BIOETHICS CASE: "Futile" Medicine: Can Doctors Withhold Treatment?

Though the controversies surrounding Dr. Kervorkian and assisted suicide have receded from the headlines, we continue to discuss the rights of individuals to end their own lives and the role of physicians in serving patients. In general, we have established that patients have "rights" to direct their own care—and some-times to discontinue care, if they so choose. The assisted suicide issue sparks debate for two further reasons, though. First, we tend to distinguish between omission and comission: some do not regard lack of treatment as "causing" death, even if we are certain it will precipitate death. The other contested issue is the role of the doctor and the meanings of care, compassion and respect for life. These questions are even more keenly profiled in cases of medical futility.

Consider the converse situation. A doctor feels that there is nothing more that can be done for a patient. Can the physician decide to discontinue treatment? At first, this may seem like blatant abandonment of professional duties. However, the doctor may be trying to respect the patient by not contributing to further pain or struggle and to respect the family by not raising false hopes. One may also consider the distribution of scarce medical resources (important due to our limited world): will the same investment of time and equipment have greater value elsewhere? Will further deteriora-tion of the body preclude the patient's option for donating organs for transplant, often valued as a final life-giving act?

Suppose you are the physician in the following scenario [based on a real case]:

Your patient is a 29-year-old-male, married, with two young children. You have been treating him for several years and in the past 6 years, he has had a stroke, a heart attack and liver trouble—as though he were in his sixties. The condition cannot be traced to any definable disease or known genetic condition but suggests rapid aging. Now he is..... Of course, you would like this man's life to be otherwise, but you feel there is nothing more medically you can do. You inform the wife and family. The wife concurs that further treatment may not be warranted and trusts your judgment, while the parents and siblings are adamant about using all life-preserving measures. What do you do?

Similar decisions occur when a child is born with anencephaly, or a burn victim has 80% burns. No doctor imagines full recovery.

Decisions about "chances of survival" are hardly ever absolute. Past cases yield only probabilities. What odds count as sufficiently poor: one in a thousand, one in a million? Decisions also involve judgment about whether any further treatment is worthwhile, not just whether it is effective. Can biases enter? If so, can safeguards balance them?

Fundamentally, is a doctor always to advocate life and life-promoting measures, even in extreme cases? Or does her role also include knowledge and a degree of "honesty"— in a sense, knowing enough to admit when further treatment will not benefit a patient? Do we know how to acknowledge such cases gracefully, even if sadly? Does a doctor have a "right" to withhold treatment even when a patient or family urge "all heroic measures"?

[Two aspects of futility deserve special mention: inability to restore consciousness and inability to sustain life without technological support (such as is provided only by an intensive care unit, or ICU).]

Cases of futility highlight the challenge of knowing how to "let go" at the end of life—and perhaps reflect our failure to include death as an appropriate topic in "life" science classes.

Further Reading