The principle of proportionality, succinctly stated, affirms that life-prolonging treatments are contraindicated when they cause more suffering than benefit. This principle also comes to expression in the Canadian Law Reform Commission’s recommendation that the Criminal Code should not bind physicians to administer therapeutically useless treatments or treatments that conflict with a patient’s best interests. Other position papers have also cited this principle or its equivalent. The Vatican Declaration on Euthanasia proposes that it is ethically justifiable to discontinue the use of life-prolonging techniques ‘where the results fall short of expectations’. Direct appeal is made to the principle of proportionality when this document observes that patient, family, and staff may judge that ‘the techniques applied impose on the patient strain or suffering out of proportion with the benefits which he or she may gain from such techniques’.

It was on the basis of a proportionality judgment that the court supported a mother’s and grandmother’s refusal of additional chemotherapy treatment for Carole Couture-Jacquet’s saccrococcygeal teratoma. This little girl, under 5 years old, had already suffered greatly from the side-effects of previous chemotherapeutic regimens. The suffering included constant nausea, loss of at least 50 per cent of kidney function, and a significant diminishing of hearing function. Physicians estimated that a renewed chemotherapy regimen had a 10-20 per cent chance of arresting the advance of Carole’s cancer.

The Quebec Court of Appeal did not find the mother’s and grandmother’s refusal of additional chemotherapy for Carole to be unreasonable. That refusal, rather, was seen as based on reasonable proportionality judgment that the low probability of success did not justify submitting Carole to more of the intolerable suffering she had already endured.(

Case study: A 42-year-old man, severely handicapped intellectually, and with multiple metastases to the brain, presented his two sisters and a clinical team with a choice initially found by all involved to be most difficult. The treatments available at the time would probably prolong this man’s life for a period of 6 months to 1 year beyond the time he could be expected to live without treatment. Yet these treatments required the patient’s collaboration, and he could not collaborate. He didn’t understand what doctors and nurses and hospitals were, and had no concept whatsoever of disease, treatment, and side-effects. He was a powerfully built person and still capable of quite devastating resistance to anyone he thought threatening or harmful. He also had lovely hair, and prized this personal characteristic above everything. He would spend hours grooming himself and admiring himself in the mirror, and would glow when complimented about his hair.

How, his sisters and physician asked, would he react to the hair loss and other side-effects of his treatment? Would he resist treatment if he made the connection between his hair loss and what doctors were doing to him? Would it not be better for our brother, the sisters asked, if he could have a relatively comfortable 8 months of life rather than 11 months or so of life filled with losses, complications of daily living, and misery he could never understand? This is how the sisters and the clinical team came to understand the choice they had to make for this man, and they judged aggressive antitumour treatment as being out of keeping with what this patient could tolerate, as likely to cause this man harm out of all proportion to the good it would bring him.

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