On the good of patients and the good of society

I ran across this article, which is a critique of this article in the Huffington Post. As a brief synopsis, the case of Mr. Betancourt, who was left in a vegetative state after cancer surgery is considered. The team of doctors at Trinitas Hospital decided that treatment for Mr. Betancourt, such as kidney dialysis, artificial nutrition and hydration was futile and unnecessary but his daughter wanted him to undergo treatment. Since he left no advanced directives, she obtained a court order for additional care and a legal battle is ensuing now between the family and the hospital.

Jacob Appel, who wrote the Huffington Post article, thinks that money is wasted on these individuals who are in a vegetative state:

There is a fundamental difference, however, between asking to be permitted to keep a vegetative relative on costly machinery, and asking the taxpayers or society as a whole to pay for such machinery. Money spent on vegetative patients is money not spent on preventive care, such as flu shots and mammograms. Each night in an ICU bed for such patients is a night that another patient with a genuine prognosis for recovery is denied such high-end care. Every dollar exhausted on patients who will never wake up again is a dollar not devoted to finding a cure for cancer. While the visible victims may draw the headlines and attract indignant protests from so-called “pro-life” organizations, the invisible victims are people like you and me who will suffer from diseases that are never cured because funds are being poured down a healthcare sieve in order to maintain permanently-unconscious bodies on complex and costly forms of life support.

I will let Syd Johnson rebuttal:

While there may be some savings to be reaped from terminating the lives of patients with chronic disorders of consciousness, it will not be the substantial windfall that Appel imagines. Neither can it be assumed that “every dollar” will be diverted, as Appel suggests, to preventive care, or finding a cure for cancer. Public money saved could well be redirected to priorities outside health care.

There are substantial social costs to declaring an entire class of patients “worthless.” Allowing health care providers, including institutions like acute care hospitals, to unilaterally decide, against the wishes of patients or their legal guardians, to withhold life-sustaining medical treatment invites abuse and diminishes transparency and due process.

In a society that values patient autonomy and decisional authority, taking decisional power away from vulnerable patients or their surrogates would amount to abandoning them and leaving their fates to others who may or may not be motivated by patient welfare. It would change the culture of medicine – at least for these patients, if not for others – from one that is patient-centered to one that is beholden to the bottom line. In weighing the possible financial savings against the social costs of declaring these patients “worthless,” it is not at all obvious that ending treatment for all permanently vegetative patients will result in a net benefit.

I guess patient autonomy is only good if patients make the “right” decision. Usually with discussions regarding euthanasia the issue involves patients wanting to die and not suffer anymore but in the above case the opposite is happening. A proxy for a patient wants the patient to live and it is the medical team that is denying treatment. I do not agree obviously with Appel’s opinion that we should allocate precious resources from those “less worthy” individuals to others in society but he brings up a point regarding doctors refusing treatment to those patients who want it:

What this case asks is: Are there circumstances in which patient autonomy, as expressed through surrogates, should be overruled in the name of resource allocation and/or sound medical practice?

Medical treatment (which does not include basic care such as food and hydration) is optional and patients have a right to refuse treatment if they feel it is not going to be of great benefit. However, what about patients or their surrogates wanting to undergo treatment that doctors feel will not be beneficial? What line should be drawn with regard to refusing treatment so that abuses do not occur? Since comments have been quiet for a bit I will open this up for discussion.

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1 Comment on “On the good of patients and the good of society

  1. I would state Margaret Somerville from her article « Samuel Golubchuck and moral dilemmas : A Canadian man’s life depends on a ventilator. His relatives want to keep it on; his doctors want to turn it off ») :

    « “Medical futility” is a narrower concept than futility that does not involve the same risks of abuse. There is no ethical or legal obligation to provide treatment that will have no effect – for instance, give a blood transfusion to a person not needing blood. Mr Golubchuck’s ventilator is keeping him alive so it is not medically futile. That does not mean the ventilator must not be withdrawn ; rather, its withdrawal cannot be justified on the basis of futility. The facts of the Herman Krausz case, in which the treating-physician turned off Mr Krausz’s ventilator, are very similar to the Golubchuck case. That resulted in a 16-day, Quebec coroner’s enquiry. The coroner ruled the ventilator supporting Mr Krausz’s life was not “medically futile”; that he was competent and had not given informed consent to its withdrawal ; and that this withdrawal caused his death. But she also found — somewhat confusingly and without explaining the relevance or proper application of this previously unknown concept — that the ventilator was “therapeutically futile”. That meant, she explained, the patient could not be cured and would die, whether or not the ventilator was withdrawn ; the
    only difference was when he would die. But that’s true for all of us who need medical treatment to keep us alive, and it’s also true that in the end we all die » Margaret Somerville, « Who dare call it futile ? » (March 14, 2008), en ligne : Mercator.net .

    Eric Folot

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