Transcript 10-10
Medical Futility What is Futility? Basic common sense idea: “It won’t work” Always an incomplete thought: “It won’t work to accomplish what goal?” Any medical futility judgment is a mixed fact and value statement Statistical probability of outcome Whether outcome is a “benefit” How confident one is of predictions Can Futility Be Value-Free? “No chance of survival to hospital discharge if perform CPR”-- clearly value laden because assumes that relevant goal is to survive to discharge Therefore, define “futility” in physiologic terms-- any chance that CPR will restore spontaneous heartbeat and respiration (even if only for a few moments)? Is Physiology Value-Free? Physiologic futility criteria take the value stance that the proper and desirable goal of medicine is physiologic function independent of whether the patient considers such function to be a benefit Conclude: There cannot be a truly valuefree definition of futility Why an ethical issue? “Typical ethics case” in 1975: Patient or family wished to stop aggressive treatment; physicians felt obligated to keep treating “Typical ethics case” in 2000: Physicians feel obligated to stop aggressive treatment; patient or family demands ongoing aggressive care Futility: Principles Respect for autonomy: Patient or agent has a right to decide on what care to accept or refuse Is it ever the case that physician’s prediction of futility is so firm that it should override usual presumption in favor of patient choice? What Principles May Override? Physician vs. patient autonomy: does it matter on what basis physician wishes to withhold therapy? Justice: futile therapy is a waste of money and others are in need of care (Murphy)-is this core idea of futility or is it a secondary consideration? Role of Futility in Justice “The reason we should give physicians the discretion to refuse to provide futile care is so that the system can save money” “If we have limited money for medical care and have to ration care, it makes sense to eliminate totally futile care first, before we start to limit very expensive yet beneficial care” Physician/Nurse Integrity Joanne Lynn’s observation: Nursing staff required to provide ongoing intensive care which seemed incapable of improving the patient’s status (but which was often painful) described themselves as feeling like they were forced to act as “moral monsters” Integrity Wholeness Related more to virtue theory than other approaches My moral actions, attitudes, and values are coherent and coordinated over time Compare: “moral chameleon” (M. Benjamin) Levels of Integrity Personal: My own “private” moral values are reflected in my attitudes and behaviors Professional: The core values of my profession are reflected in my attitudes and behaviors Futility and Professional Integrity Unprofessional to: Cause harm without benefit Portray oneself fraudulently Setting out to do what doesn’t work violates these professional duties Requires a firm grounding in professional consensus as to “what doesn’t work” The Real World Most futility disputes resolved by effective communication over time Rubin example of S.E. Asian woman: often goal clarification suffices to remove source of dispute Cases that go to court are therefore highly atypical Are These Futility Cases? Wanglie: 80yo woman on respirator in PVS, family stated that unconscious life is still of value Baby K: Infant born with anencephaly, needed intermittent intensive care with respirator, mother demanded that hospital continue to admit and support Arguments Against Futility Factual: Too much uncertainty or slippage in deciding what works and what does not work Value: Futility seems to be a power play allowing physicians and end-run around respect for patient autonomy CPR Counter-Argument Do physicians and nurses have the right to decide when to stop CPR based on their own determination of futility, independent of family wishes? If so then seems logically required that at least in some cases they could decide not to start CPR on same grounds Veatch’s Argument Based heavily on position that no physician can truly decide what counts as a benefit to any given patient-- even in “ideal” situation where physician and patient come from identical value communities Rejoinder: Does Veatch ever buy gifts for his family?