Education And Debate

Withholding and withdrawing life sustaining treatment from elderly people: towards formal guidelines

BMJ 1994; 308 doi: (Published 25 June 1994) Cite this as: BMJ 1994;308:1689
  1. L Doyal,
  2. D Wilsher
  1. Department of Human Science and Medical Ethics, London
  2. and St Bartholomew's Medical Colleges, London E1 2AD
  1. Correspondence to: Mr Len Doyal.

    Clinicians often decide either to withhold or to withdraw lifesaving treatment in elderly patients. Considerable disagreement exists about the circumstances in which such actions can be defended. Debates about the scarcity of resources in the NHS add urgency to the need to resolve this disagreement. Competent elderly patients have a legal and moral right to decide whether to receive life sustaining treatment. Such treatment should not be withheld or withdrawn on the basis of a patient's age alone. Principles for making decisions about life sustaining treatment in incompetent elderly patients can be defended and should exist as written guidelines.

    Clinicians working with elderly patients often face difficult decisions about withholding or withdrawing life sustaining treatment. They must balance the sometimes uncertain benefits of active intervention against the potential burdens. Despite the frequency of such dilemmas little clear guidance exists on the moral and legal status of “non-treatment.”

    The lack of such guidance is unsatisfactory for several reasons. Firstly, clinicians often disagree about what is morally and legally required of them. Secondly, this disagreement leads to arbitrary differences in the treatment that elderly patients receive; indeed, on occasion, non- treatment on the basis of old age is used unacceptably as a mechanism for rationing scarce resources.1,2 Finally, when disagreements arise within clinical teams or with patients or relatives no agreed policy exists to help to resolve these disagreements.

    In recent years the extent of the legal duty to provide life sustaining treatment has been substantially clarified. Allowing elderly patients to die is now without doubt lawful in certain circumstances. Furthermore, developments in moral theory have reinforced the acceptability of such actions. In this paper we build on these results to defend specific principles for non-treatment which can be applied to characteristic dilemmas in geriatric medicine. While many of our arguments …

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