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Countering "The Seven Reasons that Might Justify Unilateral Refusal " of Medical Treatment (Futile Care Theory)

Posted Apr 28 2009 11:08pm
Law professor Thaddeus Pope runs the Medical Futility Blog, the best such site dedicated to medical futility of which I am aware. He swings from the futilitarian side of the plate, but is always fair and even handed.

Today he has posted "Seven Reasons For Supporting the Unilateral Refusal" of life sustaining treatment, or as I would call it, the "Seven Reasons to Justify Imposition of Futile Care Terminations." I republish that post here in full with my brief comments. From Pope's blog:
It might be useful to collect and list--in very rough order of importance--the arguments for refusing medically inappropriate treatment requested by a surrogate.

1. Prevent patient suffering: Aggressive treatment can cause significant pain and suffering. This is unacceptable if there is no countervailing benefit to be achieved by the treatment.
If the countervailing benefit is continued existence--and that is what the patient/family wants--then this justification is nonsensical. Too often today, we hear futilitarians speak about "return to full functioning," or "this is merely extending the dying," turning on its head the fact that the treatment is actually extending the living. Such interventions can only be deemed "nonbeneficial" if the life of the patient is denigrated by others as not worth living.
2. Protect patient autonomy: In many cases, the aggressive treatment demanded by a surrogate is treatment not wanted by the patient. And where patient preferences are unknown, continued treatment is not in the patient's best interests.
But futile care theory is a frontal assault on patient autonomy, with some proposals even permitting patient advance directives to be overturned. If the patient truly did not want the treatment, that would not be futile care theory. Deciding in "the patient's best interests," would often really mean imposing the prevailing bioethical "quality of life" views onto patients. If the patient's views are not known, the strong overriding presumption should be to continue the life of the patient as the surrogate requests.
3. Prevent family distress: Often the surrogate wants the burden of decision lifted from herself. And even if not the surrogate, other family members are often relieved to see the patient’s preferences or best interests protected.
That is not the job of doctors or bioethics committees. To assume that strangers should substitute their values to supposedly relieve relatives of the "burden" of deciding for their loved one is the epitome of paternalism, perhaps crossing into arrogance.
4. Preserve the integrity of the medical profession: Those in the health profession surely must have some role in defining the ends and goals of medicine.
The integrity of medicine is preserved by supporting the goals of medicine that have existed for millenia; saving life and palliating suffering. Medical professionals are fiduciaries of the patient. That is what makes them "professional." They serve the patient, not the other way around.
5. Reduce nurse distress: Numerous measures show high levels of moral distress. This can both drive people from the profession and thus reduce access. It can also reduce staffing levels and make people operate less well, adversely impacting other patients' quality of care.
Surely, this is not a proper reason to cut someone off from wanted life support! Indeed, it borders on blackmail--either you take away life support or I walk away from medicine! Bogus.
6. Responsibly steward scarce hard resources (e.g. ICU beds) to maximize health care access: In an under-bedded region like NM, the ICU bed used by a patient with PVS and multi-organ failure is the very same bed that could be used to achieve recovery for an accident victim.
We have triage for such matters. We don't need futile care theory.
7. Responsibly steward scarce soft resources (e.g. dollars) to maximize health care access: the billions spent treating PVS patients could be used to cover more people who now have no coverage. As costs rise, premiums rise, and access drops.
This creates an explicit caste of disposable patients based on invidiously discriminatory "quality of life" assessments. It is, in effect, establishing a "duty to die."
Of course, there are also arguments against unilateral refusals. Those will vary according to the specific circumstances of a case. Whether unilateral refusal is ethically justified, on balance, will require some sort of weighing.
If "weighing" truly is required, it should not take place behind closed doors, conducted by a bioethics committee that will express an institutional culture, reacting to the desires of doctors whom the committee members all know--as opposed to the family/surrogates who are strangers and may not be well educated or articulate. Such disputes belong in open court, with a record, the right to a lawyer paid by the hospital, due process, and the right to appeal. If cutting off care is so urgent, make the hospital do it in front of the klieg lights.
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