Wednesday, March 16, 2005

The Distinction Between the Withdrawal of Futile Therapy and Euthanasia

My thanks to hgstern (author of Insureblog) for pointing out a Captain's Quarters entry entitled "Texas A Signatory to Groningen Protocol?" (entered Tuesday, timed at 8:44PM).

In it, there is discussion of a case in Texas in which life support was discontinued for a critically ill 5-month-old boy. This case represents a good opportunity to discuss the important distinction between the withdrawal of futile therapy and euthanasia. In this essay, I'd like to explain the meaning of this distinction.

See complete essay here.
The Captain's Quarters blog had a very pertinent entry I'd like to talk about. Heroic life support was recently discontinued for a critically ill 5-month-old boy in Texas. This unfortunate baby was born with a fatal genetic disorder and had been ventilator-dependent since birth. This case did not fall under the category of euthanasia in that no active measure was taken to end this child's life. Instead, he died because his prognosis, according to the best available medical opinion, was determined to be hopeless. Heroic interventions (such as invasive ventilation and other techniques) were felt by the hospital and its ethics committee to be futile and were therefore discontinued.

Such decisions can pose great ethical, philosophical and moral dilemmas but the issues involved are very different than those of euthanasia.

Futile therapy is a medical intervention that is deemed by the best clinical data and expert opinion to be without any known, provable benefit. Obviously, this is open to interpretation and yet such assessments are made every day.

In a patient with no hope of meaningful life (in this case, no hope of ever being weaned from the ventilator) all nonpalliative therapy would be considered futile. It is generally thought by almost all bioethicists that truly futile therapy as defined here is of no benefit to a patient and it is therefore ethically permissible to discontinue such therapy.

This is not to say that there is no role for discussion in determining the futility of such care. I have no doubt that the ethics committee for this hospital as well as the doctors, nurses, social workers and other professionals involved went through many gut-wrenching discussions. Yet once the determination of futility was made, deciding not to initiate (or in this case to terminate) such care would not be expected to cause a major ethical problem.

More clear examples would be the use of dangerous, unproven chemicals to treat disease for no other reason than that a patient "wishes" it. No practitioner should be required to pursue treatment that he or she has no faith in or has reason to believe will be harmful or prolong suffering.

Years ago, I remember a fad of treating advanced cancer with "laetrile", a component in apricot pits that was popular in Mexico. Cancer patients were demanding that their American physicians administer it, despite a complete lack of proof that laetrile was in any way efficacious. In reality, withholding such treatment really posed few ethical dilemmas.

Should a hospital or physician be required to pursue a therapy of no known benefit only because a bereaving parent is unwilling to "let go"? Should they be required to support a therapy that its staff felt prolonged suffering or was otherwise harmful? Should society or an insurance company be required to pay for it?

These are rather different issues than the issue of euthanasia, the active killing of a human being. The Texas case in question was more a case of allowing nature to take its course by refusing to keep a baby alive by strictly artificial means. It was felt that there was no hope for recovery and all that remained was the very real possibility that continuing such care would only prolong suffering.

Mention was made that the boy's mother apparently suffered from delusional thinking. Evidence of potential mental illness on the part of the baby's legal guardian should be of no relevance at all. Only the treatment's futility or utility ought be considered.

If the hospital's assessment of the futility of further treatment was arrived at in a careful, measured manner, then its actions in withdrawing support were justified.

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Blogger Henry Stern, LUTCF, CBC said...

"If the hospital's assessment..."

That's a pretty big "if." IIRC, the infant wasn't SUPPOSED to survive the first 5 days, let alone 5 months. So I'm less sanguine than you appear to be regarding the nature of this "assessment."

And I think that maybe the, uh, delusional mother's state of mind may well have played a role in the final decision. How would the hospital have reacted had both parents been relatively sane, upstanding members of the community, who were willing to pay for the extensive treatment, and/or taken on the task themselves (when appropriate)?

I don't know the answer to that, but I suspect that this case may not have been so cut-and-dry in that circumstance.

I guess we'll just have to agree to disagree.

March 16, 2005 3:37 PM  

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