Sunday, November 22, 2009

The Immorality of Futile Care.

Thanks, Jacob Appel, for breathing some sense into end of life care dialogue. And by the way, it's great to hear that Texas is doing something right.

Of course, a true utilitarian will argue that a just society should spend and ration its resources sensibly in order to save as many lives as possible. One does not have to adopt such an unforgiving position to acknowledge that care, beyond a certain point, is unreasonable. A grim prognosis does not necessarily justify an end to care, but a truly futile prognosis is another matter. Hospital ethics committees, which have the insight of collective experience to guide them, are well-suited to make these determinations. In contrast, families are often driven by false hope, or guilt, or a basic misunderstanding of the cruel realities of the patient's prognosis. By allowing for input by ethics committees, which often draw members from a wide range of disciplines including medicine, nursing, law, theology and social work, the Texas model offers an excellent blueprint for other states to follow.

Unfortunately, a peculiar orgy of bedfellows -- ranging from anti-abortion crusaders to a letterhead disability rights organization called "Not Dead Yet" -- have joined forces to derail the expansion of medical futility statutes. Most recently, this motley band fended off efforts to adopt a Texas-style statute in Idaho. The great irony is that these same groups often argue for a healthcare provider's "right of conscience" to refuse participation in well-established medical therapies such as the prescription of birth control. However, they are unwilling to accept that many physicians find providing futile care to be not merely inconvenient, but morally repugnant. In all states, a medical resident has a right to refuse to participate in an elective abortion. In most states, a medical resident who is unwilling to provide futile care can be fired. The same groups that argue for the autonomy of physicians and private hospitals refuse to allow those hospitals a right to decide that certain patients are truly beyond hope.

In an ideal world, every patient who entered a hospital could be restored to full health. (Unlike the conservative humanist Leon Kass, I see nothing ethically wrong -- and only pure unadulterated good -- in extending the human life expectancy by as many years as possible.) The stark reality is that some patients are leagues beyond hope. If they are not dead yet, they are certainly darn close: accumulations of failed organs supporting permanently unresponsive brains, fed through stomach tubes, hydrated via IVs, often with the help of artificial lungs and artificial kidneys and, increasingly, ventricular assist devices to replace damaged hearts. Some physicians, examining such patients every day, inure themselves to a task they view as pointless but unavoidable. In contrast, I cannot help thinking of the desperate patient on a gurney in the emergency room, waiting for a hospital bed, whose care is delayed because -- in all states but Texas -- first come is still first served.

We have witnessed considerable public controversy in the past months over claims that the relatively benign end-of-life counseling provisions advanced by Republican Senator Johnny Isakson of Georgia and Democratic Congressman Earl Blumenauer of Oregon amount to "death panels" -- assertions which everyone other than Sarah Palin now seems to recognize as patent nonsense. That does not mean that there is no role for ethics panels to determine that some patients are beyond medical hope. If these are "death panels," then I support them wholeheartedly, as did George W. Bush and many conservative Texans. As physicians, we are in the business of saving lives, not pandering to ideologies. A national medical futility law, modeled on the Texas Advance Directives Act of 1999, is a long-ovderdue and life-saving measure.

Labels: , ,


Post a Comment

Subscribe to Post Comments [Atom]

<< Home