Ira Bedzow: Doing Something about medical futility
Some of the most conscience-wrenching situations in end-of-life care involve patients whose families insist that treatment be continued even though the medical team considers it futile. Aversion is exacerbated when futility is understood as futile care rather than futile treatment. Situations of medical futility should never presuppose the notion that it is pointless for physicians to continue caring for patients. As the American Medical Association makes clear, “When further intervention to prolong the life of a patient becomes futile, physicians have an obligation to shift the intent of care toward comfort and closure.” Futility, therefore, should be understood in light of the goal of providing physiological benefit to patients (in accordance with the patient’s values and beliefs) and not in holistic terms that encompass both the spiritual and physical aspects of human life.
Medical futility cases have increased as a result of advancing medical technology, and the definition of futility has become more fluid due to the changing nature of the patient-physician relationship, in which the priority of alleviating suffering is becoming on par with maintaining life. Therefore, what once might have been considered a beneficial medical intervention may now be seen as an improper decision to advance the quantity of a patient’s life over its quality.
In futility cases, physicians may be torn between a number of conflicting priorities. In one respect, the patient’s autonomy and the beliefs of the family and/or his or her proxies must be respected. On the other hand, physicians are duty-bound to act beneficently and to do no harm, which continued treatment might be considered.
While doctors have a legal right to refuse treating a patient against their own conscience, how a doctor should proceed in such a case is ambiguous and variable across states. For example, in Colorado, doctors must transfer patients to physicians who will treat them. In Texas, medical teams can withdraw treatment against the desire of the patient’s advance directive or a proxy’s insistence after 10 days if a hospital ethics committee agrees that further therapy is futile.
Conflicts between physicians and patients’ family members often arise from disagreements over the meaning of words. For example, suppose a physician says that he or she will do everything possible to ensure the patient’s comfort and dignity. To the family, “everything” might mean exactly that, whereas the physician might be placing greater emphasis on the word “possible” to imply his or her true meaning. To family, “dignity” might mean “of life,” whereas to the physician, it might mean “of the patient,” with the goal of maintaining life at any expense hung in the misinterpreted balance.
Family members also may be suspicious if they perceive economics to be a factor. While society as a whole may have to consider rationing limited health care resources, no individual would want to give up his or her family member’s chance of continued life for the sake of opening up a hospital bed or for the sake of curbing “wasteful” spending.
Cases of medical futility demand better communication between health care professionals and their patients’ families. Therefore, medical education must include training in how to provide humane and professional support as well as technical skill. Patients also must become more informed and involved in their own health care management. Only when the patient-physician relationship is strengthened by mutual respect and trust will end-of-life cases involve proper joint decision making rather than potential conflict between patient autonomy and physician beneficence.
Ira Bedzow is the Director of Biomedical Ethics and Humanities at New York Medical College and Senior Scholar at the Aspen Center for Social Values. Join him and top scholars July 20 for “When Life Nears Death: A Conversation of Medical & Social Values” 5:30 to 7 p.m. at 435 W. Main St. in Aspen. The event is open to the public.
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