Response to “Bringing Clarity to the Futility Debate: Don't Use the Wrong Cases” by Howard Brody and “Commentary: Bringing Clarity to the Futility Debate: Are the Cases Wrong?” by L.J. Schneiderman (CQ Vol 7, No 3): Mediating Disputes about Medical Futility

Cambridge Quarterly of Healthcare Ethics

Volumn 8, Issue 4, 1999, Pages 527-537

  Trotter, Griffin ^a  

^a NONE

Author keywords

[No Author keywords available]

Indexed keywords

ANALYTICAL APPROACH; ARTICLE; CONFLICT; CONSENSUS; DEATH AND EUTHANASIA; DECISION MAKING; DOCTOR PATIENT RELATION; ETHICAL THEORY; GROUP PROCESS; HUMAN; IN RE BABY K; IN RE WANGLIE; LONG TERM CARE; PATIENT PARTICIPATION; SOCIAL BEHAVIOR; SOCIAL PSYCHOLOGY; TREATMENT OUTCOME; TREATMENT WITHDRAWAL;

ANALYTICAL APPROACH; DEATH AND EUTHANASIA; IN RE BABY K; IN RE WANGLIE;

CONSENSUS; DECISION MAKING; DISSENT AND DISPUTES; ETHICAL THEORY; GROUP PROCESSES; HUMANS; LIFE SUPPORT CARE; MEDICAL FUTILITY; PATIENT PARTICIPATION; PHYSICIAN-PATIENT RELATIONS; SOCIAL RESPONSIBILITY; SOCIAL VALUES; WITHHOLDING TREATMENT;

EID: 0033195299     PISSN: 09631801     EISSN: 14692147     Source Type: Journal    
DOI: 10.1017/s0963180199004156     Document Type: Article

References (33)

1. Brody H. The physician's role in determining futility. Journal of the American Geriatric Society 1994;42:875–878.
2. Tomlinson T, Brody H. Futility and the ethics of resuscitation. JAMA 1990;264:1276–1280.
3. In The Loyal Physician: Roycean Ethics and the Practice of Medicine (Nashville, Tennessee: Vanderbilt University Press, 1997)
4. I use Brody's conception of the “broken story” to discuss the importance of narrative in clinical medicine, endorsing his opinion that clinical medicine involves the physician in an effort “to develop over time into a certain sort of person-a healing sort of person-for whom the primary focus of attention is outward, toward the experience and suffering of the patient, and not inward, toward the physician's own preconceived agenda” (emphasis in original). However, Brody's account of the physician's personal transformation into a person dedicated to helping patients reestablish a satisfying life narrative does not sit well with his contractarianism. For instance, Brody criticizes “covenant” models of physician obligation because they imply broad personal commitments on the part of physicians. He writes: “it is crucial not to extend the scope of the physician-patient relationship beyond legitimate bounds,” then goes on to criticize Charles Fried for stating that physicians are servants of patients' life plans. (Brody H. The physician-patient contract: legal and ethical aspects. Journal of Legal Medicine 1976;4:25–29.)
5. For the material cited in The Loyal Physician, see Brody H. My story is broken; can you help me fix it? Literature and Medicine 1994;13:79–92.
6. See note 3, Brody 1976:26.
7. Schneiderman LJ, Jecker NS. Wrong Medicine: Doctors, Patients, and Futile Treatment. Baltimore, Maryland: Johns Hopkins University Press, 1995.
8. Interestingly, when proponents of Schneider-man's version of quantitative futility assessed medical residents' use of the concept of futility, they found the residents diverged from Schneiderman. Instead of concluding that Schneiderman's account needs revision, they concluded that the residents were in error. Curtis JR, Park DR, Krone MR, Perlman RA. Use of the medical futility rationale in do-not-attempt-resuscitation orders. JAMA 1995;273: 124–8.
9. Bayesian analysis mitigates this difficulty, but has not been applied rigorously to standards of medical futility. For a general discussion of Bayesian statistics, see Lewis RJ, Wars RL. An introduction to the Bayesian analysis of clinical trials. Annals of Emergency Medicine 1993;22:1328–1336.
10. Hackler JC, Hiller FC. Family consent to orders not to resuscitate: reconsidering hospital policy. JAMA 1990;264:1295–1296.
11. Brody H. Bringing clarity to the futility debate: don't use the wrong cases. Cambridge Quarterly of Healthcare Ethics 1998;7:269- 272.
12. See also Schneiderman LJ. Commentary: bringing clarity to the futility debate: are the cases wrong? Cambridge Quarterly of Healthcare Ethics 1998;7:273–278.
13. Royce J. The Philosophy of Loyalty. Nashville, Tennessee: Vanderbilt University Press, 1997[1908]:9.
14. See also Royce J. The Problem of Christianity. Chicago: University of Chicago Press, 1968[1918]:41.
15. Royce J. The Hope of the Great Community. New York: Macmillan, 1916.
16. What I have called “naive communitarianism” is not the same as“new communitarianism.” The latter is a movement affirming the importance of community and democracy while explicitly rejecting majoritarianism. See The responsive communitarian platform. In: Etzioni A, ed. The Essential Communitarian Reader. New York: Rowman and Littlefield, 1998.
17. See note 3, Trotter 1997.
18. In Democracy's Discontent: America in Search of a Public Philosophy (Cambridge, Massachusetts: Harvard University Press, 1996), Michael J. Sandel argues at length that a sound public philosophy depends on social commitments to a conception of the good. This work builds on his earlier thesis that theories, such as Rawls', that epistemologically prioritize the right over the good are unworkable.
19. See also, Sandel MJ. Liberalism and the Limits of Justice, 2nd ed. Cambridge: Cambridge University Press, 1998.
20. Cassell EJ. The Nature of Suffering and the Goals of Medicine. New York: Oxford University Press, 1991.
21. See also Jonsen AR, Siegler M, Winslade WJ. Clinical Ethics, 4th ed. New York: McGraw-Hill, 1998.
22. See note 15, Sandel 1998:1.
23. Rawls J. A Theory of Justice. Cambridge, Massachusetts: Harvard University Press, 1971.
24. Schneiderman LJ, Jecker NS. Judging medical futility: an ethical analysis of medical power and responsibility. Cambridge Quarterly of Healthcare Ethics 1995;4:23–35.
25. See note 15, Sandel 1998:xi.
26. Royce J. War and Insurance. New York: Mac-millan, 1914.
27. Emanuel EJ, Emanuel LL. Four models of the physician-patient relationship. JAMA 1992;267:2221–2226.
28. Trotter G. Royce, community and ethnicity. Transactions of the Charles S. Peirce Society 1994;30:231–269.
29. See note 5, Schneiderman, Jecker 1995:15.
30. Payne K, Taylor RM, Stocking C, Sachs GA. Physicians' attitudes about the care of patients in the persistent vegetative state: a national survey. Annals of Internal Medicine 1996;125:104–110.
31. Despite occasional claims that it depends on purely medical values (or that it is value neutral), the concept of physiologic futility hinges on general moral values in two important ways. First, the selection of physiologic end points for a treatment requires valuation. For instance, should the physiologic purpose of CPR be maintenance of organ perfusion during cardiopulmonary arrest, return of spontaneous circulation, return of cerebral function, or survival to discharge? (See Mahmoud RA. Letter to the editor. Annals of Internal Medicine 1996;124:76.) Second, even if the physiologic end points are given, the selection of a suitable criterion for “virtual certainty” that these end points cannot be achieved with a given intervention is a moral question.
32. James W. The Will to Believe and Other Essays in Popular Philosophy. New York: Longmans, Green and Company, 1897:2–3.
33. Interestingly, patients who expect to receive antibiotics for viral infections are usually quite satisfied when antibiotics are with-held-just as long as physicians take the time to thoroughly explain the rationale for non-treatment. See Hamm RM, Hicks RJ, Bemben DA. Antibiotics and respiratory infections: are patients more satisfied when expectations are met? Journal of Family Practice 1996; 43:56–62.