Voices Online Edition
Volume XVIII, No. 1
Futility policies: Part of the culture of death
Editor's note: The following editorial appeared in The Saint Louis Review, the newspaper of the Archdiocese of Saint Louis, December 7, 2001.
Over the past decade many articles in legal, ethical, and medical journals have argued for a new concept in the distribution of health care and in treatment decisions, called "medical futility". At least two Catholic healthcare systems have been at the forefront of the implementation of medical futility policies. There is not much agreement about what "medical futility" actually means, though.
In terms used by its proponents, medical futility means that a physician can refuse to provide a patient with treatment that he or she does not believe to be useful for the patient. For years, medical ethicists promoted the patient's autonomy in health care decisions. Now, with medical futility, some ethicists argue for a limitation on the patient's decision-making power. For the physician, theologian, or other professional, understanding the complexity of the issues raised by medical futility policies requires careful study - and even that is apt to leave important points unresolved about the application of such policies. For the average person seeking good medical care carried out in accordance with Catholic moral principles, the notion of medical futility is completely baffling. Even advocates of medical futility policies admit that there is very little agreement over the meaning of the concept. The American Medical Association has suggested that the idea ends up being mostly subjective.
Reverend Peter Clark and Catherine Mikus, two authors working for a Catholic health care system in Pennsylvania, have subtly argued that physicians should ignore a patient's request for treatment when it conflicts with the physician's judgment. Anticipating reticence on the part of physicians due to the legalities, they write, "If the physician has acted according to generally accepted medical standards and/or in conformance with the expressed wishes of the patient, the physician will generally prevail [in subsequent litigation]". The authors do not indicate how a decision to refuse requested treatment could be in conformance with the patient's expressed wishes. However, a previously-executed health care directive comes to mind (such as those one is asked to fill out upon entering the hospital these days and the so-called "living will").
These authors argue that when patients make irrational requests for treatment the physician should refuse. Of course physicians should not be required to provide medical interventions that offer no medical benefit. But that is not what the current theory of medical futility is about or what the authors mean by irrational. In this case the desire to terminate treatment is prompted by the fact that it actually does sustain life. To put it in the words of anti-euthanasia task force lawyer Wesley Smith, "It isn't the treatment that is deemed futile but, in effect, the patient".
Medical futility policies seem acceptable until one grasps the transformation of words to mean things that most of us would not take them to mean ordinarily. For example, authentic Catholic moral teaching accepts the idea that treatment should have a benefit in order to be required. But Clark and Mikus state plainly, based on the principle of beneficence, that "treatment that merely preserves permanent unconsciousness or is incapable of ending dependence on critical care should also be considered futile. In judging futility, physicians must distinguish between an effect (which is limited to a part of the patient's body) and a benefit (which appreciably improves the patient as a whole)".
As Smith points out, "Treatments withheld under this policy might include antibiotics to treat infection, medicines for fever reduction, tube feeding and hydration, kidney dialysis or ventilator support". Persons could dehydrate or die of an infection when water or antibiotics is withheld. But for Clark and Mikus, to intervene medically in such cases is "only to prolong a seemingly meaningless life".
Catholic institutions should resist medical futility policies as part of the culture of death. Those who do adopt such policies should provide prospective patients and their families with clear notice of such a departure from the authentic principles of Catholic moral teaching and the Hippocratic principle that excludes doing harm to the patient.
Once medical futility becomes the standard in health care, a poor prognosis, which can be erroneous and is seldom precise, will become a death sentence.
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