Futility and Hospital Policy

Hospital futility policies are ethically defensible, but they require the proper understanding of futility and should be embedded in a larger process for making decisions about limiting treatment.     

A Futile Use of Futility

As the rates of intravenous opioid use have increased, so have its associated medical complications, such as endocarditis, and known interventions, such as heart-valve replacements. For many patients, including Jacob, whose case was brought to my psychiatric consult service and to my colleagues in the clinical ethics service, relapse increases the risk of repeat endocarditis and the need for repeat surgical interventions. Previous works have posed the bioethical quandary regarding the responsibilities of a surgeon in these repeat procedures and whether a surgeon may ethically refuse to perform a repeat intervention in a patient who has relapsed. Notions of futility are commonly used to navigate this complex terrain, and they were the focus of the ethics consideration given to Jacob's case, in which surgeons were reluctant to perform valve replacements. In this narrative essay, I interrogate the concept of futility by appealing to its history and variable meanings, and I argue against its relevance in cases like Jacob's. I propose that a more suitable bioethical approach in such cases would consider resource allocation, the sociocultural stigma of addiction, and the interpersonal and narrative factors that make each case unique.     

Futility, conscientious refusal, and who gets to decide

Most discussions of medical futility try to answer the Futility Question: when is a medical procedure futile? No answer enjoys universal support. Some futility policies say that the health care provider will answer this question when the provider and patient (or surrogate decisionmaker) cannot agree. This raises the Decision Question: who has the moral authority to decide what to do in cases where futility is disputed? I look for a procedural answer to this question, an answer that does not turn on whether a given party happens to answer the Futility Question correctly. I argue that these policies get it right; the provider should decide because providers have a right of conscientious refusal that extends to refusing procedures on grounds of futility. This is a procedural answer because providers have this right even if they are sincerely mistaken about whether a procedure is futile.     

Talking about Rights

Book reviewed in this article: Rights Talk: The Impoverishment of Political Discourse . By Mary Ann Glendon     

On Talking Together about Ordinary Abortion

The scarlet “A” that the protagonist of Nathaniel Hawthorne's seventeenth‐century novel is forced to pin to her dress symbolizes the shame and social disgrace that she endures for conceiving a child out of adultery. In Scarlet A: The Ethics, Law, & Politics of Ordinary Abortion, Katie Watson argues that abortion is our era's scarlet letter: a mark of stigma that is invisible yet no less shameful, causing unnecessary cultural silences around what is a remarkably common practice. In this brilliant new book, Watson draws on legal proceedings, bioethics literature, and personal experience; offers cultural and literary analysis; and uses her unique vantage point as a lawyer, bioethicist, and medical educator to develop a thought‐provoking and thoroughly fresh perspective on one of the most divisive moral issues of our time.     

What About the Family?

The prevalent ethic of patient autonomy ignores family interests in medical treatment decisions. Acknowledging these interests as legitimate forces basic changes in ethical theory and the moral practice of medicine.     

What We're Not Talking about When We Talk about Addiction

The landscape of addiction is dominated by two rival models: a moral model and a model that characterizes addiction as a neurobiological disease of compulsion. Against both, I offer a scientifically and clinically informed alternative. Addiction is a highly heterogenous condition that is ill-characterized as involving compulsive use. On the whole, drug consumption in addiction remains goal directed: people take drugs because drugs have tremendous value. This view has potential implications for the claim that addiction is, in all cases, a brain disease. But more importantly, it has implications for clinical and policy interventions. To help someone overcome addiction, you need to understand and address why they persist in using drugs despite negative consequences. If they are not compelled, then the explanation must advert to the value of drugs for them as an individual. What blocks us from acknowledging this reality is not science but fear: that it will ignite moralism about drugs and condemnation of drug users. The solution is not to cleave to the concept of compulsion but to fight moralism directly.