven sets of specific comments should set helpful limits for the

difficult decisions in each unique case.

Answers to ‘Section 3 – Specific questions on which the BMA is seeking views’

1. Are there gaps which need filling in current UK ethical/legal guidance about

withdrawing or withholding life-prolonging treatments? Are there other legal and

ethical problems associated with withdrawing or withholding treatment which are

not mentioned in this paper?

As outlined above, we don’t believe there is currently the right kind of

guidance that takes adequate account of the natural history of the illnesses in

question or of their responses to therapy. Our own conceptual framework

indicates the way we view the legal and ethical issues.

2. Are international consensus documents such as the 1992 Appleton International

Consensus used in practice when decisions need to be made? If so, is review of

such guidelines necessary?

Few of us are aware of the Appleton Consensus. We doubt this approach is much

used by clinicians.

3. If guidance were to be produced, are there good reasons for distinguishing

between withdrawing and withholding treatment? If so, what are they?

In principle, and from a moral philosophy perspective, we agree with the BMA’s

position that there is no ethical difference between withdrawing treatment which

has become futile and not introducing that treatment at an earlier stage.

However, in practice the two may well feel very different to professional and

family carers and this must be taken into account at the bedside.

4. Are there good reasons for distinguishing between the treatment of adults and

children when drawing up guidance? If so, what are they?

We do not believe there are valid moral differences, though it seems to be a

(well-documented [6]) human instinct to try harder for children. On clinical

grounds, children in many situations will tend to do better than adults and

prognosis is even more difficult. For physiological but not moral reasons,

guidance about treatment of children may need to be distinguished from treatment

of adults in some clinical situations, since their resilience greatly exceeds

that of adults.

5. When patients lack the ability to make decisions for themselves, will not

recover sentience, and there is no clear indication of their wishes, should

withdrawing or withholding treatment be an issue to be decided by health

professionals and families alone?

We presume from its phrasing that this question addresses issues including the

withdrawal of tube feeding in PVS patients. Because to stop giving food and

fluid to a patient will inevitably and certainly cause their life to end, we

believe this decision, if it has to be considered, should continue to come

before the courts. Other treatment decisions which are more clearly ‘clinical’,

such as considering withholding antibiotics for life-threatening infection,

could ethically be taken by professionals and family together.

If so, should the decision-making process conform to strict criteria?

N/A

What kind of criteria would be appropriate?

N/A

Are the ones discussed in this paper sufficient?

N/A

6. Is there a foreseeable stage at which withdrawing nutrition and hydration

from patients who have irrevocably lost sentience would no longer need to go to

court?

No. See (5)

7. Is there a role for ethics committees to be involved in making decisions

about withdrawing or withholding treatment from patients who cannot express

their own views?

No (see our Specific Comments above). Most current committees are research

ethics ones. New structures of unproven benefit would be needed. Many such

decisions are too acute to await ‘the next meeting of the committee’.

8. Are there particularly problematic decisions of this type which should be

made only by the courts?

As stated, we believe decisions about withdrawing food and fluid from patients

in PVS should come to court. Whilst equally sincere doctors disagree about the

intention of withdrawing food and fluid from such patients, the fact that the

patient’s death is the inevitable consequence means this decision is different

from others.

If so, can clear parameters be defined to differentiate those cases sufficiently

problematic to require legal overview from those which could legitimately be

decided jointly by families and health professionals?

It is the certainty of death following the withdrawal of food and fluid from

patients not otherwise at the end of their natural lives which leads to this

ethical dilemma. For many professionals such action represents a breach of duty

of care, and is outside the ‘clinical’ decision to stop attempts at cure. There

would be particular pressures on nurses in such situations.

Would ambiguity about the terms of a patient’s refusal of treatment or about

competence to make valid refusal be the type of case where courts should be

involved?

Other examples of cases that should come to court might include major conflicts

between parties that cannot be resolved after ’second opinions’. However, we

repeat our conviction that there should be as little legal involvement in

medical decision-making as possible.

9. Does withdrawing or withholding artificial nutrition and hydration form a

separate category of decision from any other type of treatment which might be

withheld or withdrawn?

Yes.

If so, why?

The patient will inevitably die as a consequence of withdrawing food and fluids,

though the time of death may be unpredictable. Most health professionals feel

this is wrong – in the five years since the death of Antony Bland a conservative

estimate of 1-2,000 patients have gone into PVS and died of it. Only ten or so

cases have come before the courts in that period to request permission to

withdraw food and fluids. This suggests that whatever the difficult

philosophical issues, the intuitions of about 99% of family and professional

carers are that such an action is wrong.

Does society need to agree clear and strict criteria for withdrawing or

withholding artificial nutrition and hydration?

No.

If so, what kind of criteria?

N/A

Are the criteria and safeguards discussed in this paper (e.g. a period of

monitoring before a decision is made; an independent second medical opinion)

sufficient?

No.

10. When decisions about withdrawing or withholding have to be made, what are

the main factors which health professionals currently take into account when

discussing the matter with competent patients?

Likely prognosis is the main issue, but the integrity of the health professional

in question is important – he or she can so bias the presentation of information

as to obtain the decision they would prefer the patient made.

When deciding how to proceed for patients who cannot express an opinion?

Communicating difficult and uncertain issues to the family, with the highest

integrity.

11. How should “best interests” be defined for incapacitated people? What

criteria should be taken into account?

In general, we agree with the document’s discussion at 2.9.4. We would certainly

see capacity for relationships as valuable, but the absence of such capacity

where there appears no sentience does not reduce the intrinsic worth of that

person in God’s eyes. They are always of value because they remain made in the

image of God and He has a continuing relationship with them.

12. If a patient has left no indication of who should be consulted on his or her

behalf, how widely should views be sought from people caring for an

incapacitated adult?

Although there are no legal rights involved, it would certainly be good practice

to seek the views of those directly involved in care. However, caution is needed

because of the emotional reactions of loved ones, and their other interests,

which may or may not be ulterior motives.

Should the views of blood relatives take precedence over others?

No. The social work concept of ‘Most caring other’ is probably the best guide.

13. Is conflict common between different categories of health professionals or

between health professionals and relatives?

No, but it is not that unusual in most practices and departments.

Could conflict between health professionals be avoided or is it a positive spur

to well-rounded discussion?

‘Conflict’ in the sense of adversarial discussion can be constructive and should

not be avoided at all costs.

Are there good models for resolving disputes within and between health teams,

carers and relatives?

Prevention is better than cure. Good communication is important, and the time

pressures on understaffed and overworked teams are therefore regrettable. The

dialogue between the ‘partnership of two experts’ is based on mutual respect and

open communication, with the aim being to find consensus.

14. Is there still place for separate sets of professional guidance, attempting

to reflect the particular perspective of each profession or is it desirable that

all guidelines attempt to reflect a wide multi-disciplinary approach?

No. The different health disciplines should all be partners in the same

enterprise, and guidance must reflect commonly accepted principles.

15. Should there be more research into how decisions about withdrawing or

withholding treatment are made?

Yes, but rather than subjective research on the behaviour of health

professionals who may not know why they are doing what they are doing, we would

favour objective research on outcomes to allow the best clinical evidence base

possible. These decisions are often more ‘clinical’ ones than ‘ethical’ ones.

16. Do you consider that there is broad concern about the use of the “double

effect” argument concerning treatment at the end of life?

No. We hold the principle of intention as critical in this whole area and have

stated above that we believe intentional medical killing is always wrong. Once

explained properly, our experience is that health professionals and the public

readily understand and support the concept.

Incidentally, we find the phraseology ‘double effect’ unnecessary and unhelpful,

seeming in itself to suggest ‘double standards’, ie hypocrisy. We favour the

single word ‘intention’. The doctor’s intention is the relief of pain or

suffering even though this may very occasionally shorten by hours or days a life

which it is not possible to save.

Of course, there may in practice be hypocrisy, as doctors can pretend one

intention while having another, or there may be unconscious self deception about

motives. There are also issues about the ‘knowledge gap’ – we may intend one

thing but because of limited foresight achieve another, the ‘meaning well but

doing badly’ situation.

However, despite these issues, ‘intention’ is the most helpful concept we have

in this area. It has legal standing, and there are safeguards. A safeguard to

‘How do we know what the doctor’s intention actually was?’ would be to ensure

that major decisions were taken out in the open with the widest possible

discussion of foreseeable consequences and involving the patient as fully as

possible. In addition, where the administration of treatments is concerned,

there would be pharmacological safeguards in prescription records of drug dosage

and frequency.

If so, is the concern shared by health professionals and the public?

Such concern as there is partly reflects genuine confusion, which should be

amenable to explanation and education. However, confusion is also encouraged by

the euthanasia movement as a cynical campaign strategy. It is in their interests

to try and convince professionals and patients that ‘doctors are doing

euthanasia already with these big doses of powerful painkillers and what we need

now is a law to clarify the position’.

Would health professionals welcome more debate about the implications of “double

effect”?

Some need this helpful and very clear point explained more effectively.

17. Are there additions or amendments that should be made to the list of general

points concerning withholding or withdrawing treatment mentioned in section 2.11

of the discussion paper?

We would only emphasise that parts of this generally excellent summary seem to

take too simplistic a view of the likely natural history of clinical conditions

and of their responses to therapy. Patients can surprise us by getting better

against the odds.

18. Do you know of any existing local or national guidelines which the BMA

should take into account if it moves ahead to draw up new guidance?

No.

Do you know of any innovative ways of resolving problems connected with

withdrawal or withholding of treatment?

No, other than our approach which establishes the boundaries within which

individual decisions are taken. We do not believe that more prescriptive

guidelines will ever give the best results. In these dilemmas, a decision-making

framework is of more value than a formula.

Ten key concepts in summary:

1. Intentional killing is always unnecessary and wrong.

2. Life has a natural end and there is not necessarily anyone to blame when a

patient dies.

3. Doctors tend to overtreat towards the end of life, causing demand for

euthanasia.

4. Society needs to break its current taboo about facing death.

5. Considering the Christian faith is essential for a healthy exploration of the

concept of death.

6. When accepting that cure is either not possible or not sought by the patient,

care continues.

7. The most senior clinicians should be central figures in these decisions.

8. Many of the difficult decisions are more ‘clinical’ than ‘ethical’.

9. Medicine is a biological science with uncertain outcomes but research must

improve its evidence base.

10. Principles for guidance which define ethical boundaries are more helpful

than prescriptive guidelines.

References

1. Submission from the Christian Medical Fellowship to the House of Lords Select

Committee on Medical Ethics. 1993

2. Personal view. Doctors fighting, fleeing or facing up to death. Goodall J.

British Medical Journal, 1 August 1998; 317: 355-6

3. Editorial. Where’s the chief knowledge officer? Muir Gray J A. British

Medical Journal, 26 September 1998; 317: 832

4. Guidelines in general practice: the new Tower of Babel? Hibble A, Kanka D,

Pencheon D, Pooles F. British Medical Journal, 26 September 1998; 317: 862-3

5. Withdrawing and Withholding Treatment: a consultation paper from the BMA’s

Medical Ethics Committee. 1998. p5

6. Ibid. p14

Christian Medical Fellowship

October 1998

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