Medical Futility The essence of good medical care is to attempt to be as clear as possible about the outcomes of the proposed interventions. If the proposed intervention (e.g., continued respiratory support or initiating support) has a slight or highly unlikely chance of success, intervention might be considered futile. Physicians have no obligation to continue or initiate therapies of no benefit (29). The decision to withdraw or withhold care is one that must be accompanied by an effort to ensure that the patient or her surrogate decision maker is educated about the decision and agrees with it. Other issues, such as family concerns, can and should modify decisions if the overall well-being of the patient and of the family is best served. For example, waiting (within reason) to withdraw life support may be appropriate to allow a family to reach consensus or a distant family member to see the patient for a last time.
Quality of Life Quality of life is a much used, often unclear term. In the care of patients, quality of life is the effect of therapy on the patient’s experience of living based on her perspective. It is perilous and speculative to assume that physicians know what quality of life represents for a particular patient judging from a personal reaction. It is instructive, however, to attempt to guess what it means and then seek the patient’s perspective. The results may be surprising. For example, when offered a new drug for ovarian cancer, a patient might prefer to decline the treatment because the side effects may not be acceptable, even when there may be a reasonable chance that her life may be slightly prolonged. Conversely, the physician may not believe that further treatment is justified but the patient finds joy and fulfillment in entering a phase I clinical trial because it adds meaning to her life to give information to others about the possibilities of a new treatment. Informing patients of the experiences of others who had alternative treatments may help in their decision making, but it is never a substitute for the individual patient’s decisions.
Conﬂict of Interest All professionals have multiple interests that affect their decisions. Contractual and covenantal relationships between physician and patient are intertwined and complicated by health care payers and colleagues, which create considerable pressure. The conﬂict with financial considerations directly inﬂuences patients’ lives, often without their consent. Rennie described that pressure eloquently: “Instead of receiving more respect (for more responsibility), physicians feel they are being increasingly questioned, challenged, and sued. Looking after a patient seems less and less a compact between two people and more a match in which increasing numbers of spectators claim the right to interfere and referee” (30). One response to this environment is for the physician to attempt to protect his or her efforts by assuming that the physician–patient relationship is only contractual in nature. This allocation of responsibility and authority to the contract precludes the need for the ethical covenant between the physician and patient. For example, a pre-existing contract, insurance, a relationship with a particular hospital system, or a managed-care plan may discourage referral to a specialist, removing the physician’s responsibility. All health care professionals will experience this tension between a covenantal or contractual relationship. A reasonable consideration of that relationship is “one that allows clients as much freedom as possible to determine how their lives are affected as is reasonably warranted on the basis of their ability to make decisions” (31).
Health Care Payers An insurance coverage plan may demand that physicians assume the role of gatekeeper and administrator. Patients can be penalized for a lack of knowledge about their future desires or needs and the lack of alternatives to address the changes in those needs. Patients are equally penalized when they develop costly medical conditions that would not be covered if they moved from plan to plan. These situations often place the physician in the position of being the arbiter of patients’ coverage rather than acting as an advocate and adviser. It is an untenable position for physicians because they often cannot change the conditions or structure of the plan but are forced to be the administrators of it.