The Journal of Critical Care Medicine, has long supported Futile Care Theory—the putative right of doctors to refuse wanted life-sustaining treatment based on their values as to the quality of the patient’s life. This imposition is justified as being beneficial to the patient—even if it directly contravenes the patient’s desires—and to protect physician autonomy.

But the real agenda is health care rationing and imposing a duty to die— sooner rather than later—based on social policy.  This agenda has now been tabled in a new article in the JCCM, on the matter, “Medical Futility, Personal Goods, and Social Policy,” by Lisa Day, RN, PhD (May 2009, Vol. 18, No. 3) : 

If in determining reasonable treatment for one patient the provider also takes into account the needs of other members of the community, the disproportionate means argument takes on new meaning. How will providing the treatments one patient demands burden or benefit others in the community? Can the resources used to support the life of one dying patient be redistributed to benefit others? These questions come up in critical care units when a dying patient is using intensive care resources while another patient with the potential to benefit in a more commonly valued way waits for a bed to open

Although providers privately struggle with these concerns, they typically do not bring them forward in provider-patient discussions. The fiduciary relationship the provider has with her patient demands loyalty and commitment to the good of the individual. Therefore, a tension exists in the practice of many critical care providers between their commitment to the individual patient and their desire to be good stewards of community resources and to provide care to all in need...

But this solution does not resolve the tension providers feel between responsibility to the patient and responsibility to society. The ultimate question is: Should anyone have the right to the treatment demanded by the patient in the hypothetical advanced directive? In certain circumstances,should the provider’s responsibilities to the larger community override her or his responsibilities to the individual patient? These are questions that should be debated in larger social forums rather than at the bedsides of individual patients.

Make no mistake: This is an opening gambit to create a dual—and sometimes conflicting—mandate for physicians; one to patients, but the other to “society.” It is the end of professionalism because it will force the physician into divided loyalties.  Indeed, if we look back in history at the awful crimes committed in the name of medicine, the skids to horror were greased by transforming physicians into fiduciaries for society as well as to their patients.  And in this approach, is born a duty to put yourself out of our misery.

Articles by Wesley J. Smith

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