Asking the courts to set the standard of emergency care--the case of Baby K

Secular Clinical Ethicists Should Not Be Neutral Toward All Religious Beliefs: An Argument for a Moral-Metaphysical Proceduralism

Secular clinical ethics has responded to the problem of moral pluralism with a procedural approach. However, defining this term stirs debate: H. Tristram Engelhardt Jr. has championed a contentless proceduralism (P1), while others, conversely, argue for a proceduralism that permits some content in the form of moral claims (P2). This paper argues that the content P2 permits ought to be expanded to include some metaphysical commitments, in an approach referred to as P2+. The need for P2+ is demonstrated by analyzing and rejecting three standards (the best interest or harm principle, internal reasonability, and the child's right to an open future) used by P2 to justify overriding religiously motivated refusals of treatment for children. These approaches fail because each maintains a neutral stance regarding the truth of religious belief. This paper drives at the broader thesis that the proceduralism of secular clinical ethics requires some moral and metaphysical commitments.

Compassion and mercy are not helpful in resolving intractable family-physician conflicts on end-of-life care

"Compassion and mercy" are important values for humanizing medicine. There are limits, however, in their ability to help resolve disputes between physicians and families regarding appropriate end-of-life care. The recent cases of Charlie Gard and Alfie Evans in England highlight the issue. The English courts resolve such conflicts by an independent assessment of a court. The American judicial system does not share the centralized system of the English courts. In the United States Federal structure some 50 state legislatures and 50 state court systems go their separate ways. The result is differing, frequently conflicting, standards. We explore possible ways to avoid court involvement in the American context for resolving such disputes within the patient-physician relationship.

Ideology and Palliative Care: Moral Hazards at the Bedside

Palliative care has had a long-standing commitment to teaching medical students and other medical professionals about pain management, communication, supporting patients in their decisions, and providing compassionate end-of-life care. Palliative care programs also have a critical role in helping patients understand medical conditions, and in supporting them in dealing with pain, fear of dying, and the experiences of the terminal phase of their lives. We applaud their efforts to provide that critical training and fully support their continued important work in meeting the needs of patients and families. Although we appreciate the contributions of palliative care services, we have noted a problem involving some palliative care professionals' attitudes, methods of decisionmaking, and use of language. In this article we explain these problems by discussing two cases that we encountered.

Moral Hazard in Pediatrics

"Moral hazard" is a term familiar in economics and business ethics that illuminates why rational parties sometimes choose decisions with bad moral outcomes without necessarily intending to behave selfishly or immorally. The term is not generally used in medical ethics. Decision makers such as parents and physicians generally do not use the concept or the word in evaluating ethical dilemmas. They may not even be aware of the precise nature of the moral hazard problem they are experiencing, beyond a general concern for the patient's seemingly excessive burden. This article brings the language and logic of moral hazard to pediatrics. The concept reminds us that decision makers in this context are often not the primary party affected by their decisions. It appraises the full scope of risk at issue when decision makers decide on behalf of others and leads us to separate, respect, and prioritize the interests of affected parties.

Living in hope and desperate for a miracle: NICU nurses perceptions of parental anguish

The birth of an extremely premature baby is a tragedy, and it is only natural that the parents will rely on the spiritual and religious beliefs that guide the rest of their lives. At this difficult time, parents with strong religious beliefs will hope for divine intervention and pray for a miracle. This paper outlines the difficulties experienced by neonatal nurses when caring for an extremely premature baby whose parents hold on to hope and their belief in divine intervention and a miracle. Data were collected via a questionnaire to Australian neonatal nurses and semi-structured interviews with 24 neonatal nurses in NSW, Australia. A qualitative approach was used to analyse the data. The theme of "hoping for a miracle" was captured by two sub-themes "praying for a miracle" and "oscillating between hope and despair". For some families, the hope of divine intervention seemed all consuming, and the nurses were witness to the desperation and disappointment of families when a miracle was not forthcoming.

Position of the academy of nutrition and dietetics: ethical and legal issues in feeding and hydration

It is the position of the Academy of Nutrition and Dietetics that individuals have the right to request or refuse nutrition and hydration as medical treatment. Registered dietitians (RDs) should work collaboratively as part of the interprofessional team to make recommendations on providing, withdrawing, or withholding nutrition and hydration in individual cases and serve as active members of institutional ethics committees. RDs have an active role in determining the nutrition and hydration requirements for individuals throughout the life span. When individuals choose to forgo any type of nutrition and hydration (natural or artificial), or when individuals lack decision-making capacity and others must decide whether or not to provide artificial nutrition and hydration, RDs have a professional role in the ethical deliberation around those decisions. Across the life span, there are multiple instances when nutrition and hydration issues create ethical dilemmas. There is strong clinical, ethical, and legal support both for and against the administration of food and water when issues arise regarding what is or is not wanted by the individual and what is or is not warranted by empirical clinical evidence. When a conflict arises, the decision requires ethical deliberation. RDs' understanding of nutrition and hydration within the context of nutritional requirements and cultural, social, psychological, and spiritual needs provide an essential basis for ethical deliberation. RDs, as health care team members, have the responsibility to promote use of advanced directives. RDs promote the rights of the individual and help the health care team implement appropriate therapy. This paper supports the "Practice Paper of the Academy of Nutrition and Dietetics: Ethical and Legal Issues of Feeding and Hydration" published on the Academy website at: www.eatright.org/positions.

The History of Ethical Decision Making in Neonatal Intensive Care

Neonatal ethics has focused on 2 questions: is withholding potentially live-saving treatment from neonates ethically justified? and if so, who has the authority to decide? This article details how these questions developed and provides a description of the possible answers. In the first section, we review a selection of seminal articles by noted authors in the fields of ethics, medicine, and law. The second section provides a detailed account of the development of the Baby Doe Regulations and the impact they had on neonatal ethics, with particular attention to the emergence of the Best Interest Standard as a guideline for decision making. In the last section, we review the landmark position statements by the American Academy of Pediatric (AAP), and the focus on evidence-based decision making. We conclude that forgoing life-saving treatment is ethically justified. However, this requires a rigorous evidence-based process and is limited by the Best Interest Standard. The second question is more difficult to answer, but we feel that in light of legal limitations, physicians acting as both the infant advocate and a proxy for the state, decide what falls in the range of acceptable treatment options, with the parents free to choose within that range.

Moral distress in pediatric palliative care: a case study

End-of-life decisions for children can be complicated by disagreements between families and health care teams. These conflicts can lead to moral distress in providers. In addition, difficulties in prognostication aggravate the problem. How teams and institutions address potential staff distress is essential to providing effective palliative care for children. Through a case study of a child with a severe life-limiting syndrome, an analysis of both the ethical and legal implications of parental and team conflict are discussed. An ethics team can help provide guidance for teams and help mediate goals of care discussions with families. Palliative care consultation can also be useful, especially in providing support for both the parent and the child.

New and lingering controversies in pediatric end-of-life care

OBJECTIVES

Professional societies, ethics institutes, and the courts have recommended principles to guide the care of children with life-threatening conditions; however, little is known about the degree to which pediatric care providers are aware of or in agreement with these guidelines. The study's objectives were to determine the extent to which physicians and nurses in critical care, hematology/oncology, and other subspecialties are in agreement with one another and with widely published ethical recommendations regarding the withholding and withdrawing of life support, the provision of adequate analgesia, and the role of parents in end-of-life decision-making.

METHODS

Three children's hospitals and 4 general hospitals with PICUs in eastern, southwestern, and southern parts of the United States were surveyed. This population-based sample was composed of attending physicians, house officers, and nurses who cared for children (age: 1 month to 18 years) with life-threatening conditions in PICUs or in medical, surgical, or hematology/oncology units, floors, or departments. Main outcome measures included concerns of conscience, knowledge and beliefs, awareness of published guidelines, and agreement or disagreement with guidelines.

RESULTS

A total of 781 clinicians were sampled, including 209 attending physicians, 116 house officers, and 456 nurses. The overall response rate was 64%. Fifty-four percent of house officers and substantial proportions of attending physicians and nurses reported, "At times, I have acted against my conscience in providing treatment to children in my care." For example, 38% of critical care attending physicians and 25% of hematology/oncology attending physicians expressed these concerns, whereas 48% of critical care nurses and 38% of hematology/oncology nurses did so. Across specialties, approximately 20 times as many nurses, 15 times as many house officers, and 10 times as many attending physicians agreed with the statement, "Sometimes I feel we are saving children who should not be saved," as agreed with the statement, "Sometimes I feel we give up on children too soon." However, hematology/oncology attending physicians (31%) were less likely than critical care (56%) and other subspecialty (66%) attending physicians to report, "Sometimes I feel the treatments I offer children are overly burdensome." Many respondents held views that diverged widely from published recommendations. Despite a lack of awareness of key guidelines, across subspecialties the vast majority of attending physicians (range: 92-98%, depending on specialty) and nurses (range: 83-85%) rated themselves as somewhat to very knowledgeable regarding ethical issues.

CONCLUSIONS

There is a need for more hospital-based ethics education and more interdisciplinary and cross-subspecialty discussion of inherently complex and stressful pediatric end-of-life cases. Education should focus on establishing appropriate goals of care, as well as on pain management, medically supplied nutrition and hydration, and the appropriate use of paralytic agents. More research is needed on clinicians' regard for the dead-donor rule.

A new model of medical decisions: exploring the limits of shared decision making

This article proposes a model of medical decisions based on 2 fundamental characteristics of each decision--importance and certainty. Importance reflects a combination of objective and subjective factors; certainty is present if 1 intervention is superior and absent if 2 or more interventions are approximately equal. The proposed model uses these characteristics to predict who will have decisional priority for any given decision and shows how one class of decisions lends itself particularly well to shared decision making. Three other types of decisions are less well suited to a collaborative decision: 1) For major choices that have low certainty, patients should be encouraged to be the primary decision makers, with physician assistance as needed. 2) Most minor decisions that have high certainty are expected to be made by physicians. 3) Major decisions that have high certainty are likely to cause serious conflict when patients and physicians disagree.

Fetal anomalies: ethical and legal considerations in screening, detection, and management

A number of ethical considerations arise with regard to screening for, detecting, and managing fetal anomalies. Some of these considerations involve the need to give attention to emotional distress the pregnant woman might be experiencing. The ethical principle of beneficence gives rise to a duty of the obstetrician to provide emotional support when needed in relation to screening, confirmatory testing, giving bad news, making abortion decisions, making management decisions after viability, and dealing with the grieving process. Other issues involve ethical decision-making, such as deciding what recommendations to make concerning management of fetal anomalies after viability. The ethical principle of autonomy creates a duty of the obstetrician to help the pregnant woman make informed management decisions based on her values and goals. A recommendation for a particular approach to management is sometimes ethically justifiable on the basis of an analysis of the risks and benefits to the mother and fetus. Legal considerations are relevant because they create requirements or prohibitions that must be taken into account in ethical decision-making. The discussion in this article does not exhaust the range of issues that arise. For example, sometimes a delivery procedure is considered that is traumatic to the fetus, such as cephalocentesis for vaginal delivery of a fetus with hydrocephaly. The reader is referred to other sources for a discussion of the ethics of delivery procedures that might injure or kill the fetus. Other issues involve deciding when there is a duty to offer new prenatal genetic tests, routinely or for high-risk couples, and whether to carry out maternal requests for prenatal tests for late-onset diseases and susceptibilities to diseases. These issues have been discussed elsewhere.

Finding a way through the hospital door: the role of EMTALA in public health emergencies

This article examines the Emergency Medical Treatment and Labor Act (EMTALA) in a public health emergency context. Congress enacted EMTALA in 1986 to prohibit the practice of “patient clumping,” which involved hospitals’ refusal to undertake emergency screening and stabilization services for individual patients who sought emergency room care, typically because of insurance status, inability to pay, or other grounds unrelated to the patient’s need for the services or the hospital’s ability to provide them. But in fact EMTALA, whose conceptual roots can be found in the Hospital Survey and Construction Act of 1946 (Hill Burton) as well as an evolution in both the common law and state statutes related to hospital licensure, can be viewed as having a far broader purpose than protection of individuals, and indeed, one that is related to the protection of communities and the public health.

Life-sustaining support: ethical, cultural, and spiritual conflicts. Part II: Staff support--a neonatal case study

As medical knowledge and technology continue to increase, so will the ability to provide life-sustaining support to patients who otherwise would not survive. Along with these advances comes the responsibility of not only meeting the clinical needs of our patients, but also of understanding how the family's culture and spirituality will affect their perception of the situation and their decision-making process. As the U.S. continues to become a more culturally diverse society, health care professionals will need to make changes in their practice to meet the psychosocial needs of their patients and respect their treatment decisions. Part I of this series (April 2002) discussed how the cultural and spiritual belief systems of Baby S's family affected their decision-making processes and also their ability to cope with the impending death of their infant. The development of a culturally competent health care team can help bridge the gap between culturally diverse individuals. This article addresses the following questions: 1. What legal alternatives are available to the staff to protect the patient from suffering associated with the continuation of futile life-sustaining support? 2. What conflicts might the staff experience as a result of the continuation of futile life-sustaining support? 3. What efforts can be made to support members of the staff? 4. What can be done to prepare others in the health care professions to deal more effectively with ethical/cultural issues?

Fear of litigation may increase resuscitation of infants born near the limits of viability

OBJECTIVES

To explore how fear of litigation influences neonatal treatment decisions.

STUDY DESIGN

In a mailed survey, we presented a hypothetical vignette of a premature infant to 1000 neonatologists. We asked them to estimate prognosis, indicate appropriate intervention, and respond to parental treatment requests. Subjects were randomly assigned to receive one of two questionnaires, "litigious" or "nonlitigious," which differed only in the description of the infant's parents.

RESULTS

The response rate was 63.0%. The vast majority of respondents deferred to parental requests rather than adhering to their best judgment. They deferred whether or not parents requested treatment and whether or not parents were described as litigious (P <.0001). Among those respondents who shifted their resuscitation opinion after parental introduction, respondents to the nonlitigious version were more likely to shift their opinion from "treat" to "do not treat" after parental requests to "use your best judgment" (P <.042). The influence of parental litigiousness was primarily seen among neonatologists who thought that the infant's prognosis was dismal (P <.044).

CONCLUSIONS

There is a strong disposition among neonatologists toward respecting parental wishes. This disposition is stronger when neonatologists are given additional reason to be concerned about litigation.

Position of the American Dietetic Association: ethical and legal issues in nutrition, hydration, and feeding

It is the position of the American Dietetic Association that the development of clinical and ethical criteria for the nutrition and hydration of persons through the life span should be established by members of the health care team. Registered dietitians should work collaboratively to make nutrition, hydration, and feeding recommendations in individual cases. Registered dietitians have an active role in determining the nutrition and hydration requirements for individuals throughout the life span. When patients choose to forgo artificial nutrition and hydration, or when patients lack decision-making capacity, and others must decide whether or not to provide artificial nutrition and hydration, the registered dietitian has an active and responsible professional role in the ethical deliberation around that decision. There is strong clinical, ethical, and legal support both for and against the administration of food and water when issues arise regarding what is or is not wanted by the patient and what is or is not warranted by empirical clinical evidence. When a conflict arises, the decision to administer or withhold nutrition and hydration requires ethical deliberation. The registered dietitian's understanding of nutrition and hydration within the context of nutritional requirements and cultural, social, psychological, and spiritual needs provides an essential basis for ethical deliberation on issues of nutrition and hydration.

Life-sustaining support: ethical, cultural, and spiritual conflicts part I: Family support--a neonatal case study

As medical knowledge and technology continue to increase, so will types of life-sustaining support as well as the public's expectations for use of this support with positive outcomes. Health care professionals will continue to be challenged by the issues surrounding the appropriate use of life-sustaining support and the issues it raises. This is especially apparent in the NICU. When parents' belief systems challenge the health care team's ethical commitment to beneficence and nonmaleficence, a shared decision-making model based on mutual understanding of and respect for different viewpoints can redirect the focus onto the baby's best interest. This article addresses three questions: 1. How do nonmaleficence, beneficence, and concern about quality of life guide the use of life-sustaining support? 2. To what extent should parental autonomy and spirituality influence treatment decisions? 3. What efforts can the health care team make to support the family?

Ethical and legal issues in palliative care

This article reviews the ethical principles underlying palliative care, stressing the importance of respecting patient's rights to withdraw or withhold life-sustaining treatment, including artificial hydration and nutrition. There is no ethical or constitutional right to receive physician-assisted suicide or voluntary active euthanasia. This article discusses current ethical controversies in palliative care, including futility, medication dosage and double-effect, terminal sedation, legalization of physician-assisted suicide and euthanasia, and patient refusal of hydration and nutrition. Relevant legal issues are discussed in tandem with the ethical issues.

When health means wealth, can bioethicists respond?

Around the world the wealthy can get their lives extended while the poor get little basic medical help. Over the same years that the field of bioethics has prospered and expanded, this disparity has increased. Reasons for the failure of bioethics to successfully address this health/wealth issue include its identification with the cognitive and social authority of medicine; its gatekeeping behavior; its funding sources; its questionable use of "principlism" and its emphasis on crises and dilemmas to the neglect of "housekeeping" issues. The work of most women in bioethics rarely addresses the health/wealth issue; if it does, their work may be ignored, as were the recommendations of Canadian feminists working under government grants. To achieve equity in health care, the structure of both medicine and bioethics needs to be changed. Yet, since bioethicists generally have accepted the status quo, this seems unlikely to happen.

Antenatal counselling, resuscitation practices and attitudes among Australian neonatologists towards life support in extreme prematurity

A questionnaire survey of Australian neonatologists was conducted to ascertain their antenatal counselling and resuscitation practices, and attitudes towards life support in the extremely preterm infant. This study showed that in antenatal parental counselling, whether a paediatrician was given the opportunity to participate depends on the gestation at the time of the threatened preterm delivery The counselling employed almost invariably covered mortality and morbidity. The obstetrician's opinion was considered to be of utmost importance. Both financial and moral obligations were found to be of little importance in counselling and resuscitation. Only one-third of institutions had guidelines for limiting resuscitation. The onus remained on the neonatologists concerning which infant to resuscitate, and the level of the resuscitation to be conducted. In Australia, resuscitation at birth was restricted to infants of 23 weeks' gestation or above, and neonatologists did not believe the legal system has a role to play in limiting or mandating resuscitation of extremely preterm infants. Neither were they concerned with the threat of litigation when they decide to limit resuscitation. The majority of neonatologists agreed with their institution's approach to life support in extremely preterm infants. One grey area was the question of withholding assisted feeding in an infant for which the decision to withdraw life support has been made. Australia lacked a current consensus policy on selective non-treatment. The establishment of national guidelines would be helpful to aid Australian obstetricians and neonatologists in their clinical practice.

A critical review of cost reduction in neonatal intensive care. II. Strategies for reduction

Neonatal intensive care is extremely expensive; there is both a financial and an ethical obligation to practice efficiently. In the current era of intense cost containment in hospital care, neonatologists and hospital administrators are under pressure to find strategies for cost reduction for neonatal services. In this review, we address reducing discretionary admissions, the high costs of low-cost testing, minimizing use of selected high-cost technologies (ventilators and parenteral nutrition), shortening length of stay, and optimizing nursing allocation.

Ethical issues in treating infants with very low birth weight

The purpose of this report is to provide pediatric surgeons with an ethical framework and a process for ethical decision making that can be applied to the difficult issues that arise in the care of infants with very low birth weight (VLBW). Clinical ethical issues focus around choices for surgical intervention, the use of total parenteral nutrition (TPN), recommendations for bowel transplantation, and management of dying infants. The role of family in decision making and the appropriate use of common distinctions including active or passive, withholding or withdrawing, and ordinary or extraordinary in decisions about life-sustaining treatments are discussed. A clinical case discussion illustrates the application of the process for ethical decision making.

Avoiding family feuds: responding to surrogate demands for life-sustaining interventions

The laws and ethical guidelines governing decision making for incompetent patients evolved from controversies in which family members refused life-sustaining interventions. These cases led to a consensus that advance directives to limit interventions should be respected and that a surrogate designated by the patient or specified by statute could refuse interventions, even when other relatives disagreed. Surrogate decision-making statutes and ethical principles about respect for delegated autonomy promote an active role for family members or other surrogates in medical decisions for incompetent patients. Inviting surrogates to participate actively in medical decisions recognizes the importance of the patient's personal community and assures that decisions will reflect the patient's own preferences and values.

The standard approach to decisions for incompetent adults gives advance directives priority over a surrogate's substituted judgment, which in turn has priority over assessments of the patient's best interest. A patient may express advance directives by appointing a proxy, stating specific preferences, or articulating general values. We use case examples to illustrate the limitations of all three types of advance directives.

Futility considerations in the neonatal intensive care unit

The purpose of this article is to summarize and comment on the history of medical decision making in the neonatal intensive care nursery, emphasizing considerations of futility. Several epochs will be described, with shifting roles of health care providers, the infant's family, and proxies for society at large. Futility has been an issue in the intensive care of newborn infants throughout the last 35 years. Long before the Baby Doe regulations and the formation of ethics committees, neonatologists tried to determine which care measures were indicated. Given the frequency of severe malformations, birth asphyxia, and extreme prematurity, it has been a common event for the responsible physician to ask himself: will this treatment be beneficial or merely futile? As the therapeutic armamentarium became more powerful and complex, the choices from among a possible array of interventions became increasingly difficult. The autonomy of parents as decision makers was increasingly affirmed. In the 1980s, the federal government, the courts, and frequent malpractice suits set boundaries on medical decision making. In the 1990s, third party payors became increasingly assertive in limiting resource expenditure. These legal and societal mandates are frequently at variance with one another. Thus the issue of medical futility, as it applies to neonates in the United States, must be considered unresolved.

When do health care decisions discriminate against persons with disabilities?

Recent interpretations of laws prohibiting discrimination against persons with disabilities indicate that these laws will play a greater role in health care decision making than previously anticipated. This article employs lessons from other areas of antidiscrimination law to examine these developments and to provide a framework for making health care decisions that are consistent with these new legal interpretations. This article addresses decisions in individual cases, treatment policies adopted by health care providers, and coverage programs of third-party payers, both public and private.

Ethical and legal issues in intensive care

The findings of the SUPPORT study, the largest, most comprehensive and costly study ever undertaken on decision making for critically ill patients, revealed a wide ranging gap between patient preferences and physician behavior with regard to treatment decisions for seriously ill patients. The ethical issues raised by that disparity are intensified as we enter into a market-driven managed care delivery system. This essay explores recent ethical and legal developments on several emerging issues: the decision making process; DNR orders; brain death; withdrawal of treatment; physician assisted suicide; and the constraints of managed care.

Discontinuing dialysis in persistent vegetative state: the roles of autonomy, community, and professional moral agency

This report proposes a policy for discontinuing dialysis in persistent vegetative state (PVS) patients and attempts to address autonomy and community-based values while maintaining professional moral agency. It is recommended that the policy be adopted at a regional level (eg, the ESRD Network). The involved physicians and ethicists would communicate with the next-of-kin and surrogate decision-makers, and the local ethics committee would perform a double review of the case to assure the appropriateness of the policy to the case. Given the unique nature of PVS with its permanent loss of consciousness and autonomy, we hold that a community-based consensus can form a guideline that limits futile dialysis while respecting patient and professional moral agency. Prior consent of dialysis patients to the regional policy at a time shortly after initiating dialysis will add to its ethical impetus.

Quality control for hospitals' clinical ethics services: proposed standards

Hospital ethics committees have become widespread over the last 25 years, stimulated by the Quinlan decision of the New Jersey Supreme Court, the report of a President's Commission, and most recently by the Joint Commission on Accreditation of Health Care Organizations (JCAHO), which now man dates that each hospital seeking accreditation have a functioning process for the consideration of ethical issues in patient care. Laws and regulations in several states require that hospitals establish ethics committees, and some states stipulate that certain types of cases and disputes be taken to such committees. At least one state grants legal immunity to those who implement recommendations of an ethics committee.

Consensus statement of the Society of Critical Care Medicine's Ethics Committee regarding futile and other possibly inadvisable treatments

OBJECTIVES

Society must always face the reality of limited medical resources and must find mechanisms for distributing these resources fairly and efficiently. One recent approach for distributing limited medical resources has been the development of policies that limit the availability of futile treatments. The objectives of this consensus statement are as follows: a) to define futility and thereby enable a clear discussion of the issues; and b) to identify principles and procedures for resolving cases in which life-sustaining treatment may be futile or inadvisable.

DATA SOURCES

A literature review, synthesis, and committee discussion.

CONCLUSIONS

Treatments should be defined as futile only when they will not accomplish their intended goal. Treatments that are extremely unlikely to be beneficial, are extremely costly, or are of uncertain benefit may be considered inappropriate and hence inadvisable, but should not be labeled futile. Futile treatments constitute a small fraction of medical care. Thus, employing the concept of futile care in decision-making will not primarily contribute to a reduction in resource use. Nonetheless, communities have a legitimate interest in allocating medical resources by limiting inadvisable treatments. Communities should seek to do so using a rationale that is explicit, equitable, and democratic; that does not disadvantage the disabled, poor, or uninsured; and that recognizes the diversity of individual values and goals. Policies to limit inadvisable treatment should have the following characteristics: a) be disclosed in the public record; b) reflect moral values acceptable to the community; c) not be based exclusively on prognostic scoring systems; d) articulate appellate mechanisms; and e) be recognized by the courts. Healthcare organizations that control payment have a profound influence on treatment decisions and should formally address criteria for determining when treatments are inadvisable and should share accountability for those decisions.

Ethically justified, clinically comprehensive guidelines for percutaneous endoscopic gastrostomy tube placement

Guidelines for the placement of percutaneous endoscopic gastrostomy (PEG) tubes are not available. We developed a decision-making algorithm by integrating the medical and ethical dimensions of the decision. According to our algorithm, physicians should not offer PEG tubes to patients with anorexia-cachexia syndromes. For patients with permanent vegetative states, physicians should offer and recommend against the procedure. For patients who have dysphagia without other deficits in quality of life, physicians should offer and recommend the procedure. For the the remaining patients who have dysphagia with other deficits in quality of life, the physician's role is to provide non-directive counselling regarding the short and long-term consequences of a trial of PEG tube feeding.

Is the patient's right to die evolving into a duty to die?: Medical decision making and ethical evaluations in health care

When patient or family requests for continued life-sustaining treatments conflict with doctor recommendations, different conclusions as to what is beneficial for the patient may arise. Past practices usually accepted patient or family requests based on the principle of autonomy or that the doctor's primary responsibility is to the individual patient. Many patients die in intensive care units after doctors forego life-prolonging interventions. Health care changes and cost containment have led to a change in the classical ethical model of the patient-doctor relationship such that concerns for societal requirements increasingly overrule those for individual patient needs. The ability to keep patients alive with little likelihood of recovery and the recognition of escalating health costs have led to calls for the needs of society and distributive justice to be taken into account. A tendency to justify a duty to die for these patients has arisen. Recent legal decisions in cases with conflicts between families and health care providers and institutions over foregoing life-sustaining therapies have decided for the families against doctors and hospitals, compelling institutions and their staff to act contrary to their ethical views. Value judgments of doctors are sometimes confused with medical indications for therapy. Doctors have defined therapies as futile or non-beneficial based on their own values and even withdrawn life-sustaining treatments without patient or family input. In some cases, the right to die is leading to the duty to die even against patient or surrogate wishes. Such observations indicate the need for rigorous analyses of medical decision making in this context and for ethical evaluations in health care in general.

The Baby K case: a search for the elusive standard of medical care

An anencephalic infant, who came to be known as Baby K, was born at Fairfax Hospial in Falls Church, Virginia, on October 13, 1992. From, the moment of birth and repeatedly thereafter, the baby's mother insisted that aggressive measures be pursued, including cardiopulmonary resuscitation and ventilator support, to keep the baby alive as long as possible. The physicians complied. However, following the baby's second admission for respiratory failure, the hospital sought declaratory relief from the court permitting it to forgo emergency life support on the grounds that “a requirement to provide respiratory assistance would exceed the prevailing standard of medical care,” and that “because any treatment of their condition is futile, the prevailing standard of medical care for infants with anencephaly is to provide warmth, nutrition, and hydration.” The United States Court of Appeals for the Fourth Circuit ruled in favor of the baby's mother, citing the federal Emergency Medical Treatment and Active Labor Act (popularly known as the “anti-dumping” act), which contained no “standard of care” exception to the requirement to provide “treatment necessary to prevent the material deterioration of the individual's condition.” An appeal to the United States Supreme Court was rejected. The baby died some two and one-half years later of cardiac arrest during her sixth visit to the emergency department of Fairfax Hospital for respiratory failure.

Resource consumption and the extent of futile care among patients in a pediatric intensive care unit setting

OBJECTIVES

To estimate resource consumption and the extent of futile care among patients admitted to the pediatric intensive care unit (PICU).

STUDY DESIGN

A prospective cohort study of 353 consecutive admissions followed for 1334 patient-days during the PICU stay at the Texas Children's Hospital in Houston, Texas. Participants were 353 children and adolescents who were hospitalized in the PICU during September and October 1993. Three broad operational definitions of futility were developed to capture the maximum extent of resource consumption related to medical futility. Definition 1 (imminent demise futility) was developed by an objective, validated, severity of illness measure (Pediatric Risk of Mortality Score) to identify patients with high mortality risks. Definition 2 (lethal condition futility) was used to identify patients in the PICU whose long-term survival was unlikely. Definition 3 (qualitative futility) was used to identify patients with high morbidity. Resource consumption was measured according to the number of patient-days in the PICU and the Therapeutic Intervention Scoring System.

RESULTS

Twenty-three (6.5%) patients representing 36 (2.7%) patient-days met at least one of the definitions of medical futility for some of the days when they were in the PICU. None of the patient-days that met any of the definitions of medical futility were associated with high resource consumption compared with non-futile care patient-days.

CONCLUSIONS

Despite our use of broad definitions of medical futility, relatively small amounts of resources were used in futile PICU care. This suggests that attempts to reduce resource consumption in the PICU by focusing on medical futility are unlikely to be successful.

Withdrawal from dialysis: the role of autonomy and community-based values

By examining the ethical features of dialysis withdrawal as well as tr transcultural differences in attitudes toward withdrawal, one can have a better understanding of the role of autonomy and community-based values on medical decision-making. Three distinctive patterns of withdrawal are described herein. The first concerns patients suffering from an advanced state of physical or mental decline. When a patient or health care surrogate decision maker requests cessation of therapy because it fails to be beneficial for the patient in his or her totality, the physician should be prepared to cooperate, in accord with beneficence and nonmaleficence as well as autonomy. The second pattern occurs when the patient loses decisional capacity, and the surrogate decision maker makes unreasonable requests for nonbeneficial care. At issue is what constitutes nonmaleficence and beneficence in this setting, the provider and surrogate differing on whether continuing dialysis constitutes beneficence. Such a dilemma can alleviated by community-based consensus guidelines with consent of the patient before losing capacity. The dialysis network is potentially a unit of patient and professional community. In third pattern, the patient's decision to withdraw appears to be inappropriate to their potential for benefit from continued therapy. The nephrologist and patient are conflicted on what constitutes beneficence, with the former holding that continuation is morally superior. In such cases, the physician must mediate the situation in a beneficent fashion not solely dictated by a constraining view of patient autonomy.

Medical futility

Recent discussions about futility have been useful in elucidating health professionals' responsibility to communicate, to establish trust, and to collaborate with patients and families about end-of-life decisions. They have highlighted the often impersonal and fragmented care that patients receive in today's large medical centers. Futility also has been a stalking horse for the much more important and problematic issue of rationing. The latter must be discussed on its own merits, however painful that may be.