SOC 573 - Medical Futility

1
SOC 573 - Medical Futility

• James G. Anderson, Ph.D.
• Purdue University

2
Definition of Medical Futility

• Quantitative Definition - The expectation of
  success empirically is so unlikely that its exact
  probability cant be calculated.
• Qualitative Definition - Any treatment that
  merely preserves permanent unconsciousness or
  total dependence on intensive medical care.

3
Questions

• What is the process by which standards are
  devised and quantitative judgements made?
• Society for Critical Care Medicine - 1990
  Consensus report on the ethics of forgoing life
  support
• Medicaid stipulates that recipients are to
  receive medically necessary care but does not
  stipulate standards

4
Questions

• What is the process by which standards are
  devised and quantitative judgements made?
• The Pepper Commission in 1990 tried to
  define minimum health benefits.
• The State of Oregon combined public values,
  professional judgment, cost-effectiveness data to
  rank procedures covered under the state Medicaid
  program

5
Questions

• Who decides when treatment is futile?
• Healthcare providers
• Patients and their surrogates
• The courts

6
Determining Futility

• Determination of futility combines technical
  considerations, clinical judgments, and patient
  values.
• Determination requires shared decision making.

7
Making Judgments

• How do we make judgments that combine factual and
  normative (moral) ingredients?
• Values can influence how one recognizes and
  interprets facts.
• We must make a sharp distinction between
  scientific knowledge and moral and political
  judgments.

8
Making Judgments

• Scientific data provide probabilities not
  certainties.
• Probabilities can not always be kept free of
  values.
• The use and interpretation of scientific data for
  moral or politicalk purposes will be a function
  of the values we bring to bear on the data.

9
Questions

• How do we determine medical futility for patients
  who are in a comma, in a persistent vegetative
  state or who are suffering from multi-organ
  failure or severe dementia?
• When if ever does cost become a consideration?

10
Tension

• Physicians must have the right to act on their
  values and sense of integrity just as patients
  must be allowed to act on theirs.
• The physician is the expert but may act
  paternalistically.
• The patient and family want autonomy and want to
  follow a democratic process.
• How do we resolve the inherent tension between
  doctors and patients?

11
Questions

• If patients and their surrogates insist on
  continuing treatment that is considered futile,
  who should pay for the treatment?
• If health care providers discontinue treatment
  against the wishes of patients and their
  surrogates, will this cause the public to lose
  trust in the health care system?

12
Questions

• If the physician accedes to family wishes to
  continue futile care, is he/she sending the
  family a mixed message of false hope?
• Does the physician have an obligation to protect
  the patients interest?
• How does the physician determine what is in the
  best interest of the patient?

13
Questions

• In the absence of laws, are the family members
  best qualified to decide whether treatment is
  futile?
• When if ever are physicians justified in refusing
  to continue futile treatment?
• Should the potential costs to the provider
  (hospital) and to the public of futile care be a
  consideration?