Health Affairs, 24, no. 5 (2005): 1376-1377 doi: 10.1377/hlthaff.24.5.1376 © 2005 by Project HOPE	New Online   Obama's Success & Next Steps   3 Health Policy Options for President Obama   A Hybrid Proposal   Bipartisan Compromise

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Letters

Ethics And Futility

Veatch seems to object that we located seven major hospitals where hospital personnel recognized the potential for an ethics consultation yet claimed that not recommending one was "usual care." We should not need to point out how often "usual care" treatments are found to be useless, or even harmful, when subjected to a randomized controlled trial.

Veatch called the study controversial because "it is hard to imagine how the patients in this study could have given informed consent to take part." Indeed, most of the time, as in any clinical trial involving seriously ill, incapacitated patients, informed consent was obtained from surrogates.

Veatch also objects to "evaluating ethics consultation by...whether it saves hospitals money." Our original, broader study, published in 2003, reported that ethics consultations reduced what we regarded to be nonbeneficial treatments—namely, treatments that failed to enable the patient to survive outside the acute hospital setting (the outcome measure of every published study of cardiopulmonary resuscitation, for example).¹ There was widespread agreement among all parties—patients, surrogates, physicians, and nurses—that ethics consultations had a beneficial effect on patient care. We then analyzed the possible cost savings. Not to have done so, in our view, would have neglected one of the most important areas of health policy today.

Finally, Veatch contrasts "physiological" futility (treatment that cannot produce the outcome the patient is seeking) with "normative" futility (treatment that is likely to achieve the patient’s goal although the clinician considers the goal valueless) as though only the latter is a "value judgment." We submit that limiting the definition of medical futility to physiological rather than patient-centered outcomes is a value choice, not a value-free action. We agree that although many hospitals are adopting futility policies that oppose continuing life support on permanently unconscious patients such as Terri Schiavo, some hospitals might advocate maintaining life support for such patients. In our pluralistic society, which accepts that certain hospitals will not perform abortions, this would constitute a "respectable minority" standard of care.² If these latter hospitals would be willing to accept the transfer of permanently unconscious patients on life support, disputes over end-of-life treatments could be resolved without court intervention. So it is puzzling that Veatch considers "dangerous" the Texas law that carefully outlines steps to take in disputes over medical futility—including transferring patients—and then says that such decisions are "the moral responsibility of society or its agents administering health programs." The law was put in place after due deliberation by the Texas legislature. Is this not what Veatch means?

Lawrence Schneiderman and Todd Gilmer

NOTES

1. L.J. Schneiderman et al., "Effect of Ethics Consultations on Nonbeneficial Life-Sustaining Treatments in the Intensive Care Setting: A Randomized Controlled Trial," Journal of the American Medical Association 290, no. 9 (2003): 1166–1172[Abstract/Free Full Text]; and L.J. Schneiderman and N.S. Jecker, Wrong Medicine: Doctors, Patients, and Futile Treatment (Baltimore: Johns Hopkins University Press, 1995).
2. L.J. Schneiderman and A.M. Capron, "How Can Hospital Futility Policies Contribute to Establishing Standards of Practice?" Cambridge Quarterly of Healthcare Ethics 9, no. 4 (2000): 524–531.[CrossRef][ISI][Medline]

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