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Who decides about terminating life-sustaining interventions if the patient is incompetent? If the patient appointed a proxy or surrogate decision maker when competent, that person is legally empowered to make decisions about terminating care. If no proxy was appointed, there is a legally designated hierarchy, usually (1) spouse, (2) adult children, (3) parents, (4) siblings, and (5) available relatives.
Second, there is no ethical or legal difference between withholding an intervention and withdrawing it. If a respirator or other treatment is started because physicians are uncertain whether a patient would have wanted it, they always can stop it later when information clarifies the patient's wishes. Although physicians and nurses might find stopping a treatment to be more difficult psychologically, withdrawal is ethically and legally permitted—and required—when it is consonant with the patient's wishes.
Data show that termination of medical treatments is now the norm. More than 85% of Americans die without cardiopulmonary resuscitation, and more than 90% of decedents in intensive care units do not receive cardiopulmonary resuscitation. Of decedents in intensive care units, 90% die after the withholding or withdrawal of medical treatments, with an average of 2.6 interventions being withheld or withdrawn per decedent. Since the 1990s, the trend has been to stop medical interventions more frequently.
It generally is agreed that all patients have a right to refuse medical interventions. Ethically, this right is based on the patient's autonomy and is implied by the doctrine of informed consent. Legally, state courts have cited the right to privacy, right to bodily integrity, or common law to justify the right to refuse medical treatment. In the 1990 Cruzan case and in the subsequent physician-assisted suicide cases, the U.S. Supreme Court affirmed that there is a “constitutionally protected right to refuse lifesaving hydration and nutrition.” The Court stated that “ liberty interest on the 14th Amendment] in refusing unwanted medical treatment may be inferred from our prior decisions.” All patients have a constitutional and an ethical right to refuse medical interventions. These rulings were the basis of the consistent state and federal court rulings to permit the husband to terminate artificial nutrition and hydration in the Schiavo case.
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