8 of 9 people found the following review helpful
on August 12, 2010
Lawrence J. Schneiderman & Nancy Jecker
Doctors, Patients, and Futile Treatment
(Baltimore, MD: Johns Hopkins University Press, 1995)
(ISBN: 0-8018-5036-3; hardcover)
(Library of Congress call number: R724.S3936 1995)
This book raises a new issue in medical care:
Sometimes patients receive medical treatment because it is possible
rather than because it offers a real hope of cure.
For some patients, at least, we have passed
from the era of too little medical care
to the era of too much medical treatment.
Some foolish reasons doctors continue to treat hopeless patients:
It is automatic to attempt the next treatment when one treatment fails.
The physician does not want to admit 'defeat'.
The physician does not want to 'abandon' the patient.
The doctors have an emotional investment in this particular patient.
People can always point to miracles-cures that worked for others.
A neglectful relatives now insists "do everything".
A doctor who was unlucky in a difficult operation (or who made a mistake)
wants that to be forgotten because the patient ultimately recovered.
The family is not ready to let go, especially of a dying child.
Fears of unlikely lawsuits for malpractice.
Fear of adverse media attention if the patient dies.
If a procedure is covered by insurance, it should be done.
Family members are making a scene.
The patient has no proxy or advance directive--no one to say "enough!"
Health-care workers do not know that the law does not require useless treatments.
Doctors do not know the probabilities of success of each treatment.
Patient autonomy does not mean that the patient can demand anything he or she wants.
Doctors are not aware of the costs of the treatments they order.
Medical futility is not the same as rationing medical resources.
Futility means that the treatment does no good for the patient.
Rationing means that it costs too much to use this treatment
in light of the likely outcome.
The same medical resources would do more good if they were used for other patients.
Rationing will always be necessary when it comes to organ transplants:
There will always be more patients in need than there are available organs for transplant.
It makes good sense to shift medical care to earlier in any patient's life,
when it can do more good and provide more years of meaningful life.
Futility focuses only on one patient:
Will the proposed treatment do any good for this patient?
Rationing asks about the broader society:
Given that health-care dollars are limited, how should we spend them?
The fear of malpractice lawsuits leads to 'defensive medicine',
in which unnecessary tests are ordered to impress a jury of laypeople
rather than because they will benefit the patient.
These mostly-goundless worries leads to billions of dollars wasted
on medical documentation rather than health care.
Good medical care would focus on what the patient needs,
not what a clever lawyer might say to a jury of laypeople
about the latest medical test or gizmo that was not used.
The mass media and television dramas
give the public a false impression of how medicine ought to be practiced.
When a treatment gets into the news or into a hospital drama,
patients ask for it even if it would have no value for them.
And they threaten to sue if they are not treated "as seen on TV".
The lawyers for the hospital think of the most remote possibilities.
In actually fact, no one has successfully sued for premature termination of treatment.
Doctors must deal with the probabilities that a certain treatment will be successful or not.
In one case, the hospital did not want to disconnect a brain-dead baby
because they worried that they would be charged in the media
with killing welfare babies to save money.
The hospital wanted to avoid adverse publicity,
so it was willing to keep the tiny body on life-supports indefinitely.
"Pulling the plug" is not murder or suicide.
Lawyers know this.
Courts have always agreed.
But some doctors are not certain.
And the general public has not given the issue much thought.
But better education for all will overcome the legal myths.
Death comes as the result of the underlying disease or condition;
it was not caused by disconnecting the life-support systems.
And terminal illness need not be officially declared
in order to refuse or discontinue any medical treatment.
Ordinary as well as extraordinary treatments may be refused.
The line between these two keeps moving.
And even the Roman Catholic Church has abandoned this sort of thinking.
Another common error in popular thought is that
once a machine has been connected, it can never be disconnected.
Withdrawing treatment has the same moral and legal standing as never starting.
Thus, when the situation is uncertain, it is always best to try the life-support system.
If it does not work, it can be terminated just as easily.
But never starting out of fear of not being able to stop
could lead to serious harm or even death for the patient.
Emotionally it might feel different,
but legally and morally, we can always discontinue treatment that does not work.
When food and water are provided thru tubes,
this has always been included as forms of medical treatment,
which can also be discontinued if they do no good.
Terminating life-supports does not require a court order.
(Again, some right-to-die cases in the news
sometimes give the false impression
that the courts will always be involved in life-ending decisions.)
Some health-care workers do not know that advance directives are legal:
Decisions based on these documents and the decisions of the proxies
have the full force of law behind them.
Patients and their families sometimes demand medical treatments
that really are futile or useless in the sense that there is
no chance that these treatments will return the patient to normal life.
Some lesser goals of medical care are sometimes meaningful.
But what is possible and impossible often needs to be explained to the laypeople,
who usually have no technical information about treatments and outcomes.
And laypeople often expect or demand a miracle.
They are usually ill-prepared for accepting death as the most likely outcome.
Patients are permitted, even encouraged,
to have their own religious beliefs and practices.
They can pray as much as they please for a cure.
Most hospitals employ chaplains to take care of the religious needs of the patients.
But the medical care itself should be based on scientific evidence.
Better education of the public and common sense
should eventually reduce the amount of futile care now being given.
And better coordination among doctors who specialized in various diseases or organs
could lead to wiser decisions regarding medical care for the whole patient.
Each specialist has been mainly concerned
with keeping his or her part of the body going.
But there has been less attention to the over-all health condition of the patient.
What is the point of giving expensive treatment for one organ-system
when the whole body has little chance of surviving for another year
even if all efforts are successful?
For example, there is no point in removing a tumor
if the patient is permanently unconscious.
Such an operation can successfully remove the cancer,
but what benefit does it provide for the patient?
The over-all benefits and burdens on the patient should be weighed
in making each medical decision.
Which physician should be in charge of the whole patient's condition?
Patients should also be told about the future quality of their lives
even if all of the treatments go perfectly.
The outcome of medical treatment
should not be stated simply in terms of survival or non-survival.
What will the patient's life be in the following months and years?
And what burdens will the patient have to bear for the rest of his or her life?
For example, will the patient be able to return to work?
Will the patient be dependent on some medical devise for the remainder of life?
Wrong Medicine: Doctors, Patients, and Futile Treatment
does not answer most of the medical dilemmas it raises.
But it is the beginning of a long discussion of medical futility.
It will take decades before the general public
notices that some medical treatments are useless in specific cases.
Doctors must lead the way:
Instead of focusing just on keeping the body 'alive',
they need to be able to ask about the quality of the life prolonged.
Should it be counted as a success if the patient will never leave the hospital alive?
Let the discussion begin for all persons involved in making medical decisions.
A medical futility database could provide detailed information
about the outcomes for similar patients who tried each form of treatment.
This reviewer has published an essay on the Internet on this subject:
Search for "Medical Futility Monitor: How to Avoid the Million-Dollar Death".
If you would like to read other views on medical futility,
search the Internet for "Books on Medical Futility".
James Leonard Park, medical ethicist