Beyond the Equivalence Thesis: how to think about the ethics of withdrawingand withholding life-saving medical treatment

With few exceptions, the literature on withdrawingand withholding life-saving treatment considers the bare fact of withdrawing or withholding to lack any ethical significance. If anything, the professional guidelines onthis matter are even more uniform. However, while no small degree of progress has been madetoward persuading healthcare professionals to withhold treatments that are unlikely to provide significant benefit, it is clear that a certain level of ambivalence remainswith regard to withdrawing treatment. Given that the absence of clinical benefit means treating patients is not only ethically questionable but alsotaxing on resources that could meet the needs of others, thisambivalence is troubling. Equally, the enduring ambivalence of professionals might be takento indicate that the issue warrants further attention. In this paper, we review the academic literature on the ethical equivalence of withdrawing and withholding medical treatment. While we are not in outright disagreement with the arguments presented, we suggest that asserting theoretical and decontextualized claims about the ethical equivalence of withdrawing and withholding life-saving treatment does not fully illuminate the moral questions associated with the relevant clinical realities. We argue that what is required is a broader perspective, one rooted in an understandingthat withdrawing and withholding life-saving treatmentare different practices, the meanings of whichare fully comprehensibleonly through an appreciation of their place within the practice of healthcare more generally. Such an account suggests that ifone is to engage withthe inappropriate protraction of life-saving treatment resulting from healthcare professionals' disinclination to withdraw it,then the differences between these practicesshould be taken seriously.