Correspondence
Physicians' Refusal to Provide Inappropriate Treatment
N Engl J Med 1994; 330:144-146January 13, 1994
- Article
To the Editor:
In their Sounding Board article Paris et al. (July 29 issue)1 quote a sentence from a lengthy chapter on biomedical ethics that I wrote for a recent textbook of critical care medicine; on the face of it, this looks as though my writings support the dominance of decision making by the patient, even when care is not medically indicated2. Neither I nor my chapter supports this position. In fact, the sentence quoted refers to withholding basic life support (food, water, and supplementary oxygen), and not to the type of futile care exemplified by the case of a young boy receiving extracorporeal membrane oxygenation described by Paris et al. One could also quote other statements from my chapter: “A good example of a violation of this ethical principle [nonmaleficence] is when a health care practitioner provides a nonindicated therapy to a patient which results in morbidity or mortality” or “if a diagnostic or therapeutic management option is medically futile, the critical care team is not clearly obligated to pursue the option.”
Physicians have a responsibility not to offer or provide nonindicated medical therapy. However, in most complicated decision-making situations (e.g., in an intensive care unit), it is often unclear whether or not a specific therapy might help. The authors presented a case in which care was obviously futile, but this type of extreme situation is uncommon -- it is a boundary condition. It will be a mistake if physicians learn from this article that they have the ability to walk through an intensive care unit and separate the futile from the hopeful and then stop supposedly nonindicated medical care. We do not want to go too far in decreasing the importance and scope of a patient's autonomy. The solution in the overwhelming majority of cases calling for tough medical decision making comes through sensitive, honest, and compassionate communication with patients, families, and legal surrogates.
2 ReferencesThomas A. Raffin, M.D.
Stanford University School of Medicine, Stanford, CA 943051
Paris JJ ,Schreiber MD ,Statter M ,Arensman R ,Siegler M . Beyond autonomy -- physicians' refusal to use life-prolonging extracorporeal membrane oxygenation. N Engl J Med 1993;329:354-357
Full Text | Web of Science | Medline2
Raffin TA. Perspectives on clinical medical ethics. In: Hall JB, Schmidt GA, Wood LDH, eds. Principles of critical care. New York: McGraw-Hill, 1992:2185-204.
To the Editor:
. . . The case described by Paris et al. did not pit the patient's autonomy against his best interest, but rather represented a conflict between two inconsistent interpretations of what clinical actions would be in his best interest. We propose that pediatricians may ethically terminate life-sustaining therapy that in their reflective judgment is inconsistent with a patient's best interest, despite parental objections, provided they allow an interval between announcing this decision and carrying it out. Although competent adults can refuse treatment for any reason and with any consequence to themselves, parents do not have the right to deprive their children of effective, beneficial treatment. Similarly, they do not have the right to compel their children to receive ineffective, harmful, or disproportionately burdensome treatment.
Robert M. Nelson, M.D.
Medical College of Wisconsin, Milwaukee, WI 53226Lawrence J. Nelson, Ph.D., J.D.
University of Minnesota, Minneapolis, MN 55455To the Editor:
The reasoned and valuable discussion by Paris et al. of decision making in the intensive care unit did not include a question that must be asked in every case: Why does the patient or the patient's family resist the advice and direction of professionals? Autonomy in the setting of the intensive care unit never appears as an austere and cold philosophical abstraction. It most often is wrapped in very tortured human reactions of uncertainty, ambiguity, ambivalence, distrust, fear, anger, grief, and indecisiveness. Often these emerge at the time of crisis, disguised as stubbornness, hostility, intransigence, and irrationality, especially when the catastrophe is sudden and unexpected. Understanding and penetrating this emotional and intellectual turmoil may help to resolve even the most difficult conflicts.
Distrust of strangers, even when they are in positions of authority, is an understandable human reaction. I have seen permission finally given for the removal of support when the primary care physician, that much neglected and often rejected asset, came on the scene and did the explaining. I have seen the clergy dispel the doubts and the confusion of a family and lead them to peaceful acceptance. Trust in strangers is always more easily given when someone you trust will vouch for them.
There are some occasions when physicians have an obligation in charity to persist in a process they know is futile. There are sincerely observant people whose religion teaches that preventable death must not be allowed to happen. A few extra hours or days of futile care is a small price to pay to prevent emotional and spiritual devastation in a survivor. The family in angry and hostile disagreement, and therefore unwilling to accept the termination of life support, may be harboring unresolved conflict and guilt that a few days might resolve. The wife of a brain-dead patient said to me, “Let me have him just a few more hours. It's going to be a long lonely road, forever without him.” Although we should be guided by the principles that deal with the ethic of conflict, we must sometimes relax them to allow for the ethic of understanding and compassion.
Joseph M. Foley, M.D.
Case Western Reserve University, Cleveland, OH 44106Author/Editor Response
The authors reply:
To the Editor: Dr. Raffin objects that we quote him out of context and thus mislead the reader into believing that he supports “the dominance of decision making by the patient, even when care is not medically indicated.” In a section of his chapter on “the true source of authority” in ethical decision making, Raffin writes, “Although physicians identify the options available to patients, all involved should recognize the actual authority over the patient never resides with the physician. Patients have the ethical and legal autonomy to decide what type of health care they will receive”1. There is nothing here to indicate any limit on the patient's or proxy's discretion.
In his letter Raffin seems to shift from the position that a treatment is “obviously futile” to the position that it would be a mistake “if physicians learn from this article that they have the ability to . . . separate the futile from the hopeful and then stop supposedly nonindicated medical care.” Still, it is clear from his letter that he agrees with the position that “physicians have a responsibility not to offer or provide nonindicated medical therapy.”
We concur, as we have written elsewhere,2 in the observation of Nelson and Nelson that the focus in such cases ought to be the best interest of the child. The difficulty arises -- as in the case of Baby K, the anencephalic infant whose mother demanded “everything possible” to sustain her baby's life3 -- when parent and physician differ about what constitutes the child's best interest. When that conflict proves irresolvable, as was true in our case, we agree with Miles's suggestion that “a path out of this cul-de-sac lies in reconstructing the difference between the negative right to refuse a treatment or to an informed choice among therapies that a physician is willing to prescribe and the positive right to demand a treatment which the medical profession is unwilling to prescribe”4.
The sage and insightful observations of Dr. Foley are appreciated. It proved helpful in our case that a grandmother and the family's minister were available to help the parents understand why the physicians had come to the decision to stop the extracorporeal membrane oxygenation despite the parents' request that it be continued.
4 ReferencesJohn J. Paris, S.J., Ph.D.
Boston College, Chestnut Hill, MA 02167Michael D. Schreiber, M.D.
University of Chicago, Chicago, IL 606371
Raffin TA. Perspectives on clinical medical ethics. In: Hall JB, Schmidt GA, Woods LDH, eds. Principles of critical care. New York: McGraw-Hill, 1992:2185-204.
2
Paris JJ, Kodish E. Ethical issues. In: Pomerance JJ, Richardson CJ. Neonatology for the clinician. Norwalk, Conn.: Appleton & Lange, 1993:531-45.
3
Greenhouse L. Hospital appeals decision ordering treatment for baby missing brain. New York Times. September 24, 1993:A10.
4
Miles SH . Medical futility. Law Med Health Care 1992;20:310-315
Medline
- Citing Articles (1)
Citing Articles
1
Sarah Shidler. (1998) Participation of Chronically Ill Older Adults in Their Life-Prolonging Treatment Decisions: Rights and Opportunity. Canadian Journal on Aging / La Revue canadienne du vieillissement 17:01, 1-23
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