Medical Futility and the Vulnerables: An in-Depth Analysis of the Concept of Medical Futility
Medical futility is a difficult moral and ethical issue that not only affects the lives of the family and friends of the person, but one that affects the practice from a legal perspective as well. In the case being presented, an 82-year-old woman was refused treatment for a head injury sustained in a car crash. The decision not to operate was made due to her age. She died as a result of her injuries. The proposed research will explore the issues involved in medical decisions based on a person’s age. The study will explore the issue of medical futility from the standpoint of an otherwise healthy, elderly patient who has been injured.
What is Medical Futility?
When a doctor makes the decision not to treat a patient because they determine that treatment is medically futile, they are taking a big risk. In essence, they are playing God. In the case of the 82-year-old, who was in otherwise perfect health, this issue can lead to some dangerous legal issues. The case is different where the patient has a terminal illness. All of us will die someday, regardless of the cause; we all will face our death. Old age could be considered to be a terminal illness because as people age, they come closer and closer to the inevitable. Many doctors feel that treating the elderly is futile, because they do not have that many years left anyway.
One of the key issues in medical futility is that medical technology has extended the ability to preserve life, sometimes beyond its natural expectancy. In the example of the healthy 82-year-old, it is difficult to argue that this indeed constituted a medically futile case. No one knows how long a person will live, or what they will accomplish and contribute at any stage in their life. It is possible that this healthy 82-year-old may have written a novel that changed society in her later years. No one knows. However, in this case, it could be argued that this did not constitute a medically futile case, as the person did not have any other known conditions that would threaten her life. The treatment, in this case could possibly have restored her to her previous state of perfect health and vitality for her age.
There is a thin legal line between medically futility and medical negligence. From a legal standpoint, every case is argued on its own merit. These are difficult cases, on both sides of the bench. In this case, there are many legal issues that place the physician who made the decision in jeopardy. For instance, it could be called age discrimination, as the lives of other, younger patients were deemed more important than the elderly woman in question. In this case, the physician and hospital may find their case difficult to defend, particularly if the family decides to sue for negligence.
However, the argument would be different if the elderly woman had terminal cancer or coronary artery disease in addition to the car accident. There is no way to determine when the life of a healthy person will end, in the absence of mitigating circumstances. There is simply not enough known to make a determination in this case. No beds were to be found, despite the physician’s attempt to do so. One of the key moral issues that arises in this case is that one must now decide whose life is more important to save. Other questions arise, such as the inability to provide the services required of a hospital. There are many legal and moral issues that arise from this case that could only be answered in a court of law.
Social and Legal Issues
One of the most difficult issues surrounding medical futility and the decision to withhold treatment is that the circumstances surrounding every case are different. The case previously mentioned has many “what ifs.” Know one can know for sure what the outcome would have been if the patient had been treated. There is simply no way of knowing. One of the key difficulties in medical futility is that these is no standard of practice that will work in every case.
In order to guide doctors in their decisions, a new tool has been developed that is designed to help doctors make these difficult decisions. This new tool is based on the establishment of clear treatment goals for a specific illness (Mohindra 2007). Every intervention has specific goals that it is intended to accomplish. Some treatments are intended to eliminate a certain condition. Others are supposed to extend life, while others are not expected to extend life, but to improve the quality of life that is remaining. The new factual matrix is based on the probability that the desired treatment will achieve the desired outcome (Mohindra 2007). In the case of the elderly woman, a lack of expectations and outcomes was the key factor that led to early termination of life due to lack of care. In this case, hospitals made decisions based on assumed expectations, but there were no clear parameters established.
One of the most difficult factors in medical futility is that unlike the science that drives medicine itself, medical futility and intervention is a matter of personal opinion, public attitude, and cultural norms surrounding life and death issues (Bagheri, Asai, and Ida 2006). In a study that surveyed Japanese experts regarding medical futility, it was found that 67% believed that a physician’s decision to discontinue treatment could never be morally justified (Bagheri, Asai, and Ida 2006). However, 22% did agree that refusal to treat was moral under certain conditions (Bagheri, Asai, and Ida 2006).
This attitude contrasts with a recent opinion issued in Great Britain regarding a case where a terminally ill patient had to sue for the right to receive treatment (Smith 2004). In a similar case, treatment was refused for a 12-year-old boy who was severely disabled. The decision to refuse treatment in this case was based on the opinion that the lives of these two patients were not worth living (Smith 2004). In the UK, the courts decide who has a right to live and who has the societal obligation to die. These ethical conditions differ according to the country of origin.
One of the key concerns about giving control over end of life issues to the court is that it raises fears that lives may be ended prematurely or for the wrong reasons (Mason 2008). Although medical futility judgments are highly controversial, they occur everyday in hospitals in the UK. This can create a power struggle when families and doctors disagree with a doctor’s decision to withhold treatment (Gampel 2006). This controversy highlights the need for standards to guide doctors in their decision to withhold treatment when it is considered medically futile to proceed with the treatment.
All medical facilities will be faced with the controversy surrounding medical futility at one time or another (Terra 2006). The Acute Physiology and Chronic Health Evaluation Score (APACHE II) has been developed to help guide medical facilities in their decision by providing a mortality prediction score (Terra 2006). This is a highly controversial application because it ignores the human factors involved in these decisions. It has been suggested that this system become a part of routine admissions procedures in an ICU unit (Terrra 2006). A lack of consistent standards makes decisions regarding end of life issues daunting for a healthcare organization.
In the United Kingdom, termination of artificial feeding and hydration for patients that are considered in a vegetative state requires a decision by the high courts (Faunce and Stewart 2005). However, this process is controversial, as the courts must consider both the wishes of the family the opinions of physicians. In the UK, typically, the decisions of the physicians carry more weight than that of the family (Faunce and Stewart 2005). In a recent study, the viewpoint of the patient’s perspective when the patient was competent supports the provision of life-saving measures even if it seems futile (Samanta and Samanta 2008). In cases where the patient is competent, there is support for the opinion that they should have the final say. In the case examined in the beginning of this research, it is not known if the patient was competent, or conscious. These factors weigh heavily into ethical decisions regarding life-ending medical decisions.
Medline is a leading source of information for doctors worldwide. They use this service as a guide for their practice on a daily basis. In a recent study, it was found that certain ethnic groups and cultures were over-represented in regards to death and dying issues (del Pozo and Fins 2005). Other cultures and perspectives were under-represented. This study found that decisions to withhold care differed among the various cultures (del Pozo and Fins 2005). Cultural considerations are not addressed in end of life decisions addressed by UK courts. Decisions are made with regard to the dominant culture. It is feared that religious differences in decisions regarding when to withhold treatment are being ignored by the courts.
The social and legal issues are highlighted in cases that involve pre-term infants. In the elderly, the cultural consensus is that these persons have lived their life and are close to death anyway. However, in the case of a pre-term infant, the issue is raised of what measures should be taken to preserve life, particular when there is a lack of resources (Seri and Evans 2008). In the case of premature infants, significant cases exist to aid in the establishment of criteria to predict survival rates. If the survival probability is too low, resources are typically saved for those infants that have a greater chance for survival. For instance, it is the general rule that babies under 23-week and that weigh less than 500 grams are unlikely to survive. However, babies over 25 weeks and that weigh at least 600 grams have a high likelihood of survival and therefore warrant interventions to save their lives (Seri and Evans 2008). The real question lies in infants that are in the grey zone between these two extremes. This is similar to the healthy, elderly woman discussed earlier.
This exploration of the topic of medical futility and the decision to withhold care focused on the perspective of the health care facility and the individual doctor who must make the decision. The decision to withhold care has a significant impact on the doctor’s future and ability to practice medicine. The doctor himself is under the greatest legal and moral liability in these cases, as they are the ones to make the important decisions. This research examined the question of medical futility using an example of a case that falls into the grey zone of decision making in these regards.
The literature found several sets of criteria that have been developed with the intention of aiding doctors in their decision to withhold life saving treatment. In the past, this decision has been largely decided by the personal opinions and beliefs of the doctors. In the UK, the courts can intervene in cases of coma. However, many times, the decisions must be made in a split second, particularly in the emergency room setting. Cultural and religious differences between the doctor, patient, staff, and the patient’s family may cloud the decision. In practice, it is the decision of the doctor that holds the most weight from a legal standpoint.
The need to develop a set of viable standards and guidelines for helping doctors make life saving or ending decisions is clear. However, current attempts to develop these criteria has only resulted in more controversy over bias on the part of the doctor. No studies could be identified that examined the opinions and criteria used by doctors in the UK to help determine who is treated and who does not. A study similar to this was found concerning Japanese doctors, but none was found that was culturally relevant to doctors in the UK. There is a clear need for the development of criteria for making life-ending decisions among UK doctors.
The first step in arriving at a consistent consensus is to determine what criteria a majority of the doctors in he UK use to determine whether to withhold treatment or not. This study will survey emergency room doctors, as they must often be the sole person responsible for making those decisions. They often do not have the luxury of a court making the decision, as emergency room decisions do not have the luxury of a sufficient period to obtain a court decision. This study will examine the criteria used by doctors in determining who is treated and who does not when resources are limited.
This study is a necessary step in arriving at clinically valid consensus regarding the criteria that doctors currently use to determine who gets bed space when bed space is limited. It will pay particular attention to the factor of age and when doctors feel that lifesaving measures are futile in terms of a patient’s age. This study will provide valuable insight into the decisions that are currently being made regarding age-related emergency room decisions and use of resources. It is the first step in the development of standards of care concerning withholding of treatment for the elderly.
References
Bagheri, a., Asai, a., and Ida, R. 2006. Expert’s attitudes towards medical futility: an empirical survey form Japan. BMC Medical Ethics. June 2006, pp. 7-8. Accessed February 28, 2009 http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1550716
Del Poze, R. And Fins, J. 2005. Death, dying and informatics: misrepresenting religion of Medline. BMC Medical Ethics. 6 (6). Accessed February 28, 2009 http://www.biomedcentral.com/1472-6939/6/6
Faunce, T. And Stewart, C. 2005. The Messiha and Schiavo cases: third-party ethical and legal interventions in futile care disputes. MJA. 183 (5). 261-263. Accessed February 28, 2009 http://www.mja.com.au/public/issues/183_05_050905/fau10214_fm.pdf
Gampel, E. 2006. Does Professional Autonomy Protect Medical Futility Judgments? Bioethics. 20 (2), 92-104.
Mason, T. 2008. Ellen Westwood: Unilaterally Refusing LSMT in UK. Medical Futility. July 10, 2008. Accessed February 28, 2009 http://medicalfutility.blogspot.com/2008/07/ellen-westwood-unilaterally-refusing.html
Mohindra, R. 2007. Medical Futility: a conceptual model. Journal of Medical Ethics. 33: 71-75.
Samanta, a. And Samanta, J. 2008. Do not attempt resuscitation orders: the role of clinical governance. Clinical Governance: An International Journal. 13 (3), 215-220.
Seri, I and Evans, J. 2008. Limits of viability: definition of the gray zone. Journal of Perinatology. 28, S4-S8. Accessed February 28, 2009 http://www.nature.com/jp/journal/v28/n1s/abs/jp200842a.html
Smith, W. 2004. Suing for the Right to Live. The Weekly Standard. March 11, 2004. Accessed February 28, 2009 http://www.weeklystandard.com/Content/Public/Articles/000/000/003/836zeecs.asp
Terra, S. 2006. Approach to Medical Futility in a Community Hospital: Is Use of a Prognostic Scoring System Applicable? The Internet Journal of Allied Health Sciences and Practice. 4(4): 1-11. Accessed February 28, 2009 http://ijahsp.nova.edu/articles/vol4num4/terra.pdf
