Views & Reviews Personal View

Withholding versus withdrawal of life support: is there an ethical difference?

BMJ 2011; 342 doi: (Published 09 February 2011) Cite this as: BMJ 2011;342:d728

Logic is the art of going wrong with confidence.

In these succinct few words Joseph Wood Krutch captured the dilemma
that is being discussed in Shimon Glick's thoughtful piece on the moral
difference between witholding and withdrawing life sustaining treatment.

Those who would dismiss the view that there is a difference between
the two have resorted to explaining the difference as being based upon an
emotional reaction. I believe that they are absolutely right in having
this view for reasons that are entirely obvious.

Through the work of George Lakoff It is becoming clear that most of
our thinking and expression is based upon metaphors, the neurological
equivalent of this metaphorical thinking being the presence of neural
networks. Our emotions are intimately tied to these neural networks.

Consider current work being done in the field of functional MRI where
moral concerns such as altruism can be demonstrated to be located in the
ventromedial prefrontal cortex (VMPFC). Those who might doubt such an
association need only to reflect upon neurology's most famous patient;
Phineas Gage, whose moral and social behaviour was irreversibly altered
when an explosion drove a tamping iron through his VMPFC.

Perhaps the inverse morality rule might go some of the way to explain
the difference between philosophers and
physicians in their apporach to the withdrawl and withholding of
treatment. Those who are physically, morally and emotionally closer to
the patient might have a greater degree of VMPFC activation. This
potentially ground breaking research however has not been done to my

Competing interests: No competing interests

14 February 2011
Alastair Macdonald
Renal Physician
Capital and Coast Health