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After the second World War, a cliché was repeated so often as to provoke, I fear, either yawns or giggles: “our moral sense was lagging behind our technical invention,” i.e., science had, as it were, outstripped morality. In those days, of course, the bogey scientists thought to have left morality behind were physicists, especially those who had made possible the nuclear bomb. A wholly new kind of war weapon did indeed seem to have changed the world and to require a new dimension of moral thought and moral philosophy, if we were not all to be destroyed.
Rather than discussing the economic side of competition, the actual shortage of resources, I want to discuss competitiveness itself, the competitive attitude. Certainly good causes must in a sense be in competition; that is, they must share resources. The question is should they actively compete? Should they see themselves as competing?
I want to look at a range of difficulties that seem endemic to controversy as such. Some of the difficulties are psychological, but that does not mean that they are accidental, neurotic oddities of particular disputants. They afflict almost everybody who must argue about something important. Other difficulties are in-trinsic in the nature of human life–clashes between rival values, needs, and ideals, places where no fully satisfactory resolution seems attainable.
Special Section: Medical Futility: Demands, Duties, and Dilemmas
There is large, imposing-looking box in a wing of University College, London, that contains the lifelike remains of the English philosopher, Jeremy Bentham. Bentham requested that upon his death, which occurred in 1832, his body should first be used for purposes of a medical lecture and then be place on display. His request was entirely utilitarian in character. For as a famous individual, Bentham could argue that it made less sense to be buried and then have a statue constructed of his likeness than to eliminate the burial by having himself made into a statue. He called the latter an auto-icon.
The issue of physician refusal of requested treatment has fueled a two-pronged debate in our society-one on the meaning of futility and the other on the limits of patient autonomy. The latter is a genuinely philosophic dispute; the former, it seems, is a modern relapse into nominalism.
It is not the meaning of a word, but the moral basis for the actions of the par-ticipants that should be the focus of our attention, Yet the medical literature distracts us with articles titled “Medical Futility: Its Meaning and Ethical Implica-tions” “The Problem with Futility” “Who Defines Futility?,” “The Illusion of Futility,” and even “Beyond Futility.”
The history of the futility debate, which was launched by a 1983 study of Bedell and Delbanco that demonstrated the ineffectiveness of CPR for certain catego-ries of patients, has been documented elsewhere. Here we will inquire if the term, and its rapid intrusion into the medical lexicon, serves a useful purpose or if, as Truog suggested, we would all be better off if this new buzzword were jettisoned.
Partly because physicians can “never say never,” partly because of the seduction of modern technology, and partly out of misplaced fear of litigation, physicians have increasingly shown a tendency to undertake treatments that have no realistic expectation of success. For this reason, we have articulated common sense criteria for medical futility. If a treatment can be shown not to have worked in the last 100 cases, we propose that it be regarded as medically futile. Also, if the treatment fails to restore consciousness or alleviate total dependence on intensive care, we propose such treatment be judged futile. This definition provides clear end points and encourages the profession to review data from the past and perform, prospective clinical studies that not only report treatments that work but also treatments that do not work. We have also argued that, in a variety of settings, physicians have no ordinary ethical obligation to offer futile interventions (Schneiderman et al. unpublished). Although physicians should inform, and discuss all decisions to withhold or withdraw medical treatments with patients, they need not obtain the patient's permission to desist from futile interventions.
There is little to indicate from, her circumstances that events would propel Helga Wanglie, an 86-year-old Minneapolis woman, into the center of public controversy. We know little of her life prior to the events that removed her from the world of conscious, sentient beings. By the time of her death on 4 July 1991, Mrs. Wanglie had become the focus of a nationwide public and professional debate on the rights of a patient in a persistent vegetative state (PVS) to receive aggressive medical treatment when such treatment is felt by the patient's doctors not to be in the patient's best interests.
My experience concerning cases similar to the Wanglie case indicates that there was virtually no possibility of a solution for the conflict between the different expectations of the Wanglie family and those of the physicians caring for Helga Wanglie. A persistent vegetative state precludes a return to consciousness unless an extraordinary phenomenon takes place. Therefore, the physicians expected to be relieved of the duty of continuing to give Mrs. Wanglie respiratory care. However, her family thought it their duty to provide their loved one with the best possible treatment. The family based their position on the claim that life is God's gift and that only He has the right to terminate it. Such spiritual convictions are perceived as reflective of a higher “truth” and are not predisposed to negotiation or change according to the situation.
For the 17 centuries since Hippocrates called for “the most desperate remedies in desperate cases,” physicians have adhered steadfastly to two cooperative goals: to prolong life and to relieve suffering. ut during the past 50 years, mechanical interventions at the edge of life have thrown those aims into dramatic conflict. Cardiopulmonary resuscitation, mechanical ventilation, feeding tubes, and the intensive care unit have postponed physiologic death for many patients who are anencephalic, comatose, or in a persistent vegetative state or prefer death to a life of suffering and pain. Demands from patients' families and cries for social justice have compelled physicians, hospital personnel, and the Supreme Court to analyze concepts long reserved for university philosophers. Although decisions are made daily to withhold and withdraw life support, society is gradually agreeing upon an ethical framework that balances hopeful science with dignified death. This article outlines that ethical framework, reviews recent legal precedents, and suggests practical guidelines for their application.
In the United States, at least 6% of all hospital beds are in the intensive care unit (ICU) or coronary care unit. The cost of treating a patient in an intensive care unit averages from $2,000 to $3,500 per day. At least 10–40% of intensive care patients will not survive to hospital discharge. Today, every major category of disease may be found in the modern ICU; common diagnoses are septicemia, postsurgical complications, cerebrovascular accidents, gastrointestinal bleeding, neoplasia, and respiratory failure. ICUs employ some of the most sophisticated medical technology, routinely monitoring the cardiopulmonary performance of patients and often providing assisted ventilation. ICUs are high intensity in terms of their staffing, involving 24-hour physician supervision and nurse:patient ratios from 1:3 to 1:1.
The increasing complexity of modern hospital care and the decisions that must be made were the reasons we began our research on the Acute Physiology, Age and Chronic Health Evaluation (APACHE) project. As a clinician in an intensive care unit (ICU), I felt very uncomfortable making the sorts of decisions that are common today without any source of information or any reference points. These decisions are not avoidable, they are not discretionary, and they are going to become more frequent in the future because we are treating people at later stages of disease.
Mr. F. Smith was a 63-year-old man admitted to the Veterans Administration hospital with fever, respiratory distress, and a possible recurrent pneumonia. He had entered a community hospital with pneumonia approximately 18 months earlier. His 80 pack-year tobacco history and 10-year emphysema history complicated the clinical course on the first admission, and his status worsened to the point of respiratory failure. He suffered a cardiac arrest while on a ventilator in an intensive care unit. He was asystolic for approximately 5 minutes but was resuscitated.
A physician recently asked how to respond in the case of an 87-year-old patient with advanced Alzheimer's disease, who was unable to swallow or tolerate a nasogastric tube, when the family insisted a gastrostomy tube be inserted but the physician believed the intervention futile. That question encompasses some of the crucial issues in the concept of futility of the treatment goals of physician, patient, and family; the rights of patients and families to demand care; physician judgment; family values; and, to the degree that it represents many similar dilemmas, justice. What are professionals saying when they pronounce treatment futile? What are patients' rights if they or their surrogates disagree?
The word “futile” implies a precision about outcome probability that we do not have, and it ignores the wide range of treatments for a given diagnosis. Is futile the same as useless or the opposite of hope? Futile for what? Cure? Restora tion of function? Prolongation of life? Relief from pain? Relief from anxiety? Com fort? Reassurance? To satisfy or placate the patient or the family? The word “futile” is so imprecise that, rather than clarifying, it confuses and clutters the discussion.