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.
June 11th, 2009 | 12:19 pm
[...] As we move into health care reform, the issue of health care rationing is coming to the fore. Instituting Futile Care Theory–the putative right of a doctor to refuse wantedlife-sustaining treatment based on his or her values as to the quality of the patient’s life–is the opening gambit because it targets those thought to be on their last legs. Now, the Journal of Critical Care Medicine has published an article intended to open the debate as to whether doctors have a social duty to impose medical futility. This is nothing less than the deprofessionalization of medicine by imposing upon (or granting to) doctors a dual and sometimes conflicting mandate–one to provide the patient optimal care and the other to deny optimal care based on social duty. For more details, check out my post over at Secondhand Smoke. [...]
June 11th, 2009 | 1:27 pm
I must admit to being of two minds on this one. Given a world in which medical resources were unlimited, and were available to everyone who needed them regardless of ability to pay, economic considerations should, of course, have no place in making decisions of this kind.
On the other hand, given the real world in which we live, it does not seem right to ignore completely the principles of distributive justice. Should fully conscious patients who have serious treatment needs, and who could benefit from such treatment, be denied because enormous sums are being laid out for the benefit of a patient who is in a persistent vegetative state (assuming that the PVS patient can even be said to be receiving a benefit from the treatement that he or she is getting)?
In some ways, the situation may be analogous to the early days of kidney dialysis. Given the limited availability of dialysis machines, decisions regarding allocation had to be made as to who would receive the treatment, and one of the factors considered was who would receive the greatest benefit.
June 11th, 2009 | 1:32 pm
Makarios: No, we we are not in a triage situation, which by definition, is transitory and an emergency situation. Moreover, it isn’t up to doctors to effectuate “distributive justice.” It is their job to care for their patients.
And once futile care is imposed, do you think it will stop there? I once asked a “futilitarian” what would be next once the doctor had the right to refuse treatment based on his or her values. He responded (as I reported in my book Culture of Death) “marginal beneficial care.” Asked for an example, he replied, “An 80-year-old having a mammogram.” In the end, once patients are given subjective worth by their physicians, none of us will be safe.
Thanks for contributing to SHS.
June 11th, 2009 | 2:13 pm
Interesting thoughts, Wesley. A few of my own in response:
Doctors do have a responsibility to care for all of their patients–and to supply them with appropriate treatment. But most doctors have many patients. What are they to do when supplying treatment to one patient would preclude supplying appropriate treatment to another–or, since doctors don’t practice in silos, to the patients of a colleague? The doctor must make a decision, and that decision can be made either by flipping a coin or on some principled basis. I would suggest that distributive justice might be one of the principles to be taken into account.
Now, as to the marginal beneficial care thing–I am not sure exactly what your “futilitarian” meant by that, but it may be possible that the idea was that treatment would be denied, not on the basis of “his or her values,” but on the basis of reasoned professional judgment involving, among other things, a weighing of probable risks and benefits. Note, please, that I’m not saying anything for or against the concept of medical futility–I’m simply suggesting that, when such decisions are made, they may, and probably do, involve considerations beyond personal values.
June 11th, 2009 | 2:48 pm
Futile Care Theory, which is practiced in other countries (Canada, I believe) is evidence that there is no such thing as universal health care. Health care is dispensed with varying degrees of discrimination. Our convoluted, quasi market for insurance and care entails discrimination based on price. Other systems discriminate on the basis of age. Wouldn’t it be effective to argue against the coming effort to nationalize the industry by drawing attention to this fact that universal care is an illusion.
June 11th, 2009 | 3:08 pm
Makarios:But letting the doctor decide how to institute distributive justice just allows him or her to impose his or her prejudices. One doctor might decide to deny aged patients, another smokers, etc. What if a doctor had a bias against gays and decided not to spend resources on late stage AIDS patients based on the disproportionate amount of money their care has cost? A German doctor in the 19th Century once said that once a doctor gets to decide who’s life is worth living, he “becomes the most dangerous man in the state.”
June 11th, 2009 | 3:57 pm
Wesley,
We already apply principles of distributive justice in allocating scarce resources such as organs for transplantation. The formalized protocols for such allocations may not be entirely values-free, but they seem to be the best approach available (as compared with, say, random selection or supply to the highest bidder). Other resources may be less scarce (or less dramatically so), but the same considerations would apply, mutatis mutandis.
And, by the way, in the case of lung transplants, the fact that one potential recipient is a smoker and the other is not may well be a factor in making the allocation decision–particularly if the smoker expresses no intention of quitting. This is not a matter of prejudice–it’s a matter of weighing risks and benefits.
June 11th, 2009 | 4:30 pm
Well, apparently it’s my job to ask the really important questions.
I notice the shirt image says “Satellite News”. Are you a fan of Mystery Science Theater 3000, then?
June 11th, 2009 | 6:15 pm
An eighty year old has no right to a mammogram? My mother is eighty-two, has survived breast cancer, and does lots of worthwhile stuff like volunteer at the local historical museum— she’s in charge of the guide program.
Any society which would deny her a mammogram needs to apologize to Adolf Hitler’s ghost.
June 12th, 2009 | 1:49 am
Joe, I hadn’t noticed that. I did like it, but the gag grew old quickly.
Nissa: Once you give them an inch, they will want a mile.
Thanks both for being here.
June 12th, 2009 | 1:01 pm
> refuse wanted life-sustaining treatment based on their values
Superficially, this is exactly the same as the argument for refusing assisted suicide, which makes this a very insidious argument. It’s a common trick among the sophists. Abstract way true values like “Image of God” and reduce all statements to logic to prove that two opposites are really the same. So being a mass murderer is the same as risking your life to save hundreds. It’s all just making decisions about who lives and dies and facing the consequences of those decision.
The right to refuse assisted suicide based on personal values and the right of society to refuse assisted suicide based on societal values is not a right at all and personal values don’t factor into it at all.
It’s an obligation from God, as is the obligation to provide good hospice care so that those who leave this life have the love and dignity that they need.
June 12th, 2009 | 1:24 pm
Makarios, your argument depends on the premise that such decisions will be strictly pragmatic. But will that always remain true? If the betterment of “society” is the standard, then the line between physiological and ideological seems very blurry. If you’re middle class economically, do you have more to contribute to society than someone who is poor? Would that be justice?
The fellow who just shot up the Holocaust museum probably believes quite honestly that he was acting on heroic motives (I realize this is extreme to make my point; subtle prejudice is the more insidious). In general, few people want to admit that they could harbor a dark side where the ends justify the means.
June 12th, 2009 | 1:41 pm
[...] include Assisted Suicide? Hey, do the socially-responsible thing, and help our bottom line and just die, already. After all, as the Baroness says in this old piece of mine, “If I went into a nursing home it [...]
June 12th, 2009 | 2:29 pm
What noone seems to be getting in this debate is that it isn’t just a right to life issue, it’s a personal choice issue. Where’s the “my body, my choice” response on this one? Doesn’t that principle apply to the most basic decision of choosing life saving/prolonging treatment or not? If pro lifers and pro choicers agree on nothing else in their lives, they should be able to reach a consensus on something like this.
June 12th, 2009 | 2:31 pm
Moreover, if the author feels so strongly about a duty to die, I think that she should hurry up and set a good example by jumping into a volcano or something and saving the world resources she would have used had she lived.
June 12th, 2009 | 2:31 pm
College Goyl [love the s/n, by the way], I don’t disagree with your suggestion that everyone brings his or her values to bear, in some sense, in every decision that he/she makes. Judgment calls are involved in allocation of donor organs, for example. And while such protocols can, to a large extent, be formalized, the element of value judgment probably cannot be eliminated entirely.
Nevertheless, scarce resources must be allocated somehow. The question is, what alternative means do we have to allocate them that will result in some demonstrable form of justice being done (again, let’s use donor organs for the purpose of discussion).
One possiblity is sell them to the highest bidder. That would make free-marketeers happy and be in line with their values, but would that make for the kind of society that you’d want to live in?
First-come-first-served is another possibility, but that could lead to demonstrably unjust outcomes, and I’m sure you can imagine.
And then there’s always good old random selection–when a donor liver becomes available, draw a name from the hat to see which patient gets it.
There may be other possiblities, but the final one I’ll mention is allocation through the professional judgment of the health-care team and transplant committee. Do each of the members of both of these groups bring their values with them when they consider a case? Undoubtedly. But–right hand up to God–if someone whom you loved needed a transplant, which of the allocation approaches that I’ve mentioned above would make you feel most comfortable?
June 12th, 2009 | 10:18 pm
Makarios, and all,
I think there is some difference between futile care theory and your transplant protocols example. For one thing, the protocols were developed through the cooperation and input of a large group of people, so there is less chance of personal prejudice entering into it.
Now as I understand it, FCT would involve hospital committees of some kind and at some point, but I still say the group involved is too insular and has too many competing interests to “administer” their decisions without bias.
Also, the public nature of trasplant protocols leave it open t scrutiny by the public, and so there is some ability to check and balance if some silly prejudices crept in.
I would like to know more about the ways in which FCT is supposed to be implemented. how often would lone doctors get to decide who was worth the expense? How often would it be a person or persons with no interest whatever in the financial success of the health care provider? And, If we are talking about a single-payer or government-managed system, then how often would there be government bureaucrats trying to justify their cost-cutting measures on the basis that, without them the whole economy would collapse?
(As I keep telling everyone, I object to government run health care for that reason alone: the government should not be in the business of choosing between the continued halth of our economy, or Grandma’s mammogram….or little Davey’s heart surgery when he won’t live more than three more years anyway….or the home nursing care for a MS patient….you get the idea)
June 13th, 2009 | 11:31 am
One thing has been becoming ever more clear. For all the hand-wringing about the limitations and rationing that a government-run health care system will bring, we face having the limitations and rationing based on such concepts as futile care theory anyway. Wesley has been documenting these signs for years.
If the medical industry and the government is going to impose such “solutions” to use of medical resources with or without universal health care, then we might as well get the universal health care anyway. Not having single-payer or whatever won’t make a bit of difference in the burgeoning trend toward telling some people that their use of health care resources is exorbitant and unwarranted. That is already happening now.
June 13th, 2009 | 12:59 pm
I see another aspect to this discussion. Is it morally right for a person (society) to demand unfettered access to extraordinary healthcare when so many go without even basic care? Part of what leads us into this dilemma is healthcare research that leaps ahead of any bioethical debate about its value. Just because we can do something, does that mean we should?
For instance, consider the effort by some scientists to try and prolong human life to 120 years and beyond. Some say this achievement may not be that far away. Is that a moral thing to do when our current society (I limit ‘society’ to the U.S. for this point) is economically and socially unable to sustain it? Will there be enough jobs or can people live for 50 or 60 years in retirement? Will there be quality of life as well as quantity? Are we prepared as a society to make the necessary adjustments for all or will it just be available to the wealthy? The questions about such a radical shift in lifespan are almost limitless and where is the public discussion?
I guess my basic point is that much of healthcare research and practice jumps too far ahead of sound bioethical decisions about how we should use it. Too many people look to the God of Science to try and escape natural death. Death is a part of life. We should not be so afraid to return to out Maker that we pursue prolongation of life at any cost (financial, moral, personal dignity, etc.)
June 14th, 2009 | 10:35 am
A Nurse -
Personally, I agree that the Culture of Death is mostly about people being afraid of death. They can’t control what dying will be like, so they opt for suicide. They don’t want to die, so they think about cloning and cutting up other people for spare parts to extend their own lives. They worry about their health, so they encourage people to suicide so that more resources are reserved for the “elite.” That’s how I see it.
At the same time, I’m not convinced that they can naturally extend the lifespan. My thinking is more that, if by some extraordinary means they do, then we’ll pretty much be forced to have as many kids as possible just to keep up with the demands of the aging population. Since a lot of people don’t like that (kids are cumbersom and they are bad for the planet, dontchaknow), the only way to get around *that* mess is to encourage the first group of elders to suicide rather young, and then hopefully have the next generation have enough kids to support them, so we’re not so top-heavy. So there’s something else to think about – how long before the “benefits” of extended age actually kick in?
But I’m very skeptical of the claims that they can extend the human lifespan. It’s right up there with theraputic cloning and cyborg technology: a desperate attempt to stop time, or at least pause it.
June 26th, 2009 | 2:12 pm
[...] J. Smith writing at Secondhand Smoke (now a First Things blog): “The Journal of Critical Care Medicine, has long supported Futile [...]
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