Clinical Bioethics Blog : Bioethicist : Bernard W. Freedman : Medical Consulting, Ethics, End of Life Decisions

The New England Journal of Medicine recently published an article entitled: “ The Palliative Care Information Act in Real Life,” (NEJM 364;No.20 May 2011), regarding a New York statute that requires a physician to have discussions of end of life treatment options with the patient when the patient is “terminally ill.” Alan Astrow MD and Beth Popp, MD, the authors of the article, are troubled by the phrase terminal illness. They argue that the definition in the statute is vague and an improper interference with the physician-patient relationship. The fact that they find the phrase, “terminal illness” troublesome, is troublesome.

The authors fail to understand basic concepts in clinical bioethics as well as case law as to the duties of physicians dealing with critically ill patients and the provision of information on all relevant and alternative methods of treatment. Perhaps they think like so many others, that end of life care planning is reduced, basically, to one question: If you are close to death and your brain is in a persistent vegetative state do you want us to remove you from life support or not resuscitate you if you go into cardiac arrest? This is not the case. A variety of options are available to patients who are critically ill. It is foolhardy to wait until a patient is unable to actually explain their wishes to the physician and allow an adversarial situation to be created between family members, friends, physicians and other medical staff, as well as possibly leading to referring the matter to the ethics committee, the hospital administration, or hospital attorneys.

A variety of options should be addressed as early as possible and relative to the disease trajectory. In addition to discussing the anticipated medical course, differing degrees of brain injury or damage, the likelihood of recovery and anticipated risks and treatment options and related issues of quality of life. The following are some suggested talking points:

a.     The selection of one person who will act as surrogate decision-maker: the patient must understand that the surrogate decision maker only has any say if the patient cannot speak for herself. It should be made clear that the purpose of the surrogate is to effectuate the wishes the patient, not the wishes of the surrogate. Additionally it should be made clear that the surrogate does not have to be limited to a family member.

b.     A patient has the right to know (subject to the therapeutic exception) applicable Evidence-Based Medical (EBM) information to help the patient understand and evaluate risks and benefits of various treatment options (including lack of treatment) based on clinically significant research, such as: cohort studies, double-blind clinical research, meta-analysis, etc.

c.     Discussion with family and clergy should be encouraged;

d.     Advise that he or she may seek a second opinion. Aside from the fact that the patient may or may not want a second opinion, offering to arrange one will often provide a sense of confidence in the physicians treatment plan.

e.     At some point in time the patient may want to be transferred home on hospice and die peacefully with his or her family rather than in the ICU. Thus, palliative care needs to be explained and the probabilities presented to the patient with respect to longevity and quality of life.

f.      Does the patient have any religious requirements that they wish to follow with respect to receiving pain medication that may or may not hasten death? Many patients are willing to receive pain medication but not to the point where it may hasten death. Others may want to receive all necessary pain medication and sedation should be kept as pain free and comfortable as possible.

g.     Does the patient have religious convictions with respect to receiving blood or blood products?

And so on.

The rights of patients to make their own medical decisions create reciprocal duties on the part of their physicians to respect and uphold these rights.

The authors argue that there is a “standard of care” that dictates when physicians must tell their patients all relevant medical information. This is not true.

The standard is not determined by the medical community, but rather, by the patient him or her self. It is not a medical question; it is a personal, individual and unique decision by the patient, of which can only be made if all medical information and options or explained.

As one commentator advises physicians: “If you don’t speak early, you lose your voice.” Carol Taylor, RN, PhD advises patients: “For someone who sits with families trying to make these life and death decisions, I can say that planning is the greatest gift to your family.”

What is it that stands in the way of early discussion for many physicians?

The authors of the article, Drs, Astrow and Pope, claimed that:

 “… physicians need to feel comfortable communicating their values and experiences and providing non authoritarian guidance and support while expressing interest in and respect for the experiences and values of patients and families.”

This statement is ignorant of the law, foolish and, moreover, it is surprising that the NEJM would publish this misguided advice.

Physicians do not have to feel comfortable. What difference does it make if the physician “feels comfortable” or not when carrying out his or her responsibilities. Many physicians, if not most, will never feel comfortable in such situations. What is important is that the patient is not “comfortable” and may be fearful, confused and in need of all necessary information. (Without the provision of all relevant information, there cannot be any informed consent and the physicians may be found civilly liable in addition to incurring state imposed fines).

Secondly, it is clearly inappropriate for a physician to convey his or her values to the patient. A physician’s values are of no moment whatsoever. It is, on the contrary, the patient's values alone that should guide decision. Indeed, physicians’ values should not even be discussed or mentioned. If so, the patient would receive different guidance dependent upon which physician’s door she walks through.

Thirdly, the physician is always in a position of authority.  The author’s suggestion that they can counsel a patient in a non-authoritarian manner will not work. That cannot be avoided. So, any suggestions, as to a physician’s values must be avoided. The values of the physician are not in issue.

The decisions of the patient should as John Stuart Mill once describe, be a product of  “…free, voluntary and undeceived consent and participation…”

The authors provide us with a scenario of an 85-year-old man with gastrointestinal cancer that had metastasized to the lung.

“… when his cancer and its spread were diagnosed two years ago,

 he was already frail.”

At this point, if not long before, the patient should have been given the opportunity to consider many of the types of questions listed above.

The patient may have benefited from the knowledge, for example, that in a recent study of the 151 patients with metastatic non-small cell carcinoma, early palliative care led to significant improvement in quality of life and mood and that patients receiving earlier palliative care and less aggressive care often had longer survival rate.” If this 85-year-old patient with metastatic lung cancer was not presented with these and like information from applicable and relevant and authoritative studies, then the patient lost the opportunity to have longer survival and improved quality of life.

Finally, Drs, Astrow and Pope are concerned with the interference of the state into the practice of medicine. I agree that interference of the state into the practice of medicine is something that must be vigorously challenged. In this situation, however, the statute refers to the necessity of ensuring the rights of patients rather than medical practice

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Rationing "scarce medical resources" and lying to the patient - do these go hand in hand?

7 comments

Claudia Ruiz M.D • I don't think so, I'm from Mexico, and I have worked plenty with the mayan communities, they really don't have any acces to medicines o medical attention. We did our best to get them what they need, but sometimes it is impossible. Anyways, I never lie to my patients, they deserve to know the truth always. Maybe it is a different situation in the United States and the HMOs, but in principle, I don't think it is ethical to lie and withhold information to people, specially if that information is for the best of the patient.

Henry Levenson,M.D. • No, rationing health care does not equal lying to patients. It is better to explain to the best of your ability why referrals were declined or not authorized. Patients seem to assume that physicians are responsible for the reasons why health care is rationed.

M. Sara Rosenthal • In the U.S., rationing is usually not done according to an ethical framework (such as beneficence); it is usually done according to "ability to pay": if we were transparent about THAT -- we wouldn't have opposition to universal healthcare in the U.S. by the very people who could benefit from it. Transparency about access is really the issue.

Bernard Freedman, JD, MPH • Follow up Comment: Rationing : Withholding Medical Care by Lying to the Patient 

"Rationing" of medical care and “triage” are different. 

Triage prioritizes the use of limited medical resources when sufficient resources are not available. 

Rationing is the withholding of available care for political/economic reasons. 
With respect to rationing, therefore, it must be decided whether or not the patient is going to be told the truth. 

The ethical question here is whether patients must be told that medical care is being withheld, or if a standard practice will sanction lying to their faces. 
In his book “Pricing Life” Dr. Peter Ubel provides us with his definition of rationing. He says that the clinician must, 
(1) Withhold, withdraw or fail to recommend a service that, in the clinician’s best judgment, is in the patient’s best medical interests; 
(2) Act primarily to promote the financial interest of someone other than the patient, including an organization, society at large, or the clinician himself or herself, and 
(3) Have control over the use of the medically beneficial service” (Pricing Life – why it is time for health care rationing, Peter A. Ubel, M.D., MIT Press, Cambridge Massachusetts 2000). 
The phrase “withhold, withdraw or fail to recommend” defines rationing as outright dishonesty with the patient – violative of the legally required fiduciary role in physician-patient relationships. 
So, I agree with Dr. Rosenthal that, indeed, transparency is the real issue

Marie Cartwright • Withholding, withdrawing or failing to recommend a service does not imply, in any way, dishonesty. It rather describes an informed attitude a physician will take towards a patient regarding a particular procedure and their candidacy for that procedure. A physician, for instance, can withhold a procedure from a patient while still being honest about the reasons for doing so, and rightly so. 

In the UK, for instance, candidates for hip replacement surgeries are (or were several years ago) denied the surgery until they brought their BMIs down to a healthy level. In other words, obese candidates were denied hip replacements based solely on their weight. I initially struggled with this particular topic because it seemed to have a tone of infinite regression- patients who required hip replacements would have a much easier time reaching a healthy weight if they had a healthy hip! However, if the supply is far less than the demand, we must also take into account that obese patients who received a hip replacement would also probably need another replacement sooner than those within a healthy weight range. 

In terms of honestly, however, the patient-doctor relationship cannot exist without trust. Lying should never be present, under any circumstances.

Bernard Freedman, JD, MPH • Thanks for the discussion. This is a growing quandary that calls for clarity from medical, ethical and public policy points of view. There is a difference between withholding or withdrawing efficacious treatment and telling a patient what you are doing and why, and “failing to recommend” an efficacious treatment and keeping it a secret under the guise of having what you call an “informed attitude.” So, I must ask, what is it that informs a physician’s attitude that justifies keeping the decision hidden? In other words lying to the person you have the highest duty to be honest with. Yet, you say in the next sentence of your comment that it is ok to” withhold the treatment while still being honest about the reasons for doing so.” I am unclear whether you are really saying that withholding the truth, lying, is acceptable. 
You give the example of the obese patient who needs a hip replacement but is denied the surgery unless he or she loses the weight. The denial may be justified, but is the patient told the reason for the denial? Do you tell your patient that they must lose weight before the hip replacement will be permitted? Of course, I believe, you do. Otherwise there would be no incentive for the patient to lose the weight. 
It is the trust aspect, the moral imperative of truth telling between physician and patient that is, I believe, at risk when rationing truly scarce resources.

Marie Cartwright • I think we are on the same page in many respects here. But, if I may clarify a possible misunderstanding- You said, "So, I must ask, what is it that informs a physician’s attitude that justifies keeping the decision hidden?" I definitely didn't intend to imply that physicians should keep their decisions, or reasons for their decisions, hidden. I believe quite the opposite. By informed attitude, I meant to refer to the physicians as "gatekeepers" who decide who can have what procedure, and when, and their decisions, or attitudes, are informed by factors solely about the patient. Physicians, after all, are the experts that we rely upon to help us better our health and in some circumstances, "save" us. In essence, and hopefully to answer your question, withholding a treatment and withholding the truth are two entirely different things. In my previous comment, I said that withholding a particular treatment is in no way dishonest. However, withholding a treatment without justifying or explaining it to the patient goes against the patient-doctor relationship and also is counter productive for any patient's treatment. 

Regarding the hip replacement patients, I believe the the denial must, in all situations, be explained to the patient. I don't really believe that truth telling is at risk in any situation, much less the rationing situation. A patient must be told why he/she is no longer a candidate for a particular procedure. Even when supply is scarce, to be dishonest serves no purpose.

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Efforts to encourage (or compel) physicians to lie to their patients were faced years ago when “gag clauses” were inserted into contracts between HMO’s and contracted physicians. The gag clause established a contractual obligation on the part of the physician to withhold information regarding treatment modalities that were not within the HMO protocol of allowable categories of care. 

Contractually, it is common to exclude specific types or categories of care - “We will pay for this, we won’t pay for that.” Every contract of insurance has exclusions. Gag clauses, however, go further. They contractually bar physicians from fulfilling their fiduciary duties to the patient from making clear what relevant treatments are available in the medical community. If there were more effective treatments available, the physician nevertheless had to withhold such information. Physicians, therefore, had to choose whether to breach their fiduciary duty to their patient, or breach their contractual duty to the HMO if they revealed the availability of superior care for the patient.

For a patient, there was no real choice. No information that would enable a comparison between alternative treatments, nor any opportunity to confer with other physicians regarding alternative treatments.

This, to be clear, is fraud: purposeful misrepresentation and intentional withholding of critical information by a fiduciary and relied upon by the patient to his or her detriment, namely serious injury or death.

In 1990s, the AMA asked managed care organizations to withdraw gag clauses from their contracts with physicians. Though gag clauses have drifted, we hope, out of existence, medical rationing resurrects the same fraudulent behavior and, again, attempts to persuade or compel physicians to participate in the entire charade.

Patients will have to be told the truth unless our moral foundations of democracy are to be drastically diminished. If the informed consent process is genuine it must reveal to the patient all alternative methods of treatment – whether they can afford it or not. Patients are accustomed to being told that certain categories of treatments, though needed, may not covered by their insurance. If the policy is ambiguous then that issue of coverage can be legally and rapidly challenged.

Protocols to ration health care, if they surreptitiously contribute to the worsening of illness or death, will once again be an attempt by those who make policy to encourage or compel physicians to change from their absolute loyalty to their patient to become coerced agents of fraudulent socioeconomic policy.

Part III to follow: Efforts to Ration Care and Value Based Medicine

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Rationing : Withholding Medical Care by Lying to the Patient

Rationing of medical care and “triage” are different.

Triage prioritizes the use of limited medical resources when resources are insufficient for immediate treatment. 

Rationing is the withholding of available care for political/economic reasons.

With respect to rationing, therefore, it must be decided whether or not the patient is going to be told the truth.

The requirement of informed consent cannot cease to exist because of political/economic policy. Nevertheless the degree of informed consent may vary with the degree and type of risk. Informed consent for a blood pressure medication may not require any specific discussion if the medications are reasonably the same in term of efficacy of treatment.

The physician has an affirmative duty to raise the question and answer such questions by describing all “available” treatment.

On the other end of the spectrum, withholding information about hemodialysis in a patient with multi-organ failure requires an explanation of all risks of treatment and non-treatment alike. Life expectancy, quality of life, prolongation of the process of dying and so on must be discussed in specific detail. Religious considerations may come into play as well. For example, some religious doctrines draw a line between “ordinary” and “extraordinary” care – ordinary care being required, where extraordinary care is not.

Nor can a physician simply wait to see if the patient inquires about other treatment that may be available. The physician has an affirmative duty to raise the question and answer such questions and breaking down “available” methods of treatment.

Part II will address policy considerations and legal ramifications of rationing medical care.

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At present the Missouri State Senate is considering new legislation (SB 365), which means to provide health insurance coverage for Phase I and Phase II clinical trials for cancer treatment. The law in the state of Missouri presently limits mandated insurance coverage to Phase III and Phase IV clinical trials.

Aside from the fact that this bill makes no sense whatsoever, it highlights the ignorance of what Phase I or Phase II trials are intended to accomplish. SB 365 seeks to force insurers, non profit health services plans, or health maintenance organizations to treat Phase I and II trials as if they are treatment – beneficial to the patient – which they certainly are not.  Since neither Phase I nor Phase II clinical trials are deemed treatment, or have any reasonable expectation of any real benefit to the patient, it makes no sense to compel payment for claims unrelated to actual health care treatment. 

Phase I trials are used solely to determine levels of toxicity of the drug being investigated. Phase II trial try to determine if the drug being investigated has any effect on the underlying disease, in this instance, cancer. Prior law in Missouri did make some sense by requiring insurance coverage for phase III and phase IV clinical trials would be covered because of, at least, the opportunity of benefit the patient i.e. actual therapeutic treatment. 

The bill then, in contradiction of the scheme of clinical trials, requires that “available clinical or preclinical data must provide a reasonable expectation that the treatment will be superior to the non-investigational alternatives.” This is outright stupidity because by the nature of phase I and phase II clinical trials there cannot be any clinical or preclinical data that provides any reasonable expectation that there is any treatment, actual therapeutic care, that will be gained. The bill seems to suggest that the patient will benefit from coverage for “routine patient care costs incurred for drugs…” The proposed legislation, however, defines “routine patient care cost” are the necessary costs needed to administer the drug under evaluation in the clinical trial, not actual care and treatment that will protect the patient. Accordingly, this proposed legislation is a sham, forcing insurers to pay for investigational drug research being performed by pharmaceutical companies, government, biotech companies, academia and privately run (outsourced) clinical trial programs.  

      All costs for Phase I and II trials should be born by the research investigators, including all necessary medical costs for the patient’s underlying condition as well as care during the clinical trial and thereafter to the degree that treatment is related to ill effects or adverse reaction to the drugs or medical devices being investigated.

This proposed legislation is unconstitutional by interfering in the right of freedom of contract because it requires payment for things outside the purview of the insurance contact for actual medical, therapeutic treatment.            

Many states are considering, or have passed, similar legislation. For example in Arizona (SB 1213 2000) requires cost for patient care associated with clinical trials phase I through 4. Yet coverage is limited when no clearly superior non-investigational treatment exists. California has passed the same legislation limited to , “when no clearly superior non-investigational treatment exists.” The confusion here is that neither Phase I or Phase II trials are “treatment.”

Colorado (HB 09-1059-2009) requires a similar coverage, but only when the physician believes that the patient may benefit from the clinical trial and when the patient has a disabling progressive or life threatening condition.

Connecticut (SB 325-2001) mandates coverage, but only in Phase III clinical trials and only if they involve “therapeutic intervention.” This legislation makes sense because it is limited to instances of “therapeutic intervention.”

Similarly Delaware (SB 181-2001) mandates coverage only when the clinical trial provides “therapeutic intent and where the trial is not designed exclusively to test toxicity or disease pathophysiology. This would, therefore, exclude coverage of Phase I and Phase II trials.

Indiana (HB 1382-2009) is similar to the confusion of the Missouri bill because it requires cost to be paid for Phase 1 through phase IV cancer clinical trials – but only when there is no clearly superior non-investigational alternative care available, and when the clinical data shows that the care method used in the research study is likely to work as well as approved care. This condition may make sense in Phase III or IV trials but not feasible in Phase I or II trials.

North Carolina (SB 199-2001) has some interesting additions. Patients who are suffering from life threatening disease or chronic condition may designate a specialist who is capable of coordinating their health care needs and insurers do not have to pay for “investigative” clinical trials. Similarly Wisconsin (AB 617-2006) limits insurers’ responsibility for payments when trials are intended to improve the participants’ health outcome and not designed only to test toxicity or disease pathophysiology – thus eliminating mandated coverage in Phase I and II trials.

The level of misunderstanding (feigned or actual) of the purpose of Phase I and Phase II clinical trials will have to be dealt with by the Federal Court of Appeals and possibly the Supreme Court to provide constitutional clarity as well as uniformity throughout the various States.

In addition to the confusion is a significant problem of giving credence to recruiting efforts Phase I and II cancer patients by giving the impression that Phase I and II trials are therapeutic and “paid for by your insurance company.” Informed consent is especially important in Phase II and II trials. These laws summarized above should not tend to lessen the requirement of detailed and well documented informed consent.

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Each patient deserves more than a brief discussion about end of life decision-making. In  “A Piece of My Mind” section of this month’s JAMA (volume 303, No.13, April 7, 2010) Paul Kettl M.D. argues for monetary compensation to be provided to physicians for end of life discussion and planning. He fails to make clear, however, that the decision rests with the patient, not what is best for the family.

Physicians must be careful not to wear too many hats and should turn to skilled clinical bioethicists and if necessary the Hospital Ethics Committee for review and recommendations. This will protect the patient’s interests and dignity and the physicians involved in the care from liability. Legal and ethical issues applying to the withdrawal of life sustaining care have become increasingly nuanced and face greater scrutiny and need for transparency. So physicians must be careful not to change hats from physician for the patient  to physician for the family.

Once a patient losses capacity to make medical decisions, many physicians down play patient wishes and seek instead to satisfy family needs. It is not the degree of burden on the family that must inform decision-making. It is what the patient wants that prevails. The patient remains the patient, not the family.  Indeed, it often relieves the family and friends from the overwhelming burden of “deciding” what will happen with respect to withdrawing or withholding life sustaining care. In my experience, surrogate decision makers feel more in control and can make more informed decisions if they are told: “This is really not your decision. We are not asking you to decide if your wife should live or die. We are asking you, because you know her best, to tell us what she would want if she could speak for herself. In order for you to do that the physicians caring for your wife will tell you all the important medical factors, just as they must tell any patient.”

Different disease processes have different disease trajectories that allow the physicians to plan – with their patient - for medical decisions that will have to be confronted down the road. For example, different types of dementia have varying trajectories of cognitive decline. Decline may run from 2.7 to 6.8 years from first diagnosis. Initially cognitive function may not change at all from 9 to 35 months. Thereafter rate of decline vary significantly among patients.  

Dr. Kettl, a geriatric psychiatrist, advocates for payment to physicians to spend the necessary time when patients still have the opportunity to contemplate and develop health directives with the advice and discussion with family and close friends. It is a time when a patient may ask detailed question of her doctor about: prognosis of quality of life; distinguish between ordinary and extraordinary treatment decisions. It is also the time to make non medical decisions including where the want to die, at home or in hospital; the desires for the timing of initiating palliative care and to withdraw or withhold treatment that may only serve to extend the dying process. Early discussion avoids fear that comes when decisions must be made quickly and without the benefit of the patient’s clear and autonomous choices.

Withdrawing care that will result in the death of a patient cannot be treated cavalierly. That is why hospitals must have in place well developed procedures and protocols surrounding any decision to withdraw life-sustaining care. Compensating physicians is crucial to allow specific time, and timely discussion, with the patient before loss of capacity sets in.    

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A recent article in the Journal of the American Medical Association, JAMA, discusses the need for effective public health announcements to encourage people to explain their end of life wishes and their values, goals and preferences. It has been well established that physicians are reluctant to discuss end of life choices with their patients and the norm has been to put it off until the patient is in advanced terminal disease when it is, indeed, more difficult to discuss. Studies have also shown that the majority of patients said they would choose to forego futile care but few are presented with this option.

The failure to have this conversation at an appropriate time may end up having the patient frightened and confused and unable to have a meaningful discussion after being fully and intelligently informed about the risks of further treatment and the progression of their illness and the physicians frightened to raise the subject late in the game and give their patient the impression that he or she is being giving up on.

Legislation was proposed in recent Health Reform bills requiring physicians to “offer” to discuss advanced health care planning was met with chants of “Death Panels” in the media partly as a result of prior vice presidential candidate Sarah Palin’s claim’s of “Death Panels.” She based this on President Obama’s choice for Chair of the NIH Department of Bioethics and concurrent, and seeming conflicting position, as White House Office of Management and Budget - Ezekiel Emanuel. Emanuel has forthrightly stated that young children and elderly should not receive basic health care, not only in times of epidemics or pandemics but in general as it applies to scarce medical (economic) resources. This was easy fodder for Palin’s accusations of death panels in proposed health reform legislation.

In the JAMA article Drs. Terri Fried and Margaret Drickamer; argue for public health announcements to urge advance care planning.

“Delivering these messages will require broad outreach,such as through the use of public service announcements.…Although the process of personal participation in ACP should take place on the clinical level with an individualized interaction between patient and clinician, the process of encouraging participation in ACP must occur on the population level

This will be difficult especially t this time because of recent increased mistrust of government proposals. In my view the trust exists between physicians and their patients and thus the answer lies in vigorous efforts to educate medical students and physicians in the need for, and the methods of discussing advanced care planning at an appropriate time. 

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The Los Angeles Daily News, July 11, 2009, wrote, “One doctor, who chairs the Northridge Hospital Ethics Committee, did raise the important and relevant issue of excessive, costly, end-of-life care that has no potential for significantly extending life. If consumers had to pay a significant copayment, they might not demand unreasonable or unadvisable care."

http://www.dailynews.com/editorial/ci_12817975

If this physician actually said this, of which I am doubtful, then it must be pointed out that a decision to terminate life sustaining treatment based on or informed by economic considerations is unethical and of great concern. Discussions of terminating life sustaining treatment must be grounded in evidence of the patent's intent, degree of suffering, quality of life, etc., but certainly not by demanding payment from people to persuade them to stop medical treatment and die.

Bioethics deals with the application of ethical and legal principles in medicine, not economic expediency. Physicians, and ethics committees across the nation struggle to understand each patients needs and wishes: what dignity means to them,– their religious, ethnic and racial points of view - their fears, mistrust and sometimes misplaced trust which may result from the undue influence of family, friends, business associates and others. As the California Court of Appeals wrote: “…the decision must ultimately belong to the one whose life is in issue.”

There are many people who appropriately face the economic realities of everyday hospital services. Reducing medical costs, oversight of physician owned hospitals who often generate higher costs due to the ordering of tests which have an economic benefit for the physicians ordering the tests, defensive medicine, reducing medical errors that result in serious injury and run up unnecessary medical costs, sometimes for patients who will need specialized medical care for the rest of their lives.

But, it is not for the chair of an ethics committee to declare what life is worthy of receiving life sustaining care based upon economic principles. Physicians and ethics committees must deal with the individual patient, one patient at a time.

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