Ventilation and Medical Futility


Ethical Questions to Consider

Without signed medical directive documents, the decision-making power is taken out of the family’s hands, and is left legally to the doctors in charge. The doctor’s personal values, religious beliefs, and judgments—and in most states, regardless of the family’s beliefs and values for the loved one—legally overrides the wishes of the sick person’s family.

As much as bioethicists wish for it, brain death is not as certain as they would like. The difficult end-of-life ethical debates and issues require much careful thought and deliberation.  Canadian ethicist Dr. Robert Butcher discusses ethical decision-making in his ethical argument on behalf of a brain injured ALS patient.

Let’s apply his ethical argument to that of the deep coma brain injured patient, should a critical event happen which leads to deep irreversible coma. Dr. Butcher argues that “one can be confident that in most cases, all medical efforts will be made to save the patient’s life,” regardless of whether they are an organ donor or not, until a judgment is made regarding medical or personal futility.

The ethical question in medicine is always, what should we do in this particular circumstance? Dr. Butcher notes that “this is the one area where the futility debate gets confused.”  He points out that in the ethics debate regarding medical futility one need only ask:  “Is it futile?”

Below is a sample exchange between doctors and a family of a potentially brain dead patient regarding whether the patient should be placed on a ventilator.

[Doctor] “Well yes, it’s futile. It won’t cure his deep irreversible coma.”

[Family] “OK, but will it keep him alive?”

[Doctor] “Oh yes, it will keep him alive.”

As stated by Dr. Butcher, “the ventilator- mechanical life support will do just what it was developed to do. It will keep the patient alive.”  Therefore, ventilation is not medically futile. This is an exchange you should have with your doctors if you find yourself or your health care professionals questioning medical futility.

The moral burden for removal of life support is then placed squarely on the doctors, who in turn place that burden on the patient’s loved ones by asking them to sign a Do Not Resituate (DNR) form.  However, doctors in this situation still retain the legal right, not the family, to discontinue futile medical care under the right of agency and sentience under the law.

According to the Uniform Determination of Death Act’s (UDDA) definition of death, physicians can remove a patient from life support if treatment is not medically benefiting the patient. In removing life support, they are not committing murder On the other hand, physicians who believe a coma dépassé patient is dead, but is breathing on his/her own, risks civil prosecution for wrongful death.

This is where Dr. Butcher says theory and practice can become flawed because doctors judge if the treatment is medically futile. Health care professionals may say things like, “the patient’s quality of life will be awful,” or “you would not want to live that way.”

If there are no medical directives, physicians judge quality of life based on their own personal religious and life values, not the patient’s or family’s views. Just as one cannot know the line between life and death, one cannot totally divest themselves of personal values and beliefs about life or death for they are a part of the cognitive processes of the scientific-thinking man.

It has been said that medicine is more of an art than science. Doctors must consider the proportional rights, values, and religious beliefs of the patient, and the patient’s family. They must consider the patient’s right to die according to their moral religious beliefs, and values—whatever they maybe.

The Zero-Sum Game

Doctors look at what Dr. Butcher calls the zero-sum game of scarce resources where the argument turns from futility to one of resource allocation and monetary costs. It is the idea that there are only so many ventilators to go around and they should be used to help healthier patients. Or, the idea that there are fewer beating heart organ donors available, so when they come along we should take notice to use them, if the situation looks grim.

Butcher’s argument goes like this: If this brain death patient gets this ventilator, it could be months or years before it is available for someone else to use and it could be more helpful to that other patient.

Dr. Butcher makes the point that the decision and authority to make a decision about the worth of the quality of life for ventilator treatment belongs solely with the patient (or, the patient’s family).  This decision, according to Butcher, is the core of one’s individual right to self-determination.  Why? Because the medical team has never walked in the patient’s shoes.  Seeing something from the outside is much different from viewing it from the inside soul of a man.

Medical futility is not the same as personal futility, according to Dr. Butcher.  This is why the 2009 President’s Council on Bioethics (PBCE) said, “only whole brain death and the dead donor rule stand the test of death.”

One could argue that for an injured brain dead patient the ventilator will do what it was designed to do. It will serve to keep the patient alive if the brain stem has any function.  Treatment then becomes, as Dr. Butcher argues, supportive comfort care (or interruptive, since the death process begins slowly at birth and quickens as we age and results in the final death event) rather than curative care. In this case doctors are able to make the agency and sentence judgments with regard to medical treatment and its futility. Dr. Butcher argues that this is an instance of a concept that has been misapplied.

More precisely, Dr. Butcher states being on a ventilator ethically, is not a “medically futile action,” when ventilation is “treatment that provides only minor benefit… (or)… the benefit is unlikely… (or)… if the cost is disproportionate to the benefits that might accrue to the patient. In these cases the treatment ethically is not medically futile though it may well be the case that it is inappropriate and inadvisable or ought not to be offered…” It will serve to keep a patient alive.

Here, the argument for the deep coma brain injured patient becomes one that we must consider if any part of the brain stem physiologically remains alive and working (such as maintaining normal body temperature, kidney function, pituitary function etc.).  If the body has neurogenic heart rate control, maintains a normal blood pressure and is controlling other functions, then the brain stem has function and physiologically remains alive.

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