Self-Inflicted Gunshot Wound/Self-Reported No Code Status: The Doctor’s Dilemma

Suicidal ideation and attempted suicide are important presenting complaints in the emergency department (ED). The juxtaposition of a self-inflicted gunshot wound and self-reported no code status may serve to amplify the moral distress of attending emergency providers. Imagine caring for a terminal yet capable patient, who independently attempts suicide unsuccessfully and is brought to the ED with an advance directive (AD) requesting no treatment. The exceptional consideration in this suicidal context is whether the treatment can be effective. In a case with a very low likelihood that any intervention could produce a good outcome, clinical judgment becomes the basis for withholding or withdrawing treatment, not the AD.

An Alternative Perspective on Rationing Ventilators

The COVID-19 pandemic has resulted in discussion on how to allocate scarce medical resources such as ventilators. Some bioethicists have suggested that difficult determinations about withholding or withdrawing treatment should be made by triage officers or committees to alleviate the psychological strain on frontline clinicians. However, this raises concerns about shifting important personal medical decisions away from physicians and their patients. According to the principle of subsidiarity, frontline clinicians, together with their patients, should be making these decisions, with ethics committees or triage committees serving only in an advisory capacity. Several ethical principles can help health care professionals allocate scarce resources. These include basing exclusion criteria on clinical status rather than nonmedical characteristics; randomizing treatment for clinically similar patients; obtaining free and informed consent when considering the withdrawal of treatment, even in situations where treatment is possibly futile; and emphasizing quality palliative care for all patients.

Virtue Theory and the Lawfulness of Withholding or Withdrawing Treatment or Care

Virtue theory as best understood both excludes some intentional actions and intentional omissions as inherently incompatible with the goods of worthwhile human practices and seeks the mean between excess and defect. The Hippocratic tradition excludes withdrawal of treatment with intent to end life. The virtuous physician will then seek a mean between overtreatment and undertreatment. This requires not only clinical judgment (techne), but an overall best-interest decision (phronesis). Medical law has means to prevent undertreatment due to negligence, but is less well-adapted to preventing overtreatment. The Law Lords in the Bland case seemingly approved the withdrawal of tube-feeding even with intent to end life, which would mark a radical departure from Hippocratic virtue ethics. Subsequent legal developments have restored consistency to the law by prohibiting omissions with that intent, but they have not remedied the error of condoning undertreatment through neglect of the objective goods of health and life.

Ethical Dilemmas in Postnatal Treatment of Severe Congenital Hydrocephalus

Severe congenital hydrocephalus manifests as accumulation of a large amount of excess fluid in the brain. It is a paradigmatic example of a condition in which diagnosis is relatively straightforward and long-term survival is usually associated with severe disability. It might be thought that, should parents agree, palliative care and limitation of treatment would be clearly permissible on the basis of the best interests of the infant. However, severe congenital hydrocephalus illustrates some of the neuroethical challenges in pediatrics. The permissibility of withholding or withdrawing treatment is limited by uncertainty in prognosis and the possibility of “palliative harm.” Conversely, although there are some situations in which treatment is contrary to the interests of the child, or unreasonable on the grounds of limited resources, acute surgical treatment of hydrocephalus rarely falls into that category.