Wednesday, December 12, 2007

Futile Care Case in Canada

When I was in Toronto recently at the international anti-euthanasia conference, I focused my speech on the looming threat of Futile Care Theory as the next big bioethical controversy. And already, I am proved prescient. A Canadian hospital is trying to force an elderly man off of a respirator and feeding tube over the objections of his family. From the story:

A Winnipeg family is going to court today to try to force a local hospital to keep their ailing father on life support, saying the hospital's decision to withdraw such care violates their orthodox Jewish faith. Orthodox Jews believe it is essential to do whatever possible to extend life, and "sacrilegious" in any way to hasten death, the children of Samuel Golubchuk say in court documents. They are also claiming damages for assault from the Grace General Hospital and critical-care doctors, whom they accuse of acting arrogantly and trying to remove the patient from a ventilator and feeding tube on the Jewish sabbath.

The hospital and its doctors, though, say they have gone out of their way to respect the family's wishes but would now be violating ethical guidelines to keep offering care they say would only drag out the 84-year-old's painful death.

First, we should reject the concept of "dragging out the death" which turns the concept of extending life on its head. As I often say, dying isn't dead, it is living. It is a stage of life. Refusing to extend life when the patient wants it is to turn the very purpose of medicine on its head and impose doctors' or hospitals' values onto patients and families where value judgments truly belong.

Here is what the doctors say:
But the patient suffers from a variety of irreversible ailments and trying to prolong his life now would actually contravene rules of the Manitoba College of Physicians and Surgeons that bar futile treatments, Dr. Elizabeth Cowden, the Grace's chief medical officer, says in an affidavit."I do not feel that I can ethically participate in the administration of this treatment any longer," Dr. Bojan Paunovic, head of the hospital's intensive-care unit, says in his own affidavit.
What is wrong here is that the treatment isn't being cut off because it doesn't work--which is a true futile treatment--but because it does! In effect, the patient is being declared to be futile. And just because the hospital created their own rules, that doesn't mean they should be able to dictate who loses the right to live even though they are no doubt acting in the best of faith.

I am glad this is going to court. There are "cusp" cases where it may be so against the best interests of the patient and cause so much suffering that continued treatment can be unconscionable. But that isn't up to doctors to decide unilaterally because they create their own rules. That is what we have courts for with the right to cross examination, a public hearing, and appeal, where the burden of proof should be on the doctors. In short: Due process--the very thing denied by conventional futile care hospital protocols.



At December 12, 2007 , Blogger Mort Corey said...

Not knowing first hand how the Canadian system operates, the cynic in me would wonder if the guidelines are financially motivated. This is indeed scary stuff. With certain members of the US Supreme Court taking the position that our laws should respect international views, this could be coming to our neighborhood in short order.

At December 12, 2007 , Blogger T E Fine said...

Mort -

If Canadian law finds for the family instead of the hospital, it will set a precedence in their law *and* it'll influence our laws as well, at least to a point. Keep the faith.

At December 12, 2007 , Blogger said...


I came by to see if you had commented on the CMA's response to the American College of Obstetricians and Gynecologists move to restrict conscientious refusal to provide medicines and procedures.

I flat don't see the need to pull the feeding tube - it can be used by anyone in the family to feed their father.

However, the article says that the family is demanding "every thing." Evidently the man can't ask.
And then there's this from the article, "An orthodox rabbi consulted by the family quotes from guidelines on Jewish medical care that say it is imperative for doctors to prolong life, even if the patient is "suffering greatly" and asks for care to stop."

It's my understanding that Orthodox law forbids disconnecting the machine until the heart stops, even though there has been talk of a machine in use in Israel to randomly turn off ventilators so that the people won't have to. But I've never read that the Orthodox go so far as to demand that suffering be ignored.

Do you suppose the family really believes that they should force other people to cause suffering?

In fact, withholding is acceptable. See the discussion about flickering candles, here.

Here's a very well written review of Orthodox Jewish law on end of life, from the Virtual Mentor, the AMA ethics journal.

Nevertheless, while the family may have the right to continue their father's suffering, they don't have the right to force any particular doctor, nurse, or tech to act to violate their conscience. Surely there's an Orthodox doc around somewhere.

At December 16, 2007 , Blogger T E Fine said...

We throw around the word "Suffering" a lot. By whose standard are we judging suffering? Our own? First off, none of us talking on this board are the guy in question, and second, we're not exactly in prime position to see what kinds of efforts are (and can be) made to reduce his suffering.

The rabbi they consulted said that live should be prolonged 'even if the patient is "suffering greatly."'

Now, that sounds like he's quoting from a text, rather than making a statement about the case at hand. Such texts probably come from long lines of theological speculation from way back when, before most of our modern pain-blockers were developed. It doesn't seem to me that he was describing this patient as 'suffering greatly,' just explaining what's appropriate and what isn't.

So we're assuming that the doctors think it's unethical to prolong his life because of how badly he's suffering, when we don't have any straight idea of what is being done to and for him.

Are the doctors withholding treatments that could alieviate his pain because the treatments are expensive or because they think it's futile to continue caring for him? If so, would administering those treatments decrease or cease his 'suffering?'

Is his body starting to shut down and no longer able to process food, even if given by a feeding tube? Withdrawing a feeding tube when it's not going to do anything good for the patient is acceptable. But if his body still processes food and hasn't started shutting down yet, then why shouldn't he continue to be cared for?

What I'm getting at is, isn't it a little presumptuous to say, 'This man is clearly suffering,' when we don't know that he is? Maybe he's 'suffering' because his body is no longer functioning and needs to be allowed to shut down. Fine. But maybe he's 'suffering' because someone on the hospital ethics committee thinks he's a burden and is draining resources and treatments to keep him alive and feeling good are being withheld.

People who start spewing the whole 'suffering' line remind me of Annie Wilkes in Stephen King's MISERY. The lady murdered perfectly healthy babies for years because the 'poor poor things' were CLEARLY suffering, since the world sucks.

I don't think we should transpose what we think of as suffering onto other people - do our damndest to keep those people feeling good and functioning as long as possible, and let their bodies do the rest. And that means *do* our damndest, meaning push for the absolute best care for everyone. Whatever it takes to get us to the point where everyone receives the best care right up to death, to make us as comfortable as possible until our bodies shut down. That's the best thing we can do.

At December 17, 2007 , Blogger said...

TE, I believe that "even if the patient is "suffering greatly" and asks for care to stop," " it would be the patient's judgment.

The links contradict the rabbi's statement.


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