It probably should not be surprising, in this time of soaring medical costs and proliferating technology, that an intense debate has arisen over the concept of medical futility. Should doctors be doing all the things they are doing? In particular, should they be attempting treatments that have little likelihood of achieving the goals of medicine? What are the goals of medicine? Can we agree when medical treatment fails to achieve such goals? What should the physician do and not do under (...) such circumstances? Exploring these issues has forced us to revisit the doctor-patient relationship and the relationship of the medical profession to society in a most fundamental way. Medical futility has both a quantitative and qualitative component. I maintain that medical futility is the unacceptable likelihood of achieving an effect that the patient has the capacity to appreciate as a benefit. Both emphasized terms are important. A patient is neither a collection of organs nor merely an individual with desires. Rather, a patient (from the word to suffer ) is a person who seeks the healing (meaning to make whole ) powers of the physician. The relationship between the two is central to the healing process and the goals of medicine. Medicine today has the capacity to achieve a multitude of effects, raising and lowering blood pressure, speeding, slowing, and even removing and replacing the heart, to name but a minuscule few. But none of these effects is a benefit unless the patient has at the very least the capacity to appreciate it. Sadly, in the futility debate wherein some critics have failed or refused to define medical futility an important area of medicine has in large part been neglected, not only in treatment decisions at the bedside, but in public discussions—comfort care—the physician’s obligation to alleviate suffering, enhance well being and support the dignity of the patient in the last few days of life. (shrink)
U.S. politicians and policymakers have been preoccupied with how to pay for health care. Hardly any thought has been given to what should be paid for?as though health care is a commodity that needs no examination?or what health outcomes should receive priority in a just society, i.e., rationing. I present a rationing proposal, consistent with U.S. culture and traditions, that deals not with ?health care,? the terminology used in the current debate, but with the more modest and limited topic of (...) medical care. Integral to this rationing proposal?which allows scope to individual choice and at the same time recognizes the interdependence of the individual and society?is a definition of a ?decent minimum,? the basic package of medical treatments everyone should have access to in a just society. I apply it to a specific example, diabetes mellitus, and track it through a person's life span. (shrink)
The Institute of Medicine and the American Heart Association have issued a “call to action” to expand the performance of cardiopulmonary resuscitation in response to out-of-hospital cardiac arrest. Widespread advertising campaigns have been created to encourage more members of the lay public to undergo training in the technique of closed-chest compression-only CPR, based upon extolling the virtues of rapid initiation of resuscitation, untempered by information about the often distressing outcomes, and hailing the “improved” results when nonprofessional bystanders are involved. We (...) describe this misrepresentation of CPR as a highly effective treatment as the fetishization of this valuable, but often inappropriately used, therapy. We propose that the medical profession has an ethical duty to inform the public through education campaigns about the procedure's limitations in the out-of-hospital setting and the narrow clinical indications for which it has been demonstrated to have a reasonable probability of producing favorable outcomes. (shrink)
Partly because physicians can “never say never,” partly because of the seduction of modern technology, and partly out of misplaced fear of litigation, physicians have increasingly shown a tendency to undertake treatments that have no realistic expectation of success. For this reason, we have articulated common sense criteria for medical futility. If a treatment can be shown not to have worked in the last 100 cases, we propose that it be regarded as medically futile. Also, if the treatment fails to (...) restore consciousness or alleviate total dependence on intensive care, we propose such treatment be judged futile. This definition provides clear end points and encourages the profession to review data from the past and perform, prospective clinical studies that not only report treatments that work but also treatments that do not work. We have also argued that, in a variety of settings, physicians have no ordinary ethical obligation to offer futile interventions. Although physicians should inform, and discuss all decisions to withhold or withdraw medical treatments with patients, they need not obtain the patient's permission to desist from futile interventions. (shrink)
Should the nation provide expensive care and scarce organs to convicted felons? We distinguish between two fields of justice: Medical Justice and Societal Justice. Although there is general acceptance within the medical profession that physicians may distribute limited treatments based solely on potential medical benefits without regard to nonmedical factors, that does not mean that society cannot impose limits based on societal factors. If a society considers the convicted felon to be a full member, then that person would be entitled (...) to at least a decent minimum level of care — which might include access to scarce life-saving organs. However, if criminals forfeit their entitlement to the same level of medical care afforded to all members of society, they still would be entitled to a kind of rudimentary decent minimum granted to all persons on simple humanitarian grounds. Almost certainly this entitlement would not include access to organ transplants. (shrink)
Regina R. is a 12-year-old girl with recently diagnosed insulin-dependent diabetes. Before discharging her from the hospital, her family physician and consulting diabetes specialist try to instruct the girl and her parents in the appropriate program of treatment, including diet, insulin, and regular self-monitoring. However, the parents become upset when they learn what is involved in insulin treatment and inform the family physician they plan to employ the services of an alternative healing clinic that promises to cure their daughter with (...) a combination of herbal potions, macrobiotics, aroma therapy, therapeutic touch, Ayurveda, homeopathy, and guided imagery. (shrink)
Howard Brody expresses concern that citing the “two cases that put futility on the map,” namely Helga Wanglie and Baby K, may be providing ammunition to the opponents of the concept of medical futility. He in fact joins well-known opponents of the concept of medical futility in arguing that it is one thing for the physician to say whether a particular intervention will promote an identified goal, quite another to say whether a goal is worth pursuing. In the latter instance, (...) physicians are laying themselves open “to the criticism of taking on basic value judgments that are more appropriately left to patients and their surrogates.” Brody states that in both the Wanglie and Baby K cases, the “basic value judgments” had to do with the worthiness of maintaining unconscious life via medical technology. He classifies this as “a question of professional integrity—but not a question of futility,” adding that “more than semantics hinges on this distinction.” The “more than semantics” factor is a pragmatic, even political one. Failure to make this distinction renders physicians “that much more suspect and less trustworthy in the public debate.”. (shrink)
A few years ago a battered infant was admitted to a California hospital. After a period of observation and testing, the physicians concluded that the infant had been beaten so badly that his brain was almost completely destroyed, leaving him permanently unconscious. The hospital had just adopted a policy specifying that life-sustaining treatment for permanent unconsciousness was futile and, therefore, not indicated. According to this policy, after suitable subspecialty consultations and deliberations, including efforts to gain parental agreement and documentation of (...) unanimous ethics committee support, the patient's physician had the authority to discontinue life-sustaining treatment. The infant's physician wished to do this. The mother, however, who was the prime battery suspect, insisted that the baby be kept alive. (shrink)
One of the most entrenched commandments in medicine is: “Never take away a patient's hope!” Often it is issued during the treatment of a terminally ill patient to spur and justify the continuation of aggressive life-prolonging efforts. Hope has been called one of a patient‘s “most powerful internal resources,” and “a powerful ally, our last defense against despair.” One editorialist confidently stated: “[C]ommunicating hope can improve patients’ prognosis.”.
Two recent policy statements by providers of critical care representing the United States and Europe have rejected the concept and language of “medical futility,” on the ground that there is no universal consensus on a definition. They recommend using “potentially inappropriate” or “inappropriate” instead. As Bosslet and colleagues state: The term “potentially inappropriate” should be used, rather than futile, to describe treatments that have at least some chance of accomplishing the effect sought by the patient, but clinicians believe that competing (...) ethical considerations justify not providing them. Clinicians should explain and advocate for the treatment plan... (shrink)
In situations where experience shows that a particular intervention will not benefit a patient, common sense seems to suggest that the intervention should not be used. Yet it is precisely in these situations that a peculiar ethic begins to operate, an ethic that Eddy calls “the criterion of potential benefit.” According to this ethic, “a treatment is appropriate if it might have some benefit.” Thus, the various maxims learned in medical school instruct physicians that “‘an error of commission is to (...) be preferred to an error of omission,’ or ‘when in doubt, cut it out’ or ‘if but one patient is helped, then the treatment is worthwhile.’”. (shrink)
Previous studies have documented the fallibility of attempts by surrogates and physicians to act in a substituted judgment capacity and predict end-of-life treatment decisions on behalf of patients. We previously reported that physicians misperceive their patients' preferences and substitute their own preferences for those of their patients with respect to four treatments: cardiopulmonary resuscitation in the event of cardiac arrest, ventilator for an indefinite period of time, medical nutrition and hydration for an indefinite period of time, and hospitalization in the (...) event of pneumonia. (shrink)
An anencephalic infant, who came to be known as Baby K, was born at Fairfax Hospial in Falls Church, Virginia, on October 13, 1992. From, the moment of birth and repeatedly thereafter, the baby's mother insisted that aggressive measures be pursued, including cardiopulmonary resuscitation and ventilator support, to keep the baby alive as long as possible. The physicians complied. However, following the baby's second admission for respiratory failure, the hospital sought declaratory relief from the court permitting it to forgo emergency (...) life support on the grounds that “a requirement to provide respiratory assistance would exceed the prevailing standard of medical care,” and that “because any treatment of their condition is futile, the prevailing standard of medical care for infants with anencephaly is to provide warmth, nutrition, and hydration.” The United States Court of Appeals for the Fourth Circuit ruled in favor of the baby's mother, citing the federal Emergency Medical Treatment and Active Labor Act , which contained no “standard of care” exception to the requirement to provide “treatment necessary to prevent the material deterioration of the individual's condition.” An appeal to the United States Supreme Court was rejected. The baby died some two and one-half years later of cardiac arrest during her sixth visit to the emergency department of Fairfax Hospital for respiratory failure. (shrink)
D.T. a 35-year-old woman, was found to have breast cancer. At the time of mastectomy axillary lymph nodes were positive and the cancer was classified as adenocarcinoma, grade 4. The patient underwent conventional chemotherapy. When it became apparent the disease was metastatic, the patient's oncologist contacted a well-known cancer center regarding the possibility of treating the patient with high dose chemotherapy and autologous bone marrow transplantation. The patient's health insurance provider informed the patient, however, that the treatment—estimated to cost in (...) the range of $150,000–200,000—was “considered experimental or research in nature” and therefore was not included in coverage. D.T. did not pursue this further. Approximately 2 years later, cancer was detected in the patient's spine. This time she applied to another well-known cancer center for HDC/ABMT. The cancer center agreed to accept her on the condition of proof of ability to pay for the treatment. Again her insurer refused coverage on the same grounds as before. D.T. found another source for the money, underwent treatment, then sued the insurance carrier. She sought a declaratory judgment that the treatment was covered under the insurance policy. The court ruled in favor of D.T. finding the contract phrase “considered experimental” ambiguous. (shrink)
The writers in this symposium are drawn together under the topic of medicine — not to discuss any new discovery in the prevention or treatment of disease. Quite the contrary. We are drawn here to consider a phenomenon. We are here to consider whether a collective romantic fantasy called alternative medicine that has seized our society really deserves the acclaim it is receiving. This, for the most part, is what people like us do when we gather in symposia or meetings (...) to discuss alternative medicine. We argue about beliefs and claims, not results. Are the beliefs and claims of this collective romantic fantasy justified by empirical data? Or rather, will the beliefs and claims of this collective romantic fantasy be justified by empirical data because the fantasy is already securely in place in our political and fiscal, medical and educational, structures? (shrink)
The writers in this symposium are drawn together under the topic of medicine — not to discuss any new discovery in the prevention or treatment of disease. Quite the contrary. We are drawn here to consider a phenomenon. We are here to consider whether a collective romantic fantasy called alternative medicine that has seized our society really deserves the acclaim it is receiving. This, for the most part, is what people like us do when we gather in symposia or meetings (...) to discuss alternative medicine. We argue about beliefs and claims, not results. Are the beliefs and claims of this collective romantic fantasy justified by empirical data? Or rather, will the beliefs and claims of this collective romantic fantasy be justified by empirical data because the fantasy is already securely in place in our political and fiscal, medical and educational, structures? (shrink)
Researchers tracking social trends have discovered a remarkable labor-saving device called the computer. They sit down before the instrument, call up a search engine, enter a key word that they believe represents the trend, and count the number of articles aroused by that key word. They track these numbers over a period of time and even graph them. Those who dislike a certain concept are happy to report the concept's rise and fall. Such has occurred with two articles, one of (...) which appeared in CQ, reporting the rise and fall of medical futility. We are impressed with the power of this research methodology, which seems capable of eliminating concepts, even when our own more labor-intensive yet apparently less perceptive daily experience finds evidence of their existence all around us. (shrink)
Previous studies have documented the fallibility of attempts by surrogates and physicians to act in a substituted judgment capacity and predict end-of-life treatment decisions on behalf of patients. We previously reported that physicians misperceive their patients' preferences and substitute their own preferences for those of their patients with respect to four treatments: cardiopulmonary resuscitation in the event of cardiac arrest, ventilator for an indefinite period of time, medical nutrition and hydration for an indefinite period of time, and hospitalization in the (...) event of pneumonia. (shrink)
