Conscious refusal and renunciation of healthcare in the patient-doctor relationship

24 October 2008

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The opinion deals with the issue of the refusal (request to not begin) and the renunciation (request to suspend) of life-saving healthcare by a conscious patient of sound mind, who has been suitably informed of the therapies and who is able to express his own will on the question. A difference is made between the situation of the autonomous patient, or the patient who is able to avoid undesired therapy without involving others and the patient in conditions of dependency who needs the doctor’s intervention to carry out his own will.
Two different positions have emerged within the Italian Bioethics Committee. The first thesis is that, even though recognising that the protection of health is not liable to coercive imposition, there exists a duty to protect health at an ethical level (as a duty towards oneself and responsibility towards others) and that therefore the refusal and renunciation of care is ethically problematic, both in conditions of autonomy and dependence (in this second condition there also exists the doctor’s duty to treat the ill person, persistent therapy being the only limitation). The second thesis is that the request to not begin or to interrupt therapy is justified at an ethical level, as an individual choice of acceptance of the limits of human existence, in both conditions of autonomy and dependence, as the right exists for the individual to refuse treatment and to see his desires for the end of his own existence realised. The Italian Bioethics Committee holds that in conditions of dependence the patient can ask for the suspension of therapy, and that the doctor has the right to abstain: the Italian Bioethics Committee argued by a large majority that the patient has the right to realise his own request.
Several members refer to the distinction between “bring about death” and “let die”, maintaining that the active intervention causing death is illicit, but that it is acceptable for the doctor to abstain from coercive behaviour on the body if the patient expresses no consensus to treatment. The Italian Bioethics Committee unanimously stressed the importance of the therapeutic alliance between doctor and patient, underlining the doctor’s duty to inform the ill person, to gather his new awareness and to do everything possible to persuade him to accept the therapy: it is bioethically important to pay great attention to the conditions of vulnerability of the 
patient at the end of his existence, avoiding any kind of bureaucratisation of dying. Furthermore, the Italian Bioethics Committee considers that forms of persistent therapy and the withdrawal of treatment and life-support are unacceptable, maintaining that palliative care must be given to alleviate suffering.
The opinion is accompanied by numerous notes expressing other opinions or integrating the text with further reasoning.

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