Abstract
This chapter resolves a long-standing debate. It examines what has been called the Equivalence Thesis in respect of withdrawing and withholding life-sustaining treatment (LST). The Equivalence Thesis holds that there is no morally relevant difference between withholding and withdrawing LST: wherever it is morally permissible to withhold LST, it is morally permissible to withdraw LST, and vice versa. Several prominent bioethicists hold the Equivalence Thesis to be true, including John Harris, Dominic Wilkinson and Julian Savulescu. Some of these writers use the Equivalence Thesis to argue for greater rationing in the ICU, with a view to maximising the sum total of lives saved. We argue, however, that the Equivalence Thesis is false, and so cannot be used to support an argument for greater rationing in the ICU. We do not argue against greater rationing, but argue only that the Equivalence Thesis cannot be used to support the case for greater rationing.
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Notes
- 1.
Hope et al. (2012) acknowledge that quality of life is also important when seeking to assess the benefit that intensive care confers, but to simplify their analysis, they defer indefinitely the question of how quality of life ought to inform ICU resource allocation. For the most part, we do the same.
- 2.
The belief being denied by claim 1 might be held because withdrawing involves acts whereas withholding involves only omissions, though this need not be the only reason for holding such a belief.
- 3.
Some writers, including Savulescu, have suggested that withdrawal may be killing (unlike withholding, which is letting die) but that there may nonetheless be no morally relevant distinction between them. Except for one point in our discussion where this issue may be relevant, we shall here leave aside the separate issue of whether withdrawing is killing or letting die. For discussion see McGee (2014), (2015). For a different view, see Miller and Truog (2012, ch. 1).
- 4.
Note here that ‘acts’ is being used in a broad sense to include withholding and not merely withdrawing. As Malm (1989) notes, nothing need turn on this particular use of ‘act’ in this context; it should be understood in a similar way to ‘do’, which can include actions and omissions, as when I refrain from kicking the ball by keeping my feet still.
- 5.
The term ‘equivalence thesis’ was first used by James Rachels, in discussing the better known killing versus letting die distinction. The issues of whether killing and letting die are morally equivalent, and whether withholding and withdrawing LST are morally equivalent, are not the same issues, since, on some views (including ours), withholding and withdrawing LST are both cases of letting die. We discuss whether ET is false in respect of withholding and withdrawing LST in a way that remains neutral on whether withdrawing LST is killing or letting die. See note 3.
- 6.
We give an abbreviated version of a longer example given by the authors. For excellent discussion of a similar example given by Dan W Brock, see Truog (2014).
- 7.
We have greatly simplified and slightly altered the cases presented by Wilkinson and Savulescu (2014).
- 8.
It might be thought that an alternative to making the patient’s capacity to benefit the same in each case is instead to alter the withholding version so that one patient arrives in the ICU before the other, both requiring life-saving ventilation and only one of whom can be connected. We then assume that neither has yet been connected. If we thought that the fact that one of these patients arrived earlier than the other is morally relevant, that might make the withholding v withholding case more like the withholding v withdrawing case, and it might be taken to show that withdrawal of itself does not make a moral difference. However, we believe that, even if we compared this alternative version of the withholding v withholding case to the withholding v withdrawal case, there would still be a moral difference between withholding and withdrawal, since there is moral significance in the fact that an allocation decision has been executed and the resource in question is already now being used. We discuss this in more detail in Sect. 15.6.
- 9.
The example is actually from Michael Tooley – Malm reproduces it in her criticisms of Tooley.
- 10.
On some views, Alan would not be ‘withholding’ the ventilator from Mary because there is no ventilator left to withhold. We address this briefly below.
- 11.
We say ‘bringing about’ rather than ‘killing’, for reasons we explain shortly in the text.
- 12.
- 13.
Not, as we noted above, the different issue of whether killing is in itself worse than letting die.
- 14.
Suppose someone replies that, in fact, it is not counter-intuitive. It seems, they might claim, intuitively right to say that it is just as arbitrary. We would reply that this objector should imagine having this conversation with the mother of the first child, who is already on the ventilator and consider how they would justify this to her at the hospital bedside. We should also note that, while this objector could claim that there is randomness in who arrives first in the hospital, it would be a mistake to focus on this as the basis for claiming that a first-come-first-served rule involves systemic bias and cannot be justified. The randomness point does not help the objector, because randomness is so pervasive and ubiquitous as to be incompatible with a claim about systemic bias. If a country person and an urban person become sick at the same time, then the urban person will arrive in the ICU first. But in practice there are countless variables shaping who becomes sick first, which can readily offset the country/urban distinction here, and there could easily be an infinite regress in the quest for a morally relevant point from which we can then work forward to calculate who should be treated first, even if someone is already being treated. We should note, too, that the argument of the objector would undermine many practices widely regarded as fair, such as queuing (see the text). As we argue below, however, there is further moral relevance in the fact that the decision has been executed, and this is always the case when considering withdrawal of LST.
- 15.
We are very grateful to Franklin G Miller and Nathan Emmerich for comments on earlier versions of this chapter. We are also grateful to the audience at the Australasian Association of Bioethics and Health Law 2018 for helpful comments.
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McGee, A., Carter, D. (2020). The Difference Between Withholding and Withdrawing Life-Sustaining Treatment. In: Emmerich, N., Mallia, P., Gordijn, B., Pistoia, F. (eds) Contemporary European Perspectives on the Ethics of End of Life Care. Philosophy and Medicine, vol 136. Springer, Cham. https://doi.org/10.1007/978-3-030-40033-0_15
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