In recent decades, there have been drastic changes in what is known as the ideal model for the relationship between patients and health care providers (Maddocks, 2018). Paternalism has become a more common and helpful method in withdrawing CAHN from a patient with a prolonged disorder of consciousness. Paternalism occurs when health care providers make decisions for their patients without the patient’s informed consent, and the control of the relationship still lies in the physician’s hands (Catley et al., 2020). Although paternalism has been beneficial in the clinical field, controversy still exists on how non-Paternalism is the best in withdrawing CAHN from patients with a prolonged disorder of consciousness.
Best of Interest
Agreeably, paternalism is beneficial not only to physicians or other providers but to patients too. Paternalism enables physicians and healthcare providers to make the best decisions in the best interest of patients. Health care providers always act in the best interest of patients. According to Birchley (2017), the Best of Interest principle requires that any action taken or decision made by care providers on behalf of a patient deemed incapacitated must be done and made in his interest. The autonomy-enhancing act of mental capacity principle was first introduced in 2005. Many studies claim that it is virtually impossible for medics not to be paternalistic because physicians present all the medical details to the patient, making it inevitable for them not to act with their instincts by choosing what to present to the patient (Catley et al., 2020). However, before the paternalistic era, non-paternalism was used in hospitals, and studies were done to observe if the best interest principle was permissible (Maddocks, 2018).
The studies validated the best of interest principle, which has since been introduced in the mental capacity act and used by many medical practitioners. A study by Maddocks (2018) reported that Anthony Bland is an excellent example of how the best interest principle to be legalized lawfully. The case of Bland, which was appealed in 1993, is a big test case for the lawfulness of withdrawing life support in the UK. The case plays a huge role in the clinical field when making decisions as it outlines terminology encountered in similar cases. Although MCA sets the legal framework for making life or death decisions for adults lacking capacity, the court and its care providers helped make the decision. Bland’s case is viewed as a reflection of a need for a pragmatic approach in the medical world and also as a moral decision that needed justification. Bland had catastrophic brain damage, and the court held that it would be lawful to withdraw medical treatment because death was the inevitable result.
Although the best interest principle has proved beneficial in the medical field, research in the past decade posits that medical practitioners should also adopt the balance sheet approach when deciding to withdraw CAHN. The balance sheet technique requires medics to consider factors such as a patient’s medical history to decide whether to withhold or withdraw treatment (Huxtable, 2019). The approach also emphasizes the importance of understanding that treatment decisions differ from patient to patient in PDOC (Catley et al., 2020). Therefore medical practitioners need to learn how to weigh the benefits and burdens of a patient in a “balance sheet” to determine whether treatments and procedures are in a patient’s best interest (Huxtable, 2019).
Although Physicians have vastly superior knowledge of medical issues such as certainty of a diagnosis, its treatment, risks and benefits involved, and alternate treatment options, which makes more sense for medical practitioners to evaluate and make decisions, it is still essential to use the ‘balance sheet’ technique too (Maddocks, 2018). Advisably, when a physician feels like further treatment is inappropriate for an incapacitated patient, the BMA reiterates GMC, and it is advisable for the healthcare team to stop offering care (McCrossan & Siegmeth, 2017). This also means that even when a patient has requested a particular treatment, it doesn’t mean it must be provided and efforts must be made to offer the treatment, but a clinician should also know when to stop (Yelden et al., 2017). Courts in England and Wales, Australia, and New Zealand insist on knowing when it is acceptable to withdraw or withhold treatment because it is also beneficial to weigh the benefits and burdens of the treatment to sustain life (Maddocks, 2018). Hence, the balance sheet approach is crucial.
Sanctity of Life
Despite the numerous benefits of the paternalistic principle, as highlighted by the best interest and the balance sheets, some people still critique the approach. Research indicates that many critics argue that the paternalistic approach goes against the inviolability of life, also known as the sanctity of life (Bito & Asai, 2018). Critiques stand by the sanctity of life, which implies that life is holy and must be protected at all times (Bito & Asai, 2018). Bito and Asai (2018) posit that by law, moral and intellectual integrity expects the withdrawal of treatment decisions from those barely in conscious states as per the sanctity of life doctrine. The doctrine holds that human life may never intentionally be brought to an end by another through an act or omission.364 (Bito & Asai, 2018).
Sanctity of life proponents believes that the terminally ill can only be helped by restoring human dignity through caring for each other in the hard times and leaving the rest to God because God is ultimately sovereign over life situations such as illnesses. They argue that palliative care and PDOC violate what they stand for because “it is God who gives life, and He is the only one that is allowed to take it” (Birchley, 2017). People commonly refer to the sanctity of life when they want to express that it is wrong to cause death by withdrawing treatment (Kitzinger et al., 2017). Some people believe that it is unethical and is associated with assisted suicide because nutrition and hydration are basic factors of care. They also believe that it is only morally right when those whose interests are at stack lack the capacity for self-determination. One study by Huxtable (2019) showed that the paternalistic model doesn’t have respect for life as it fails to preserve life when withdrawing treatment or life-support. Critiques also posit that dying with dignity, like Justice Smith adopts respect for human rights to autonomy and gives a justification that withdrawing treatment in PDOC declines religious adherence and other moral values they hold (Huxtable, 2019). However, paternalism and the best interests outweigh moral contractualism by justifying that given the right knowledge and motivation, any reasonable person would agree to the interference of treatment in certain situations to prevent suicide and harm.
Allocation of Limited Healthcare Resources
In addition to the benefits of paternalism mentioned before, it also allows medical practitioners to balance the continuation of ineffective treatment and the allocation of medical resources. One of the binding obligations of the care providers is to promote their patient’s well-being, and this is made possible by having the necessary equipment (Maddocks, 2018). Physicians have the duty of distributing hospital resources fairly and in the correct form (Maddocks, 2018). Due to the high demand in hospitals, resources needed in critical departments like the ICU have a short supply. This research argues that ongoing ineffective treatment of individuals suffering from a prolonged ailment of consciousness will place an unnecessary burden on scarce resources (Maddocks, 2018). Concerns have recently risen due to resource scarcity, leading to many proposals considering cost rise as a factor in all clinical decisions made for barely conscious patients.
Although resource scarcity in clinical fields is inevitable, the Practice of best interest has increased life expectancy because many decisions are made to save the patient. Paternalism is a patient-centered approach that shadows the essence of freeing up space for more promising patients by withdrawing treatment for those whose inevitable result is death (Catley et al., 2020). However, despite these shortcomings, it is vital for medical practitioners always to practice their ethical obligations fairly to ensure the best health outcomes for patients.
Birchley, G. (2017). ‘…what god and the angels know of us?’ character, autonomy, and best interests in Minimally Conscious State. Medical Law Review, 26(3), 392–420. doi.org/10.1093/medlaw/fwx051
Bito, S., & Asai, A. (2018). Attitudes and behaviors of Japanese physicians concerning withholding and withdrawal of life-sustaining treatment for end-of-life patients: Results from an internet survey. BMC Medical Ethics, 8(1). doi.org/10.1186/1472-6939-8-7
Catley, P., Pywell, S., & Tanner, A. (2021). End-of-life Decisions for Patients with Prolonged Disorders of Consciousness in England and Wales: Time for Neuroscience-informed Improvements. Cambridge Quarterly of Healthcare Ethics, 30(1), 73–89. doi.org/10.1017/s0963180120000584
Huxtable, R. (2019). Dying too soon or living too long? Withdrawing treatment from patients with prolonged disorders of consciousness after re y. BMC Medical Ethics, 20(1). doi.org/10.1186/s12910-019-0424-4
Kitzinger, J., Kitzinger, C., & Cowley, J. (2017). When ‘sanctity of life’ and ‘self-determination’ clash: Briggs versus Briggs  EWCOP 53 – implications for policy and Practice. Journal of Medical Ethics, 43(7), 446–449. https://doi.org/10.1136/medethics-2016-104118
Maddocks, J. (2018). Are Recent Decisions concerning the Withdrawal of Life-Staining Treatments from Patients in a Minimally Conscious State to Be Feared as a Complete Departure from the Sacred Principle regarding the Protection of Human Life? Manchester Rev. L. Crime & Ethics, pp. 7, 87.
McCrossan, L., & Siegmeth, R. (2017). Demands and requests for ‘inappropriate’ or ‘inadvisable’ treatments at the end of life: What do you do at 2 o’clock in the morning when …? British Journal of Anaesthesia, 119, i90–i98. https://doi.org/10.1093/bja/aex359
Yelden, K., Sargent, S., & Samanta, J. (2017). Understanding the decision-making environment for people in Minimally Conscious State. Neuropsychological Rehabilitation, 28(8), 1415–1426. https://doi.org/10.1080/09602011.2017.1310657