Suspension of processing

Director's note on the suspension of treatments

The purpose of this note is to provide some elements to clarify the delicate issues concerning the so-called right of the patient to refuse therapies and health treatments, so as to highlight the criteria that should guide the doctor's action.  These are complex topics that cannot be resolved only on a point of law, since in fact in  many cases they imply aspects of a relational nature and ethical evaluations that must be carried out in humanly and clinically difficult situations.

In the face of this, it is therefore necessary to illustrate some principles capable of promoting correct, conscious and responsible medical action. First of all, therefore, the distinction between the right not to undergo care and treatment – moreover enshrined in the Constitution itself and the cornerstone of a doctor-patient relationship that does not have a coercive nature – and the issue of the suspension of treatments already in progress that are configured as a safeguard and protection of the patient's life should be emphasized. Between the two situations there is, in fact, a difference that is not only factual, since in the first case it is a matter of not starting a treatment and in the other, instead, of suspending an ongoing therapeutic process.

From an ethical point of view, it is important to highlight that the problem of when and if to suspend a treatment cannot be solved simply by answering the question "who should decide", but by highlighting the question "on the basis of what criteria should the decision be made", so that the choice is not only free and voluntary, but ethically just and correct.

The therapeutic alliance is based, in fact, on the content sharing of the choice and not on the prevalence of one will over another. In this perspective, it is evident that the patient's decision or willingness to interrupt a treatment, if it has a life-saving function and retains its therapeutic efficacy, is not sufficient to make the suspension of the treatment itself ethically legitimate. In fact, just as no doctor can undertake a therapeutic act if he considers it clinically inappropriate, so too he must not suspend any intervention if he considers that, from a clinical point of view, it is proportionate to the patient's situation and capable of producing more benefits than negative side effects.

In itself, any therapeutic treatment, even after it has been undertaken, may become, due to the evolution of the disease and the clinical situation, no longer appropriate. When this happens – but the evaluation is clinical – the treatment not only can, but must be suspended by the doctor, as its therapeutic function has ceased. Such a way of operating is, therefore, connected, in fact and in law, to the proper nature of the process of care and assistance that regulates the doctor-patient relationship. On the other hand, the request to suspend a treatment that has already begun, which continues to be appropriate, aligns, in a more or less conscious way, with the logic that governs assisted suicide and the request for euthanasia.

Fatigue, resignation, suffering, are not indicators of therapeutic disproportionality, and must be overcome with appropriate methods. Elaborating a general theory that falsifies this datum confuses ideas and undermines the correctness of the bioethical debate because it makes the criterion of proportionality and appropriateness so imprecise as to qualify as obstinacy any act that is in contrast with the patient's will.

The dynamics of care and assistance, however, lose their meaning and value if they are translated into the pure ratification of wills and decisions, without the possibility of advice, confrontation, dialogue that is, yes, certainly personal and human, but in any case marked by clinical competence on the appropriateness of the therapeutic tools in place in the individual situation.

Guidelines and protocols are decisive if they help to understand the specificity of each individual clinical situation and facilitate the development of non-arbitrary criteria, which place the person at the center in his or her fundamental rights to care and assistance.