NEJM Commentary Against Futile Care Theory

What a pleasant surprise: An opinion column in the New England Journal of Medicine opposes medical futility. Written by Harvard Medical School professor Robert D. Troug, M.D., it makes some very good points about the problem with even the best-intended futile care policies. Reacting to the Baby Emilio case in Texas, Dr. Troug writes:

Although the clinicians in Austin consistently denied that they were motivated by financial considerations, concern about excessive expense may be an ethically legitimate reason to refuse continued treatment to patients like Emilio. Health care is not an unlimited resource, and physicians have an ethical obligation to ensure that it is distributed fairly. Unfortunately, the United States has been reluctant to adopt a systematic approach to allocating resources across the health care spectrum. Although futility cases may seem like an obvious target for cost cutting, the evidence suggests otherwise. Even if life support were consistently denied to patients whose situations met common definitions of futility, the monetary savings would be trivial... Aside from considerations of suffering, dignity, and money, clinicians may justify their refusal to treat on the basis of their right to refuse to participate in medical interventions that they believe violate their moral integrity. The moral distress associated with providing futile care has been cited as an important source of burnout among critical care nurses. But though these concerns can sometimes be ethically legitimate, they are questionable in cases like that of Emilio. The claim that continued life support for Emilio was morally objectionable was nothing more than an assertion that the values of the clinicians were correct while those of Ms. Gonzales were wrong...

As a liberal society, we take pride in protecting the rights of minorities against the tyranny of the majority. Of all the unpopular values and preferences that we might respect, should not we favor those that have life-or-death consequences for the persons involved? Families live with the memories of the death of a loved one for years; certainly their religious, cultural, and personal preferences during that process should be honored, or at least tolerated, whenever possible.

The principal advantage of the Texas Advance Directives Act is that it provides a path for resolving intractable dilemmas in situations in which clinicians may feel compelled to do whatever patients and families demand. The law may therefore serve a useful purpose when patients are subjected to unwarranted pain and suffering or when clinicians have defensible claims that these demands compromise their moral integrity.

On the other hand, the Texas law's effectiveness as a mechanism for reaching closure in difficult cases is also what makes it most problematic. It relies on a due-process approach that is more illusory than real and that risks becoming a rubber-stamp mechanism for systematically overriding families' requests that seem unreasonable to the clinicians involved. During a 2-year period at Baylor Health Care System, for example, the ethics committee agreed with the clinical team's futility assessment in 43 of 47 cases. Although there may be cases in which the law should be used to trump the demands of patients and families, it is doubtful that the Gonzales case was one of them. Rather than jeopardize the respect we hold for diversity and minority viewpoints, I believe that in cases like that of Emilio Gonzales, we should seek to enhance our capacity to tolerate the choices of others, even when we believe they are wrong.

Excellently said. Futile Care Theory permits the imposition of a doctor's or hospital's moral values onto the lives and deaths of patients and families. If a case of continuing life-sustaining treatment is so egregious that it amounts to a form of abuse, then the issue should be decided in open court--not by an ethics committee made up of well-acquainted people who may share an institution's culture, meeting behind closed doors.