Human Exceptionalism

AMA Playing “Hide the Ball” with Futile Care Rule?

“Futile care” is ad hoc health care rationing. It permits a doctor to refuse wanted life-sustaining treatment that is working, based on the values of the MD that keeping the patient alive is not the “medically appropriate” approach.

The term “medically appropriate” in such cases is a misnomer. The “refuse wanted treatment decision” is really a subjective values judgment of the doctor, as opposed to an objective medical medical determination.

Or to put it another way, the treatment isn’t refused because it doesn’t work, but because it does or will.

“Medically ineffective” treatment would seem to be wholly different concept, an objective determination that a requested intervention will not work.  

Wild example: If I ask my doctor to cure my earache by performing an appendectomy, she should absolutely refuse because such an intervention would be objectively futile.

The new AMA ethics rules would seem to conflate these two distinct concepts. Under the heading “medically ineffective interventions,” the AMA would empower doctors to refuse “medically inappropriate” care. From the preliminary rule (my emphasis):

5.5 Medically Ineffective Interventions

At times patients (or their surrogates) request interventions that the physician judges not to be medically appropriate. Such requests are particularly challenging when the patient is terminally ill or suffers from an acute condition with an uncertain prognosis and therapeutic options range from aggressive, potentially burdensome life-extending intervention to comfort measures only.

Requests for interventions that are not medically appropriate challenge the physician to balance obligations to respect patient autonomy and not to abandon the patient with obligations to be compassionate, yet candid, and to preserve the integrity of medical judgment.

Physicians should only recommend and provide interventions that are medically appropriate—i.e., scientifically grounded—and that reflect the physician’s considered medical judgment about the risks and likely benefits of available options in light of the patient’s goals for care. Physicians are not required to offer or to provide interventions that, in their best medical judgment, cannot reasonably be expected to yield the intended clinical benefit or achieve agreed-on goals for care​.

The “agreed on” term is especially important in this context. Under futile care, if a patient wants to stay alive, and the MD thinks that should not be done, there is no “agreed upon goal.”

In such circumstances, under futile care theory, the MD and/or a hospital ethics committee have the right to refuse wanted treatment–which works–based on their subjective personal value beliefs that it is “inappropriate.”

Coercion should have no place in medicine.

Question: Is the false heading and subsequent conflation of distinct ethical concepts a game of “hide the ball?

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