Sunday's New York Times Magazine has another in a related series of articles by David Rieff. In "Miracle Workers?" Rieff argues that doctors should accede to requests like that of his mother "to undergo any treatment, no matter how terrible."Rieff argues against "bean counting," evidence-based medicine's tendency to ignore idiosyncratic risk-benefit tradeoffs and in favor of treating patients as long as they "want to be treated." Honoring such preferences, argues Rieff, treats patients in "the full, human sense of the word." Abandoning such commitments "is to deny the complexity of each human being."
This resonates with a recent argument by articulate anti-futility scholars Jeffrey Burns and Robert Truog. In a recent issue of Chest, they urge clinicians to stop focusing on how to override requests they disagree with, and instead "turn our efforts toward tolerating the demands for care that we believe to be futile."
I suspect few who support unilateral refusal would take issue with the precise situation described by Rieff. There, the patient and physician reached agreement on the course of treatment. (Presumably, the patient's payor was also in agreement.) While many physicians might refuse to provide that requested treatment, few take the even stronger position that no physician should provide it.
The troublesome futility dispute is where the patient is demanding treatment that the physician does not want to provide. If there were enough physicians willing to accede to all patient requests for aggresive treatment, then medical futility would not be such a big issue. patients would just get transferred to the willing providers and everyone gets what they want. In fact, however, such transfers are hard to find.
Shouldn't this then be called "professional medical futility"?
ReplyDeleteSteve,
ReplyDeleteI am not sure what exactly you want this terminology to signify. There are certainly separate types of bases for futility judgments. Most are professionally based and make appeal to the goals and ends of medicine. Others are conscience-based, appealing to personal religious reasons.
To say that we must do what ever the patient or surrogate asks for is unfortunate. Yes, the family’s wishes and hopes need full consideration and discussion and sympathy. But, just accepting what they ask for is hurting them and society.
ReplyDeleteIn many ways, when families are asking for ‘do everything,’ ‘keep the patient alive at all costs,’ they are asking for the impossible. It is our duty and responsibility to explain the reality to them. They do not have the professional knowledge and judgment to know what it means to try and keep someone with multi-organ failure on life support. We need to explain to them the difference between ‘keeping someone alive’ versus ‘prolonging the process of death.’ We need to explain to them that if 3 previous treatments have not worked, the next one is also not going to work. For Burns and Trulog to advocate that we follow the surrogates instructions is irresponsible. Professional judgment and knowledge should not be overridden by an irrational request.
How far we go to override such requests, how much discussion is needed, and how far we allow ‘autonomy’ to take us will be a matter of discussion. It will be different in each case (depending on the specifics) but the principle of professional judgment being more important than emotional desires has to be accepted.
Paternalism was common in the old days, autonomy is a good principle but like any generalization, there are limits and it is for us to go beyond the ‘principle’ to realities in some situations. The responsibility lies with us.
amangalik@salud.unm.edu