c. The Physician's Decision. While a living will may request that life-sustaining
procedures be withheld or withdrawn under certain conditions, it is only the physician
who can determine whether or not the patient meets the criteria for withdrawal of life
support. The order for withdrawal of life support is written with the concurrence of the
patient or, in the case of incompetent patients, with the concurrence of the next of kin or
surrogate decision maker. If the next of kin does not wish the living will to be honored,
the matter should be referred to the hospital ethics committee.
d. Brain Death Not a Criterion. The traditional clinical definition of death is not
required for life support to be withdrawn. Once brain death has occurred, there is no
legal obligation to continue treatment.
brain death: the irreversible cessation of circulatory and respiratory
functions or of all functions of the entire brain, including the brain stem.
2-10. REFUSAL IN AN EMERGENCY
a. Competent Patients Refusing Emergency Care. Normally, in an
emergency, treatment can be given without obtaining prior consent and without fear of
liability if there is a threat of serious bodily harm or death. However, if a competent
patient refuses treatment in an emergency, the normal emergency rule waiving consent
requirements does not apply. For example, the police alert an ambulance to the scene
of an auto accident. The ambulance picks up a person who is unconscious. By the
time the ambulance reaches the emergency room, the patient is conscious and raises
objections to treatment. This person cannot be treated even though it is an emergency.
Nor can the physician, in this case, wait until the patient's condition worsens or until the
patient lapses into unconsciousness to commence treatment.
b. Refusal as a Possible Sign of Incompetence. Health care providers are
required to respect a competent patient's right to refuse treatment, even in an
emergency. But providers have an equal responsibility to identify cases in which
irrational self-destruction is contemplated by the patient. In these instances, refusal of
care may be a sign of incompetence. Let us imagine that a patient is brought to the
emergency room with slashed wrists and says that he or she does not wish to live or be
treated. It cannot automatically be assumed that the patient really wishes to die.
Bioethicists hold that the slashed wrists may be a cry for help. In such cases, treatment
should be provided under implied consent, until such time as the patient's competence
and consent can be ascertained. Only after the patient is revived and the situation is
talked through can a determination be made as to the patient's true needs and desires.
If, at that point, the patient still wishes no further treatment, the physician has a moral
obligation to seek help for the patient.