A referral was made to our Cardiac Transplant Program for a patient who was in the New Jersey Prison System. The Medical Director of the New Jersey Department of Corrections called regarding a 39-year-old inmate who was being treated in a New Jersey hospital that has a unit for prisoners from a nearby cor- rectional facility. The referring physician described the patient to our Medical Director of heart transplantation as a “murderer” who had been incarcerated since 1987 and sentenced to prison for 30 years without eligibility for parole before completion of his 30-year sentence. The patient was being treated in the CCU of the facility and according to preliminary studies, was suffering from a possible dilated cardiomyopathy. There was evidence of a prior cerebrovascular accident (etiology unknown) with a dense hemiplegia of the left side. The patient was alert but unable to care for himself. There were a number of specific tests necessary to evaluate the patient's candidacy for heart transplantation before actually placing him-on a waiting list. However, the transplant director was uncertain about having the patient brought to our facility for further testing and called some members of the Transplant Selection Committee team to discuss the case.

Mr. Bernard was a homeless man, aged 58. His medical history revealed alcohol abuse, seizure disorder, and two suicide attempts. Brought to the emergency room at a local hospital after being found “semi-comatose,” his respiratory distress led to his being intubated and placed on a ventilator. The healthcare team suspected the patient ingested antifreeze. Transferred from that hospital to the intensive care unit (ICU) of the university hospital, his diagnosis was “high osmolar gap with high-anion gap metabolic acidosis, most likely secondary to ethylene glycol ingestion and renal insufficiency.”

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.

D.T. a 35-year-old woman, was found to have breast cancer. At the time of mastectomy axillary lymph nodes were positive and the cancer was classified as adenocarcinoma, grade 4. The patient underwent conventional chemotherapy. When it became apparent the disease was metastatic, the patient's oncologist contacted a well-known cancer center regarding the possibility of treating the patient with high dose chemotherapy and autologous bone marrow transplantation (HDC/ABMT). The patient's health insurance provider informed the patient, however, that the treatment—estimated to cost in the range of $150,000–200,000—was “considered experimental or research in nature” and therefore was not included in coverage. D.T. did not pursue this further. Approximately 2 years later, cancer was detected in the patient's spine. This time she applied to another well-known cancer center for HDC/ABMT. The cancer center agreed to accept her on the condition of proof of ability to pay for the treatment. Again her insurer refused coverage on the same grounds as before. D.T. found another source for the money, underwent treatment, then sued the insurance carrier. She sought a declaratory judgment that the treatment was covered under the insurance policy. The court ruled in favor of D.T. finding the contract phrase “considered experimental” ambiguous.

In September 1994, the New York Times carried a front page article declaring healthcare reform dead in Congress. The obituary on healthcare followed a Congressional decision not to pursue the issue further in 1994. Although Congress and the President will likely revisit healthcare reform during 1995, the choices may be between various incremental steps, rather than substantive changes to bring about universal coverage.

In situations where experience shows that a particular intervention will not benefit a patient, common sense seems to suggest that the intervention should not be used. Yet it is precisely in these situations that a peculiar ethic begins to operate, an ethic that Eddy calls “the criterion of potential benefit.” According to this ethic, “a treatment is appropriate if it might have some benefit.” Thus, the various maxims learned in medical school instruct physicians that “‘an error of commission is to be preferred to an error of omission,’ or ‘when in doubt, cut it out’ or ‘if but one patient is helped, then the treatment is worthwhile.’”

High moral standards and adherence to a moral code have long been strong tenets of the profession of medicine, even though there have been occasional lapses that have led to renewed calls for a revitalization of moral integrity in medicine. Certainly, a moral component has generally been held to be an important aspect of the concept of a physician.

Over the next 15 years, the government-funded human genome project will map and sequence each of the human cell’s estimated 100,000 genes. The project’s first fruits will be a vast quantity of information about genetic disease. This information will contribute to the design of quicker, cheaper and more accurate tests for identifying deleterious genes in individuals. Because genetic conditions are often regarded as “immutable, heritable taints that intrinsically implicate the bearer’s identity,” overly-deterministic interpretations of genetic information can readily distort genetic risk and become enshrined in institutional policies of social isolation and discrimination.