Monday, December 17, 2007

Withdrawal of Futile Care vs. Euthanasia Revisited

There is a medical case brewing in Canada that's about patient autonomy, medical paternalism, futile care, euthanasia, and of course religion. Have I left anything out? It's apparently turned into a bioethical "perfect storm".

Being the opinionated guy that I am, I have some thoughts on this here.
Think this can't happen in the US? Guess what. It has.

I've written about the distinction between futile therapy and euthanasia before but this case brewing in Canada warrants another look.

I've often thought about this distinction because it's an important one. A great source of controversy and conflict can arise when these two entities are confused. This confusion often stems from the fact that medical professionals may define euthanasia and more frequently, "futile" therapy differently than the general public.

A therapy is futile when it offers no reasonable chance of helping a patient. Euthanasia on the other hand is the active use of an intervention deliberately employed to hasten a patient's demise i.e. the use of a lethal drug.

Most lay people would include as futile, unproven and potentially harmful therapies such as the sham cancer treatment laetrile. Medical professionals however, have often broadened the definition to include conventional treatments that have no real chance of meaningfully altering the natural history of disease for a given patient.

Under this more expansive definition, interventions such as ventilators, dialysis, or more dramatic, or more dramatically ECMO, would qualify as futile therapy in many settings. When a patient is hopelessly ill, has severe comorbid conditions, and is generally felt to be "poor protoplasm", such treatments may well be virtually no benefit.

A problem can easily arise when patients or their families can't be made to understand that in those utterly hopeless settings, medical interventions like ventilators or advanced cardiac life support (ACLS), are no different than laetrile. This is likely to be the situation described in the first link.

When this happens, withdrawal of life support will necessarily be seen as euthanasia. It is in these cases where serious conflicts between patients (and their families) and hospitals and doctors occur. Some of them make it to hospital bioethics committees and occasionally the press like this one.

Unfortunately, no doctor has absolute knowledge. No doctor can definitively predict the future and all outcomes. Those rare cases in which the unexpected occasionally happens can shake the faith of the most hardened physician in his ability to assess futility. But for the most part; when patients are old, demented, with multi-system failure, and other serious problems, the likelihood that aggressive so-called heroic medical care will cause more damage than good is very high.

In such instances, it is incumbent upon the physician to educate the family regarding this reality. If he is able to do so, then withdrawal of care is seen as a clear act of mercy. If he's not, such action will take on the appearance of euthanasia which for a majority of people is an anathema.

The situation in Canada has happened here and undoubtedly led to recriminations, guilt, and who knows what other deep, tragic feelings. The best that can be hoped for with this case is that some degree of understanding will emerge between the patient's medical providers and his family.

When the family conceives the withdrawal of life support tantamount to murder, it's already too late for that.

More on this case in a future post.

Update: Read more of my thoughts on this case here.

Labels: , , ,


Post a Comment

<< Home