Medical futility and the patient right to refuse treatment in nursing ethics

Medical Futility in Nursing Care

CARING AND CHOOSING

Bioethics is described as both a field of intellectual inquiry and a professional practice that examines moral questions affecting various disciplines (Arras, 2007). These disciplines include biology, medicine, law, public health, policy and ethics. In these disciplines are scholars, teachers, and clinical practitioners, including nurses. Their work has recently been subjected to an unprecedented turn in perspectives concerning relevant issues and behaviors. Among these sensitive issues are the Do Not Resuscitate Orders in hospitals; the true meaning of informed consent, especially in poor countries; a new understanding concerning clinical trials of various drugs; and the traditional doctor-patient ethics. At least three kinds of bioethical work surfaced from these developments. These are clinical bioethics, policy-oriented bioethics, and bioethics as a theoretical pursuit. The first kind, clinical bioethics, is the most troubling. It utilizes bioethical concepts, values and methods in the hospital or clinic, its specific setting. Physicians, nurses, social workers, patients and their families seek out the help of an ethicist to help reach a position and decision on actual problem situations. Unlike the second and third types, which have the advantage of time, clinical bioethics must reach that decision on the bedside (Arras). And medical futility is often the issue to resolve.

Medical Futility

Traditional Goals, the New Right to Refuse

The traditional goals of medicine have been to heal sickness and relieve pain and suffering (Schellinger et al., 2008). The physician in the early days of modern medicine could carry this goal out with limited diagnostic tools and available treatment preparations. Patients were content with the approach. In time, new techniques, treatments and technologies were introduced. These changed the outlook on deadly and terminal illnesses. It also introduced an intriguing concept for physicians and other players to contend with. This was the patient's right to refuse treatment. As a consequence, institutional policies were set up to permit a patient or his surrogate to exercise autonomy. He could limit, refuse or withdraw unwanted medical intervention imposed or suggested by his doctor. This right to refuse has the constitutional protection of the liberty clause, which is linked to the right to privacy. A market-driven economy developed and created a sort of health care consumerism. It converted the once strictly-healing art of medicine as something that can be bought or sold when wanted. Treatments are now for either a healing purpose, such as blepharoplasty, or as an elective, such as cosmetic surgery to tone down the side effects of aging (Schellinger et al.).

Individual Autonomy vs. Professional Integrity

Individual autonomy in the patient is balanced by the complementary concept of respect for professional integrity (Schellinger et al., 2008). Respect for professional integrity requires a medical practitioner to provide treatment, which will balance the good and the harm in that treatment. If the probability of good or benefit is zero, the risk is deemed not justified. Drawn from this thinking, physician-assisted suicides rest on certain justifications. The ethical goals of medical practice include healing and curing disease, promoting health and preventing disease, and relieving suffering from disease symptoms. One justification is when a treatment reasonably predicts that it will not accomplish any of these ethical goals. Another justification is the adherence to high standards of current scientific competence. Using a treatment, which predicted not to work for the patient's good or benefit, deviates from scientific competence. Another is the obligation to present to the patient the likelihood of benefit from a certain treatment. Using what is reasonably futile will make the physician lose professional credibility. And a physician may risk harm to a patient in the process of treatment if the possible benefit outweighs that harm. Futile treatments, such as CPR to a terminal patient, can cause pain and make the physician deliver harm rather than benefit (Schellinger et a.).

Applications of Futility

A treatment is considered physiologically futile when it will not produce the desired result (Schellinger et al., 2008). Treatment may also be considered futile when it requires disproportionate cost to the benefit desired. Or the burden of treatment is perceived as so great by the caregiver as to outweigh the benefit. This is called normative futility, which is confused with physiological futility. Healthcare institutions adhering to a policy of futile interventions should define their exact application of futility and the policy covering it. A policy dealing only with physiologic futility may be defensible. A policy dealing with scarce resources will be defensible only in hospitals with limited resources. But a policy based on normative futility will not be too easy to justify (Schellinger et al.).

Ethical Implications

A 62-year-old man languished at the intensive care unit with an irreversible respiratory disease (Schneiderman et al., 1990). After 3 weeks of unsuccessful attempts to withdraw breathing support, doctors decided that he would not survive outside the intensive care setting. He did not execute a previous directive of his wishes. Some doctors favor a "do-not-resuscitate" order because resuscitation looks futile. The other doctors argue that they cannot invoke medical futility because the patient can survive indefinitely in the intensive care unit. They consult the family, which asks if there is hope for the patient to recover. If there is, then all medical measures, including resuscitation, should be continued (Scheneiderman et al.).

The determination of medical futility confined to the physician's knowledge and experience alone can be subject to abuse (Scheneiderman et al., 1990). It should be derived from quantitative and qualitative reasoning separately. Futility may be quantitatively arrived at if the desired treatment has been useless in the last 100 consecutive cases he handled or observed. This gives him 95% probability that the treatment will not work or that only 3 successes are likely in every 100 similar cases.

Qualitatively, futility may be justified when biologic life is continued but without accompanying conscious autonomy. The patient has no right to invoke sustenance for the sole purpose of mere vegetative survival. Doctors do not feel obliged to offer this option or service. Other qualitative grounds are constant monitoring, breathing support, and intensive care nursing or overwhelming suffering for a foreseen brief duration. Treatment requires extensive and intensive medical treatment, which prohibits achieving any life goals, may be effective but not beneficial. In this case, the patient or his family has no right to demand it (Scheneiderman et al.).

Patients whose severe illnesses require frequent hospitalization or confinement in nursing homes are not prevented from pursuing and achieving life's goals (Scheneiderman et al., 2008). Thus, they possess the right to receive or reject treatments based on the balance between benefit and harm. The ground of medical futility does not apply to these cases (Scheneiderman et al.).

The Right to a Dignified Death

The reported 65% or 329 CPR attempts on 307 terminally ill patients with AIDS, cancer, stroke or sepsis in New York State in 1993 was appalling (Zucker & Zucker, 1997). These attempts equate to shocking indignity towards the dying, their suffering and that of their families, the waste of resources and how the entire effort affect the very view of dying. CPR is a precise example of a life-threatening intervention. It is fairly successful up to 50%. But that success is generally over-estimated by healthcare professionals, especially nurses, and the public. There seems no point when CPR is considered futile and considered useless. Patients have no right to useless or ineffective treatment and interventions. This is more so with other interventions of uncertain benefits (Zucker & Zucker).

The belief that we have a right to a long life is a relatively new idea (Zucker & Zucker, 1999). Recent technical and technological strides not only extend the life span and improve the quality of life. They also prolong the process of dying. Thus, life-prolonging interventions were invented. People today have come to feel uncomfortable in the thought that some patients cannot be saved. These interventions were recent creations of less than a century ago. Before that time, death was not a prolonged event, unlike today. In times past, people valued a patient's comfort and dignity, including his or her death. Increased medical capabilities have separated people from these traditional values concerning the quality of life. What counts now is the quantity or duration of that life (Zucker).

The authors (1999) emphasize every person's right to die if he suffers from some extreme physical condition, which is hopeless to cure (Zucker & Zucker, 1999). He should be allowed to quietly arrive at that decision after a full understanding of his medical condition, the prognosis, and all viable treatment options. Quality of life should be re-emphasized over quantity or longevity.

An Atrocity

Abortion has plagued the entire process of the country (Koop, 1980). Statistics say that more than a million abortions are performed nationwide. Japan records more than 50 million abortions yearly since World War II. But Japan is less than 1% Christian as compared to America, which is predominantly Christian. Both the Old and New Testaments contain passages on the worth of the unborn child from Exodus 21, the Hebrews, the Incarnation and the conception of John the Baptist in the Gospels. Any tampering with the unborn child carries a severe penalty of an eye for an eye and a tooth for a tooth. On the 21st day of life in the womb, the baby's heart begins to weakly beat often before the mother even knows she is pregnant. In the sixth week, the adrenal gland and thyroids begin to function. Fingerprints become indelible by the 12th week. Abortion frequently occurs at this time and it kills an already developing human being without doubt. Regardless of the size or stage of development, termination of pregnancy by any means still involves a birth (Koop).

Informed Consent

A huge movement has been driving the country in favor of informed consent (Koop, 1980). Medical conditions involve counseling between physician and patient on the best treatment. But abortion does not require counseling. Abortion clinics do not inform patients on alternatives. Informed consent terribly upsets pro-abortionists. Although practiced illegally and surreptitiously, infanticide will become legal. Eventually, it will even become mandatory on the ground of eliminating a deformity (Koop).

Medical Futility in Medical/Nursing Practice

The concept of medical futility dates back to the time of Hippocrates who advised physicians to refuse those ailments were medically futile to treat (Truog, 1992). The concept now frequently figures in court decisions and policy statements. The Baby Doe law is an illustration. The Council on Ethical and Judicial Affairs of the American Medical Association declared that physicians are not obliged to obtain patient consent in order to issue a do-not-resuscitate order if a CPR is medically useless to avert death. It now permeates law and policy but it still remains ambiguous in its applications (Truog).

Helga Wanglie

She was an 86-year-old woman from Minnesota who was dependent on mechanical ventilation and in vegetative state for more than a year (Truog et al., 1992). Her doctors declared her treatment as futile and sought a Court order to assign an independent conservator to make medical decisions for her. The Court denied the petition and recognized the authority of the husband as her legal surrogate and decision-maker. Mrs. Wanglie died three days later. Medical futility arises also in cases involving CPR and organ replacement technology. It is current practice to use CPR in all situations unless and until there is a direct DNR order. DNR orders are intended to spare patients from aggressive but useless attempts when death is imminent, anticipated and inevitable. When the patient's family insists on a CPR, the doctor's recourse is a DNR. A DNR does not require consent from the patient or his family. Organ-replacement technology includes interventions intended to prolong life of virtually dying patients. Extracorporeal membrane oxygenation to replace heart and lung function for several weeks is an example. This is used when physicians expect organ systems to recover or while patients await organ transplantation. If all these three interventions become objectively futile, the decision to refuse treatment should become justified (Truog et al.).

Medical Futility and the Nurse

Only physicians can invoke most medical futility policies (Federwisch, 1998).

However, nurses and other clinics are affected by the decision. Quite often, it is the nurse who removes the life support following a decision by the appropriate committee. The nurse's sworn commitment is primarily to the patient. This commitment, however, does not exclude discontinuing or termination non-beneficial care. If she thinks a given care is futile, she should discuss this with the physician. An ethics consult may be resorted to if a resolution does not occur. However, if a medical futility review is underway, all health professionals involved should contribute whatever their opinions. The nurse, or any other heath professional, can withdraw from the care of the particular patient if her conscience cannot agree with the verdict of the authorities (Federwisch).

A Mix of Values

The ideals of medical professionals, particularly nurses, center on respect for the patient's wishes (Truog et al., 1992). However, these ideals include other values, such as compassionate action and the reduction of suffering. To a bedridden patient, who suffered multiple strokes and now suffers from bedsores and a variety of pains at mere touch, life-sustaining interventions may be cruel and inhumane. They also deflect the legitimate use of the knowledge and skills of healthcare professionals attending to him. Surgeons who are repeatedly asked to perform surgeries no longer appropriate will suffer a loss of reputation and sense of purpose (Truog et al.).

Healthcare professionals are not required to participate in care, which goes against their conscience and morals (Truog et al., 1992). However, the law remains uncertain in this arena. In certain instances, courts uphold state interest in protecting the ethical integrity of the medical profession, such as the refusal to perform inhumane or useless treatment despite the patient's wishes. At other times, the courts upheld the decisions made by the patients' surrogates over the professional integrity of the medical profession, as in the cases of Helga Wanglie and Jane Doe of Atlanta (Truog et al.).

Social consensus is still another source of values involved in making medical decisions (Truog et al., 1992). There are deeply set differences in personal values and interests. These cannot be resolved by introducing additional facts or debate. An explicit public process may be needed to make the decision. One area requiring social consensus is the fair allocation of resources. The involvement of society is more particularly involved in crucially sensitive questions of morality, such as medical futility in abortion, infanticide and euthanasia (Truog et al.).

Comparison of Perspectives and Nursing Position

Beauchamp and Childress determine medical futility to render extraordinary means of treatment by balancing their four principles of respect for autonomy, beneficence, nonmalifence and justice. Refusal or withdrawal of treatment should pass the test of all four principles before it can be justified. Marjorie and Howard Zucker believe that a patient's life need not be prolonged. They do not subscribe to the modern notion that long life is quality life. Quality is not quantity in terms of more years. They see dignity as inherent in death as in life. They believe that a patient whose death is imminent and inevitable should be allowed to die with dignity instead of forced to live longer. Everett Koop believes that all life is sacred from the time of fertilization to death and interruption at any point constitutes a violation of that sanctity. He views abortion, infanticide and euthanasia as murders, whatever the intent.

This nursing paper takes the perspective of Everett Koop in acknowledging the sanctity of life at all stages and commits its care to every stage. It takes his view on the continuum of life, deserving respect and total care, regardless of outcomes. It also views the torrential interest in informed consent as an assault to that sanctity of life.