Wednesday, April 11, 2007
Medical Suicide and Medical Futility? Presidential Race 2008
The Washington Post and the USA Today ran articles in the past two days about very emotional and controversial issues in medicine. WaPo (or the Washington Post to those not in the know, as I was until today) covered the medical futility case in Texas where:
A 17-month-old deaf, blind and terminally ill child on life support is the latest focus in an emotional fight against a Texas law that allows hospitals to withdraw care when a patient's ongoing treatment is declared "medically futile."The Texas Medical Futility law allows physicians with the support of the hospital to declare any treatment futile, and allow the patient/family unit 10 days to find another medical facility to care for them. If one is not found, the life-supporting treatment may be stopped. Or at least that is the way the law is written. I don't think they had anything written about what happens when the case gets into the media and appeals for injunction are made. I won't go into the details of the case on Pallimed because 1) I am not a journalist and 2) the WaPo does a pretty good job describing some of the salient points which I will highlight below.
1) Patient is a 17 month old boy
2) The child has Leigh's Disease , a rare metabolic disorder.
3) Prognosis: (severe form: less than a few years, partial form: into the teenage years)
3) The child is not brain dead (thereby meeting most state laws for allowing withdrawal of life-support)
4) The mother acknowledges the terminal course ("I just want to spend time with my son. . . . I want to let him die naturally without someone coming up and saying we're going to cut off on a certain day.")
5) No trach or PEG yet but planned if a facility accepts
6) The law was approved by then Gov George W Bush
7) Right to Life groups are supporting the mother and patient to continue treatment
8) The patient has insurance via Medicaid and the hospital says money is not the issue.
Things that I do not know from some research on this story and my concerns about these issues not being mentioned.
1) Involvement of a ethics consult. I am guessing yes, but without news stories demonstrating the process the hospital and medical staff is going through it makes the decision appear rash and without appreciation for the complexities of the situation. Any ethics consult I have been involved with is long and drawn out and generally involves people getting into heated arguments and disagreeing vocally. I would imagine this happened behind closed doors in the hospital, but it would pay to give the hospital credit for going through this process.2) Involvement of a pediatric palliative care team. I am also guessing this has happened, but again it should be mentioned as part of the ongoing process.
So there is story number one...now for story number two from the USA Today.
The USA Today had a large article about the ongoing debate and advancement of the California Physician Assisted Suicide Bill. From the tone of the article the bill is advancing and has a high potential to pass. The law is modeled after Oregon's law which has been in place for eight years.
The reason I feel this is such an important issue to follow for the Hospice & Palliative Medicine field is we will be asked questions about it. We should have answers thought out ahead of time, because this is such a complex topic. Can you easily explain the ethical and medical differences among euthanasia, physician-assisted suicide, withholding unwanted treatment, withdrawal of unwanted treatment, and aggressive palliative care? If not you should brush up on it because your community, your local media is going to be asking you questions. And not only asking you, but asking your co-workers. "Oh you work for Hospice X, what do you think about that bill in California/baby in Texas?"
One key point the article made is comparing the number of deaths if the rates are similar to Oregon's. If the rates were similar about 500 people a year would die under the California PAS law. Knowing how much California is a bellwether state this IS going to be a national issue.
So that brings me to my final point. Will medical suicide and medical futility be the hot button, most-talked about, divisive issues of the Presidential Race in 2008? It almost seems like a perfect storm.
1) No political candidate has any overused canned reply to medical suicide/medical futility.
2) It is similar to abortion in being divisive, but not as ubiquitous a topic in political circles, so it may appear more 'fresh' and therefore more interesting than the same ol' stuff.
3) Health care, health care health care. Everyone is talking about it a big issue. This gets down to the meat of it.
4) Increasing health care expenditures. How easy is it to say no more payment for treatment X on a policy level as opposed to a personal level? See Boomsday for a cutting and sarcastic look at government encouraging death as a way to cut health care costs.
5) Political candidates and their own health care issues. Elizabeth Edwards, Fred Thompson, John McCain. Couldn't you see that being used in the debates as a zinger question by an opponent?
6) Iraq is important but I feel that's not going to draw a lot of attention when the candidates are all going to say similar things. You won't be able to separate candidates on this issue.
7) The environment is important but again I don't see wide divides. Going green is the new warm fuzzy for politicians.
So sorry to do some political analysis on this medical blog. But you heard it hear first this is going to be THE issue of the 2008 Presidential Race. Tell your friends. Then it will be a self-fulfilling prophecy.
Now back to Pallimed's regularly scheduled programming. I apologize about the long post.
PS. I am introducing a new term here: Medical suicide, it may not catch on, but I always tired of saying/typing physician-assisted suicide and what about the pharmacists, nurses and other medical staff that might be involved in the process. And no one knows what PAS is. Will see how it flies, I am guessing not very far.
(My Standard Disclaimer: Pallimed, Dr. Sinclair and his current and former employers and states do not endorse or practice euthanasia or physician-assisted suicide, but do encourage the open, non-judgmental discussion of these topics for educational and ethical discourse about this controversial area of medicine.)
Photo from flickr.com
Photo by Lee Jordan http://www.flickr.com/photos/leejordan/452827306/
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6 Responses to “Medical Suicide and Medical Futility? Presidential Race 2008”
April 13, 2007
I guess it was a matter of time before a major conflict due to the texas law hit the media. The quote from the mother is devastating, and, as a father of a young child I ached when I read it.
I attended an interesting lecture recently on medical futility--one of the lecturer's points was that the texas law creates a legal definition of medical futility which is essentially "treatment that no physician in texas is willing to provide."
Many people found it ironic that GW Bush helped create this law (allowing life prolonging treatments to be withdrawn against the wishes of a patient's legal decision makers) when he flew back from brush clearing in Crawford just to sign the Schiavo legislation (a situation which involved, essentially, forbidding life prolonging treatments to be withheld even at the explicit request of a patient's legal decision maker).
It will indeed be very interesting if end of life issues become big in the campaign. I'm not sure that I hope that they do: universal health insurance coverage, on the other hand, I desperately hope is central to the campaign.
April 13, 2007
The issue of how to define futility was once told to me as being futile to try, but since we need to have a working definition, I have problems with that lecturer's definition, and therefore maybe the legal definition in Texas. There are many factors that go into why another physician may refuse care of a patient in a 'potentially futile' case: Social, economic, legal, moral, medical, public relations, etc. So using the definition: "treatment that no physician in texas is willing to provide" is not really a medical futility argument it is a social futility argument. But it is a common working definition I have seen when discussing futility.
Why would you not want these issues to be important to the political debate? Is it because the actual issues are likely to be steamrolled into soundbites, or because there are more important things? Or another reason? I too am not sure if these should be a major point in the next debates, but I have a feeling it will be brought up.
Also as a new father, I tried to place myself in the mothers shoes, and I found it a very difficult place to be as well, but then my 'rational/analytical/pragmatist' side of my brain started arguing with my 'parental/emotional/caring' side of my brain and I got a headache. So that's when I decided to write the post. It is nice to know that Pallimed can be cathartic as a writer.
April 13, 2007
I agree that it's not a good definition of futility but also that the whole concept of futility is hopelessly epistemologically screwed. Insofar as we're living in a world with imperfect knowledge...I'm not sure that 'futility' is a helpful concept when talking about care of the critically or terminally ill.
As far as the election goes it's for both the reasons you mention: 1) universal health care is a more pressing problem for the country as a whole (this is my opinion) and
2) i tremble when i contemplate hours of talking heads going off about pas and the culture of death--skeptical that there's going to be an adult, non-ideological, non-batshit insane 'conversation' about it.
April 16, 2007
April 16, 2007
Beverly,
Thanks for the comments. Do you know how the North County Gazette obtained the ethics committee report?
I tried to find that information on the NCG website but I could not find a link to it, only through the directories. I guess part of my concern is HIPAA issues and not wanting this information released unless the mother or hospital have publicly released it. And also since I had not found it mentioned as released and public on any other major news sources.
April 26, 2007
The following is the edited post from Beverly Nuckols. The initial comment had a link to the ethics cmte report, which has not been publicly released, and I could not validate the accuracy nor the permission to be posted on the site. Since that this is an ongoing case, and this could be a privacy issue, I have made the editorial decision to remove the link from Pallimed. The following comment has not been altered, but the initial comment had to be deleted in order to remove the link.
-Christian
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LifeEthics.org said...
There were two separate ethics committee meetings. One in February (beginning about February 19th, Wesley Smith began blogging with reports from the mother's lawyer - the blog won't open this morning), when the committee sided against the pedi. She arranged a transfer to another doc within the hospital. The second was on March 9, and the report is available here in Microsoft Word on line at one of the blogger's websites, The North Country Gazette. (LINK Removed) I've covered the issue and debated with one of the lawyers on the case at Wesley Smith's blog and my own (from March 19 (contains part of the Ethics Committee report) thru March 22, and the few days that follow).
Beverly B. Nuckols, MD
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