Perspective from Taiwan

The key points of the controversies surround the withdrawal of treatment are: the legal effect and moral concerns behind advance directives; and the classification of artificial nutrition and hydration. By discussing the issues in the Eleuna Englaro case, we can go further into the debates concerning the legitimacy and justification of withdrawal treatment.

Withdrawal treatment is actually a type of euthanasia, essentially in the range of general euthanasia. Patient consent is a large part of this discussion. The case of Eleuna Englaro introduces the discussion of withdrawal treatment for a person in a persistent vegetative state (PVS). For both withdrawal treatment and voluntary euthanasia, they should be carried out only under the condition that patient’s consent exists. However, obtaining the patient’s consent may not always be enough to proceed with euthanasia.

In Veshi’s article, he brings up the important issue of whether the patient’s advance directives or presumed consent have binding force, even though it is not regulated by specific law.

In the well-known case of Cruzan v. Director, Missouri Department of Health (1990), involving withdrawing treatment on a PVS patient in the US, the United States Supreme Court upheld the Missouri court’s decision. It stated that Missouri was entitled to insist on clear and convincing evidence—a living will or some other formal document—before permitting the hospital to withdraw life support. But the Court also emphasised that PVS patients have the constitutional right to direct the withdrawal of treatment, and the State would impose very strenuous guidelines concerning advance directives. After the Cruzan case, several States revised their law and added provisions for honouring the living will and the use of healthcare proxies.¹

British law about the rights of unconscious patients had been clarified after the Anthony Bland case. His lungs were crushed and his brain was deprived of oxygen for so long that he fell into a PVS state. The trial judge agreed to the request of his parents to remove life support because it was in the patient’s interests. The Court of Appeals backed this decision, affirming it with the principle of respecting the patient’s right to self-determination. The House of Lords supported the Court of Appeal’s decision, but most opinions in judgement emphasised not the patient’s autonomy but his best interests.

In Anthony Bland’s case, the withdrawal of treatment was permitted by rebuilding the unconscious patient’s will by his character or lifestyle from his families and friends. However, as with Eleuna Englaro, the Court did not approve of withdrawing treatment in Nancy Cruzan’s case. Afterwards, although specific provisions about advance directives were revised in the US and Britain, it was somewhat different for Italy.

In summary, three main suggestions were made to the Italian Court:

1. 1. The definitions of withdrawal of treatment and euthanasia are not actually the same, and when this issue is discussed under aspects of ethics, more rigorous behaviour standards, principles of law and basic principles of ethics must be followed.

2. 2. Furthermore, there are some patients with other diseases or in different medical states, such as severe mental illness, and these patients may also be considered as incomplete patients, but not in the same circumstances as the person who is in a persistent vegetative state (PVS). Therefore, it is possible that the original title causes some misunderstanding to readers.

3. 3. In addition, the person who is in a persistent vegetative state (PVS) is not usually regarded as the object in the regulation of hospice palliative care. The elements of law of hospice palliative care in most countries are specifically and substantially established. In Italy, the court follows statute law to make judgements, although there is no identified answer about withdrawal of treatment for patients in PVS, as the issue is still undergoing intense debate. Therefore, the judgement of the Court of Appeal of Milan did follow international trends, accepting Mr. Beppino Englaro’s request to discontinue artificially supplied hydration and nutrition. Finally, this commentary suggests clear evidence (for instance, from a patient’s relative) that the patient would not have wished...