Wesley Smith, a well-known opponent to medical futility policies and laws, clarified his position in commenting on a new study in the Archives of Pediatrics and Adolescent Medicine. He writes: "My opposition to what I call Futile Care Theory has never been about withdrawing treatment that sustains life but does not provide cure or improvement, but about medical personnel and/or ethics committees forcing an end to treatment over the objections of those who want non elective treatment continued."
It strikes me that depending on how the term "coercion" is used, I could almost agree with Wesley here. It seems rare that providers literally coerce surrogates into stopping what the provider thinks is non-beneficial treatment. Providers typically lack the power to take any such a position. Far more relevant than coercion in this context is the ethical justifiability of persuasion and manipulation. For example, the option to continue the ventilator is simply not presented or is not presented as a "real" option.
In other words, medical personnel and ethics committees rarely "force" treatment over surrogate objections, because there often are no surrogate objections in the first place. There is no conflict. There appears to be consensus.
However, that the consensus is arguably "manufactured" in the sense that the surrogates do not get full "Canterbury
6 comments:
I don't think most could appreciate how big of an issue this is until you have a family member or situation that forces you to deal with it.
The issue of unilateral passive euthanasia of the elderly in US hospitals is pushed by fiscal concerns about the high costs of end-of-life care.
Apparently, many of these high costs are not reimbursed by Medicare/Medicade and the private insurers.
Until "futility" is defined under law in more certain terms and until the patient is part of the "futility" conversation, abuses will be rampant.
Shouldn't the elderly on Medicare/Medicade be warned awbout the "futility" scenario at the time so called "palliative" treatment is offered?
While Physicians appear to have no obligation (under the law of the Patients' Self Determination Act) to discuss end-of-life choices when paliative treatment is started, doesn't such failure to discuss amount to lack of informed consent to the treatment?
Shouldn't the "futility scenario" that enables widespread unilateral passive euthanasia of the elderly be disclosed by the physicians at the start of palliative treatment?
Palliative treatment in the hospital is a lower standard of care that doesn't offer intervening life-saving procedures to the elderly who are on Medicare/Tricare/Medicade and supplementary private insurance policies.
Don't we need more honesty about the primary purpose of palliative care and hospice, etc., which I believe to be the government's and the private sector's solution to the "managed" and "less expensive" death of the growing elderly population of the United States?
Excellent post; right to the crux of the ongoing debate. I too am almost in agreement with Mr. Smith's position, though I do not share his contextual (and conspiratorial) backing for them ("Culture of Death").
The questions ultimately distill down to: Who decides, when, and on what grounds? And if the answer to the first question is the patient or her surrogate, then what is the moral/medical/legal rationale for denying patient/surrogate requests for non life-sustaining medical treatments?
Thank you for these comments.
The debate is often framed as whether physicians must provide requested treatment. Certainly, there are a significant number of conflicts, debates, questions framed in this way.
Still, I suspect that even more cases never get framed this way. The physician never says (roughly), "We could do x but we will not." Instead, she says, "There is nothing more we can do." She says that even though it is not technically true. She says it even though other physicians do provide and would provide treatment under the circumstances.
The result: there is no conflict. The physician says, "We did everything." The physician offered no false hope. But if transparency can be sacrificed here, then where else?
In short, focusing on how to resolve the conflicts is important. But perhaps even more important is figuring out whether the absence of conflict is due to better end-of-life communication or to worse informed consent.
My observation, based on personal experience, is that the appearance of lack of conflict in futility matters is fed by the failure of physicians to SEEK "informed" consent to passively euthanize their elderly patients.
How can physicians explain and justify to elderly patients that it is both fiscally futile and medically futile to try to keep them alive for an unknown period of time?
Until there is transparency and honest discussion about the relationship of medical futility to fiscal futility, etc. the debate itself, when confined to medical, religious, moral, and ethical issues of futility judgements tends to disguise the hostile environment for the very old that exists in US hospitals today.
How many Medicare-Medicade patients have ever heard of the "futility" scenario? How many old citizens would understand how this scenario could post a threat to them when they undergo treatment in a clinic or in a hospital setting?
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