Medical responsibility

[bunny]

Background: My fiance works in a large public hospital and is currently rostered onto a general medicine ward. In South Australia this means treating old people who are very near death (the mean age of admissions to her ward last week was 86). Very often in this sort of ward (at least once a week, usually more frequently) there is an elderly patient who suffers a medical crisis and a decision needs to be made regarding whether to treat the problem and prolong their life or whether to keep them comfortable while they die. Many (if not most) of these patients are are in an advanced stage of dementia and medical choices are made by their families - people who have often had no contact with the relative for many months and now have to make the decision about whether their quality of life is "worth" fighting for.

My question: In Australia, it has become the custom for doctors to leave decisions like this to the family. To provide information only and leave the ethical decision to them. My fiance feels that this is cowardly and an abrogation of responsibility - she feels that as a doctor, dealing with this regularly and further distanced emotionally than the relatives, she is far more qualified to make this decision. What do you think is right? She advocates for what she feels is in the patients best interests (even if this involves arguing against the families wishes) rather than leaving it to relatives. Should a doctor intervene in this way? Should the relatives be making these decisions?

[Copernicus]

I think it should be left to the family. They are the ones closest to understanding the patients wishes and how big a burden continuation of support is.

There is a case you might be interested in reading about that centers on families rights in these issues, including when there is a dispute between a spouse and the patients parents. (This isnt a geriatric situtaion but has similar issues, and is complicated by suspicions that the husband may have been the cause of the patients illness.)

There are a couple of new books out, but there should be plenty on the web about Terry Schiavo.

[hmkpoker]

The patient should legally specify earlier when s/he is still functional who s/he wants to make the decisions in the event of such an emergency. The patient is his own property.

Failing that (as the case obviously is), I feel that the family should get the say. The family, having strong emotional ties to the patient, has a greater incentive to provide wellness to the patient and to seek out beneficial measures, whereas the doctor does not know the patient, and cannot be expected to care.

[MidGe]

bunny,

there are many issues raised simultaneously in your post. Allow me to get the ball rolling to talk about my personal view. I am not currently suffering from dementia, nor diagnosed, nor likely to get it, I hope, but there are many other condtitions which may warrant similar line of questioning. I recently organised my affairs in such a way, as I would be able to take care of my own exit by myself, but should this not be possible (accident, sudden dematia, etc..) I have empowered my first wife to make the decision on my behalf, should the matter arise, and that has been documented. In fact to ensure that nothing is in the way, we are even consdering re-marrying. /images/graemlins/smile.gif

If possible, I do intend to bring about my own end. I know the conditions and the means I would use. This has been discussed at length with my wife also and she fully support my decision. I would absolutely hate the notion of interference by medecine or the law, in what I consider my business solely. BTW, I cannot see this happening within the next few years but most probably within a decade. I could change my mind, altough I doubt that. /images/graemlins/smile.gif

In australia it is illegal to use electronic means (telephone, we-mail etc... maybe even posting like this /images/graemlins/frown.gif ) to support or assist suicide in any way. A quick search on the net for Derek Humphry, whose book "Final Exit" was #1 New York Times bestseller list when it came out, goes a long way to de-mystify this important subject. At least one state in the US has legislation that facilitate this (Oregon from memory) for its residents. Switzerland has facilities that will take on foreigners.

Now, your question was more specifically with someone suffering dementia. In that case, would their family know better than a doctor (a stranger)? Hard to say, but I suggest they may remember things that the person had said about this possible event, whilst the doctor would know zilcho about it. Was it ever discussed? Are there any written instructions, etc...? Those would be other things that could have a bearing on this.

From my view point, if we consider humane to put a dog or a horse out of its misery, I don't understand why a similar compassion would not apply towards a human being.

[bunny]

Do either of you think the doctor should try and persuade the family if they believe the relatives are making a mistake?

The situation that often occurs is that the family havent seen the patient for many months and are oblivious to the fact that the patient has deteriorated into dementia. These are the situations where they often demand the most be done, mistakenly believing that the confusion and senility will disappear once the heart problem (or whatever) has been treated.

[bunny]

I agree with most of what you wrote here. I didnt phrase my initial question very well, but the situation my fiance often finds herself in is that (in her opinion) the family are making a mistake. Now, she doesnt advocate ignoring their wishes - and of course complies with their directives. What she does, that is pretty much frowned on by the medical establishment, is to give advice - sometimes advocating agressive treatment if she believes there is a halfway decent chance of a good quality of life later. Other times she advocates palliative care and "death with dignity". Accepted medical wisdom seems to be that she should offer no advice whatsoever - which seems a little cowardly to me.

[Copernicus]

[ QUOTE ]
Do either of you think the doctor should try and persuade the family if they believe the relatives are making a mistake?

The situation that often occurs is that the family havent seen the patient for many months and are oblivious to the fact that the patient has deteriorated into dementia. These are the situations where they often demand the most be done, mistakenly believing that the confusion and senility will disappear once the heart problem (or whatever) has been treated.

[/ QUOTE ]

There is a fine line between informing and persauding which I think is difficult not to cross at times, but do think that the doctors role lies on the informing side.

[bunny]

nod - thanks. It might be best for me to think about it in terms of what do you most want to avoid? It is probably worse to let someone die you really shouldnt have than to keep someone alive who would have preferred to die had they been able to make a decision for themselves.

[hmkpoker]

[ QUOTE ]
Do either of you think the doctor should try and persuade the family if they believe the relatives are making a mistake?

[/ QUOTE ]

I don't see how that's necessary. A concerned family shouldn't have to be pursuaded, they should actively seek the advice of a medical expert to inform their decision. That's their responsibility not only as caring relatives, but as de facto property owners (when the patient can no longer exercise his property rights)

[MidGe]

bunny,

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...the family are making a mistake...

[/ QUOTE ]

Who really knows?


[ QUOTE ]
...if she believes there is a halfway decent chance of a good quality of life later...

[/ QUOTE ]

That latter quote is a viewpoint I disagree with. Half -decent, or even certainly, may not be sufficient cause in my opinion. But I know that I am more radical than most when it comes to that and really my issue has/had been that there is real clarity about my decision and I would be really more than miffed if it was interfered with in any way by anyone.

Medecine can/should offer information, but should not make the decision unless they have had more recent patient indication about his/her wishes than the family.

[bunny]

The situation I was referring to was where there was never a view expressed. I dont think you need to be worried that medicos will try to interfere in your wishes given you have made them so clear - it seems to me that most doctors support a patient's right to die.

[bunny]

[ QUOTE ]
[ QUOTE ]
Do either of you think the doctor should try and persuade the family if they believe the relatives are making a mistake?

[/ QUOTE ]

I don't see how that's necessary. A concerned family shouldn't have to be pursuaded, they should actively seek the advice of a medical expert to inform their decision. That's their responsibility not only as caring relatives, but as de facto property owners (when the patient can no longer exercise his property rights)

[/ QUOTE ]
It's necessary when they dont seek out advice (whether they should or not). People often make decisions for their own benefit rather than for the suffering patient in these situations (eg by keeping the patient alive so they dont have to face the responsibility of making the choice without realising that this in itself constitutes a choice).

[hmkpoker]

[ QUOTE ]
It's necessary when they dont seek out advice (whether they should or not).

[/ QUOTE ]

Necessary for whom/what? What if the relatives don't think the patient should be kept on life support, as was the case with Terry Schiavo? Why should the state get to decide on a matter that is only important to the family?-

[bunny]

Err I think you have misunderstood - I'm not advocating that at all. My question is - should the doctor volunteer advice if they think the patient's family is making a poor judgement? Or should they stand by silently offering medical information but not ethical advice? I dont think the doctor should be given the choice of overruling the patient's family.

As to being necessary - I was responding to your point that it shouldnt be necessary because the family should seek out all information. The fact is, people dont always do that. So I mean necessary in order for the family to be in a position to make the right decision.

[vhawk01]

I've just read this thread, and it brings up some very challenging questions for health professionals, and for doctors in particular. I am a first year medical student and we go to lengths to at least familiarize ourselves with this and other similar situations, so that we know what to expect when we encounter them. However, I am a student in the United States, and specifically in an area that still outlaws physician assisted suicide and euthenasia.

One of the key misconceptions that lay people, and apparently a large number of health care professionals, seem to have is that the role of the doctor is to save lives. This pervades all of our decisions, but it really isn't true. We aren't there to make decisions regarding life, AND our goal is more to improve quality of life than life itself. With these in mind, my opinion obviously comes down on the side of the family being responsible. Its best to pretend that the family 'making a mistake' is EXACTLY analogous to a patient 'making a mistake.' This is perhaps a stretched analogy, but I think it is the only one. Your job is, WITHOUT proselytizing, to provide all of the information and options, and then simply allow the patient to choose what they wish. It is NEVER to cajole or convince. Your conception of the patient's best interest is almost entirely immaterial.

The other side of this coin is that it is also NOT the physicians job to be a servant to patients. We are not Burger King employees, and we do not allow the patients to 'have it their way.' They can choose from medically necessary options, as defined by the health care staff, or they can opt out of these, but they are not in a position to demand physicians serve them and provide unnecessary care. Basically, a medical decision has to be both necessary (as determined by the physician) and wanted (as determined by the patient, or in lieu of this the guardians or legal decision-makers) so that the final decision, whether to pursue or not a specific option, really is an agreement. Your fiancee's opinions and personal beliefs come into play on the 'necessary' side of the equation, not on the 'wanted' side.

[Darryl_P]

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BTW, I cannot see this happening within the next few years but most probably within a decade.

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/images/graemlins/shocked.gif /images/graemlins/shocked.gif /images/graemlins/shocked.gif WTF!!?? /images/graemlins/shocked.gif /images/graemlins/shocked.gif /images/graemlins/shocked.gif

Did you elaborate on this somewhere before or why am I the only one shocked by this statement?

[Darryl_P]

[ QUOTE ]
... she feels that as a doctor, dealing with this regularly and further distanced emotionally than the relatives, she is far more qualified to make this decision. What do you think is right?

[/ QUOTE ]

With all due respect to you your fiancee, she can't possibly be more qualified than the family to make the decision, unless she happened to be very close to the patient on a personal level as well.

She can (and should IMO) explain to the family all the implications of the various options they can choose from. Certainly she would know the most about those, but the decision itself deals with death -- the ultimate personal decision.

The most qualified person to answer that is the person himself. The next most qualified is the person who is closest to the person in question. Depending on who it is, it could be a spouse, a best friend, a family member, or someone else. Naturally it's a judgment call and maybe the doctor could give some input on that if there is no clear candidate. But the doctor himself (or herself) is definitely not the right choice, unless of course he (she) also happened to be the patient's best friend, say.

[MidGe]

Hiya Darryl_P,

Are you shocked because you expected it sooner? /images/graemlins/smile.gif

No, I have not elaborated on this forum. I tend to talk in those terms to friends and closer acquaintances, so that it will not come as a surprise and neither will it be a misconstrued act.

I don't really wish to hijack this thread as it is a very interesting one of itself. I am quite happy to contribute to any thread regarding voluntary euthanasia, if there is some interest, I also think it an important topic.

Cheers.

[Darryl_P]

I think the doctor can ask several times a question like: "Are you sure you've considered all the implications like X, Y, and Z?"

Also, it might not be a bad idea to require a certain period like 2 or 3 days between the time the family decides death and the time it's actually carried out. There would be a good chance that they change their mind in the interim. And even if they don't, a decision made over a period of days will always be better than a rush to judgment.

But to take a side on the issue and try to convince the family is a no-no IMO.

[Darryl_P]

[ QUOTE ]
These are the situations where they often demand the most be done, mistakenly believing that the confusion and senility will disappear once the heart problem (or whatever) has been treated.


[/ QUOTE ]

Here the issue is mainly one of resources. Like the ACers on this forum I don't agree with demanding that other people spend their money on anything I decide. Naturally an expensive option will be attractive to the family if they're not the ones who have to pay for it. I say make 'em pay for it and then see what they decide!!

Or if that's not practical, make them pay a hefty insurance co-payment. If it costs them nothing then the whole system is seriously flawed.

[Darryl_P]

[ QUOTE ]
Hiya Darryl_P,

Are you shocked because you expected it sooner?



[/ QUOTE ]

Hey MidGe,

LOL, no...I'm shocked because your posts seem youthful and energetic, not like someone who has less than a decade to live.

I agree it's an important topic and it's especially enjoyable when real life situations are involved...you get the illusion that you're making a difference to someone lol /images/graemlins/grin.gif

[vhawk01]

This seems like a really....icky...consideration. I couldn't think of a better term. You really think that the financial burden of the decision should be the main factor? I think that is abhorrent.

In regards to your other point, I agree that the doctor's role is to provide MEDICAL information and offer a MEDICAL opinion. This does NOT include choosing which option you would PERSONALLY prefer and then hammering that one home if they disagree.

This case would really be easier to discuss if there were specifics given. For instance, are we talking about performing some sort of procedure that, while repairing some malfunctioning system, will do absolutely nothing to improve either the length or quality of life? In this case it is well within the doctor's authority to refuse to perform the procedure, as it does no medical good to the patient. This is far different from proscribing some active measure that will shorten the life of a patient. There is no sound medical reason to ever shorten a patient's life (although you could argue there isn't ALWAYS a sound medical reason to prolong it either) so this can never be the sole medical option.

[bunny]

To give a specific example (and also to clarify what I meant as I just dashed it off without really reading it properly):

A 93 year old patient is admitted to hospital after a massive heart attack (publicly funded at no additional cost to them if people feel this is relevant). They have been living in squalid conditions, demented, unhealthy, confused and "enjoying" what most would consider a very poor quality of life. The patients family is contacted (they havent seen the relative for several years and have no idea how bad they have deteriorated in this time) and told that although there are operations and procedures that would prolong the patient's life, they are not without risk. Also, the procedures will not address the underlying dementia and other health problems the patient has been living with for several years (often unbenownst to the relatives). The family then insists that everything be done to keep the patient alive and returned to their home (where they live largely unsupported and in squalor). I agree that ultimately it has to be the patient's relatives who decide rather than the doctor. But should the doctor actively advocate letting the patient die with dignity (NOT by disregarding the relatives but rather by suggesting that this course of action is in the patient's best interests)?

Medical practise in Australia is that the doctor should offer NO advice. My fiance's position is not to kill everyone, nor to keep everyone alive no matter what. She feels that the medical fraternity has abrogated its responsibility to provide ethical guidance in situations like this - largely due to threat of legal action. I hope this clarifies what I meant and what my ethical question is.

(Also let me add that this situation, though severe, is by no means unique or unrealistic - it has happened to her several times in the last year).

[bunny]

[ QUOTE ]
With all due respect to you your fiancee, she can't possibly be more qualified than the family to make the decision, unless she happened to be very close to the patient on a personal level as well.


[/ QUOTE ]
Just to clarify - I dont mean more qualified to know what the patient would want were they able to express a view. I meant more qualified to weigh evidence when making life-or-death decisions and more qualified to divorce herself from her own wants or prejudices and to consider what is best for the patient - just from experiencing death and related issues day-in-day-out.

[pvn]

[ QUOTE ]
The family then insists that everything be done to keep the patient alive and returned to their home (where they live largely unsupported and in squalor).

[/ QUOTE ]

Of course, someone else is paying the bill, why not max it out?

The other alternative with state-supplied health is that since the state pays, they decide for you, instead of you deciding what you want. What if the state decides that a life-extending treatement is "wasteful" and denies it to you? If you could get treatment on your own, you could pay for it out of your own pocket if you really wanted it, but many states that supply healthcare outlaw private healthcare or make it very difficult to obtain.

Neither scenario is very appealing.

[ QUOTE ]
Medical practise in Australia is that the doctor should offer NO advice.

[/ QUOTE ]

In any situation, or just end-of-life situations? And how serious is this rule? Is it just a guideline, or a hard-and-fast order?

[ QUOTE ]
My fiance's position is not to kill everyone, nor to keep everyone alive no matter what. She feels that the medical fraternity has abrogated its responsibility to provide ethical guidance in situations like this - largely due to threat of legal action.

[/ QUOTE ]

Action from the state, or from families that make a decision and regret it later (or both)?

[madnak]

Are you sure experiencing death and related issues day-in-day-out doesn't result in its own bias? In my experience, people who deal with something too often lose a certain perspective.

[vhawk01]

Thank you for the additional information. Let me quickly add a caveat to my responses thus far and future: I'm only an MS1. I really enjoy debates about this, both with medical personnel and laypeople, because these issues are very controversial and completely unsettled, both in my own mind and in the U.S. and elsewhere in general. That being said, I will give my view as best I can, in the idealistic goal that I am representing the view that American physicians are supposed to have.

It is never appropriate for a doctor to advocate measures that would shorten a patient's life, in and of themselves. There are apparent exceptions to this, but they are only apparent exceptions. For instance, it is reasonable to prescribe a course of treatment that involves elevating pain medications to a point where they may eventually interfere with respiration and lead to death. But the justification for this is that the pain meds themselves ARE indicated by the uncontrollable pain that the patient is feeling. (This is sometimes not the case, depending on the state laws and guidelines). But you cannot simply prescribe a morphine overdose for a patient that wants to die. This is the difference between Oregon hospitals and Dr. Kevorkian.

In your above example, I would find it very unproffesional for your fiance to 'advocate' any course of treatment that was not medically necessary. The heart surgery, while obviously carrying its own risks, is indicated by the patients condition. Therefore, the doctor's role should be to advocate for the treatment. I'm obviously not familiar with this case in particular or really any general concerns about alternative procedures, but lets stay general here. The patient 'needs' a procedure, this much is agreed upon. Just because you personally feel that the patient will not get much out of continuing to live, this has NO bearing on the medical decision. Not only is it completely inappropriate to advocate doing nothing and allowing the patient to die, the physician should be more or less actively advocating for the procedure. At the very least, the physician should explain the options, and recommend someone else to consult about 'other' options. Perhaps a chaplain, or someone from palliative care?

What it comes down to, for me, is that the medical staff serves a very specific role in the health care system. I am incredibly leery of this role expanding into realms of 'moral' decisions, or even more alarmingly, spiritual ones. As a person, I am strongly in favor of the notion that any person should have a right to determine their own fate, and think euthenasia and assisted-suicide are perfectly reasonable and acceptable procedures. They just aren't medical procedures.

I hope that I have been able to keep seperate my own views and what I see as the medical communities views on this topic. Its really hard to do! Again, I am but a lowly MS1 and so am fairly naive when it comes to issues like this, so don't take me too seriously.

[bunny]

[ QUOTE ]
[ QUOTE ]
Medical practise in Australia is that the doctor should offer NO advice.

[/ QUOTE ]

In any situation, or just end-of-life situations? And how serious is this rule? Is it just a guideline, or a hard-and-fast order?

[/ QUOTE ]
I think it is more "the done thing" than a legislated rule as to what you can and cant say.

[ QUOTE ]
[ QUOTE ]
She feels that the medical fraternity has abrogated its responsibility to provide ethical guidance in situations like this - largely due to threat of legal action.

[/ QUOTE ]

Action from the state, or from families that make a decision and regret it later (or both)?

[/ QUOTE ]
Action from families who claim they were forced into making a choice they now regret.

[vhawk01]

[ QUOTE ]
Are you sure experiencing death and related issues day-in-day-out doesn't result in its own bias? In my experience, people who deal with something too often lose a certain perspective.

[/ QUOTE ]

This is a great point, and really is only one of MANY potential complications with allowing medicine to go in this direction. As someone in favor of euthenasia or assisted-suicide or whatever you want to call it, I think it is completely unrelated to the health-care system, and should remain so.

[vhawk01]

[ QUOTE ]
[ QUOTE ]
[ QUOTE ]
Medical practise in Australia is that the doctor should offer NO advice.

[/ QUOTE ]

In any situation, or just end-of-life situations? And how serious is this rule? Is it just a guideline, or a hard-and-fast order?

[/ QUOTE ]
I think it is more "the done thing" than a legislated rule as to what you can and cant say.

[ QUOTE ]
[ QUOTE ]
She feels that the medical fraternity has abrogated its responsibility to provide ethical guidance in situations like this - largely due to threat of legal action.

[/ QUOTE ]

Action from the state, or from families that make a decision and regret it later (or both)?

[/ QUOTE ]
Action from families who claim they were forced into making a choice they now regret.

[/ QUOTE ]

And of course, the problem is, how can you be sure they weren't?

[bunny]

[ QUOTE ]
Are you sure experiencing death and related issues day-in-day-out doesn't result in its own bias? In my experience, people who deal with something too often lose a certain perspective.

[/ QUOTE ]
I think you're right that it brings its own problems. I still think someone who experiences it daily will be better able to avoid the situation of emotional or personal issues clouding their judgement.

[vhawk01]

[ QUOTE ]
[ QUOTE ]
Are you sure experiencing death and related issues day-in-day-out doesn't result in its own bias? In my experience, people who deal with something too often lose a certain perspective.

[/ QUOTE ]
I think you're right that it brings its own problems. I still think someone who experiences it daily will be better able to avoid the situation of emotional or personal issues clouding their judgement.

[/ QUOTE ]

Unfortunately, there is no 'scientific' or objective answer, though. Emotion and personal issues ARE judgment, in issues like this! Is there some 'right' answer to who should continue to live and who shouldn't, that the doctor's are in a better position to judge?

[bunny]

[ QUOTE ]
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Action from families who claim they were forced into making a choice they now regret.

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And of course, the problem is, how can you be sure they weren't?

[/ QUOTE ]

This is clearly a problem with providing ethical advice in this situation. The fear is that people are now getting a reduced service from their doctor because the doctor is frightened of getting sued - this is a bad reason to refrain from giving advice imo (although refraining on the grounds of differentiating moral from medical advice, as you advocated above, is not a bad reason).

Thanks for your response. (I should perhaps hasten to add that all this musing is on my behalf - my fiance finds the practise a cop-out (and peculiarly australian) but follows the widely agreed practise.

[bunny]

[ QUOTE ]
The heart surgery, while obviously carrying its own risks, is indicated by the patients condition. Therefore, the doctor's role should be to advocate for the treatment. I'm obviously not familiar with this case in particular or really any general concerns about alternative procedures, but lets stay general here. The patient 'needs' a procedure, this much is agreed upon. Just because you personally feel that the patient will not get much out of continuing to live, this has NO bearing on the medical decision. Not only is it completely inappropriate to advocate doing nothing and allowing the patient to die, the physician should be more or less actively advocating for the procedure.

[/ QUOTE ]
This is interesting because (at least here) there are times when the medical fraternity says "Well, you need the procedure and it would (probably) extend your life but you're too old so we're not going to do it." This is done by a board of medicos rather than just one doctor, of course and there are guidelines or indicators as to when the procedure should be attempted (no bypasses for 90 year old chain smokers, etc) it does indicate though, that there are times when the medical fraternity advocates "giving up"

[bunny]

[ QUOTE ]
Of course, someone else is paying the bill, why not max it out?

The other alternative with state-supplied health is that since the state pays, they decide for you, instead of you deciding what you want. What if the state decides that a life-extending treatement is "wasteful" and denies it to you? If you could get treatment on your own, you could pay for it out of your own pocket if you really wanted it, but many states that supply healthcare outlaw private healthcare or make it very difficult to obtain.

Neither scenario is very appealing.


[/ QUOTE ]
I didnt know other countries banned private healthcover. Here there is a socialised health system that means nobody will die from being broke. But if you want bells and whistles you need to get private cover.

[vhawk01]

[ QUOTE ]
[ QUOTE ]
The heart surgery, while obviously carrying its own risks, is indicated by the patients condition. Therefore, the doctor's role should be to advocate for the treatment. I'm obviously not familiar with this case in particular or really any general concerns about alternative procedures, but lets stay general here. The patient 'needs' a procedure, this much is agreed upon. Just because you personally feel that the patient will not get much out of continuing to live, this has NO bearing on the medical decision. Not only is it completely inappropriate to advocate doing nothing and allowing the patient to die, the physician should be more or less actively advocating for the procedure.

[/ QUOTE ]
This is interesting because (at least here) there are times when the medical fraternity says "Well, you need the procedure and it would (probably) extend your life but you're too old so we're not going to do it." This is done by a board of medicos rather than just one doctor, of course and there are guidelines or indicators as to when the procedure should be attempted (no bypasses for 90 year old chain smokers, etc) it does indicate though, that there are times when the medical fraternity advocates "giving up"

[/ QUOTE ]

Perhaps you are right about that. I think this has more to do with the likelihood of surviving the surgery, however. Like, the patient is so old and weak that they will almost certainly suffer more as a result of likely complications/recovery than they would from simply abstaining from the procedure. I cant imagine a person whi is undergoing an MI hearing, "Yeah, but he's really old, don't bother cracking him." Perhaps I am wrong?

[bunny]

[ QUOTE ]
Perhaps you are right about that. I think this has more to do with the likelihood of surviving the surgery, however. Like, the patient is so old and weak that they will almost certainly suffer more as a result of likely complications/recovery than they would from simply abstaining from the procedure. I cant imagine a person whi is undergoing an MI hearing, "Yeah, but he's really old, don't bother cracking him." Perhaps I am wrong?

[/ QUOTE ]
I dont really know - all my information is second hand but I believe they do exactly this. I could easily be wrong though.

[Darryl_P]

[ QUOTE ]
I meant more qualified to weigh evidence when making life-or-death decisions and more qualified to divorce herself from her own wants or prejudices and to consider what is best for the patient - just from experiencing death and related issues day-in-day-out.

[/ QUOTE ]

Has she ever asked a patient after he died whether it was the right decision or not? If not, then how could she know if she ever made a single correct decision (on the death issue)?

[Darryl_P]

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You really think that the financial burden of the decision should be the main factor? I think that is abhorrent.


[/ QUOTE ]

I find it abhorrent that you think it's ok to steal money from me at gunpoint to have a 0.2% probability of saving your dying relative.

[MidGe]

[ QUOTE ]
Has she ever asked a patient after he died whether it was the right decision or not?

[/ QUOTE ]

/images/graemlins/smile.gif

[Darryl_P]

Besides, my point was not that the financial stuff should be the main consideration but rather that, in the case bunny described, it is whether anyone likes it or not.

People are being offered a chance to snap their fingers and have tens of thousands of dollars of other peoples' money spent on their relative. Even if they get only $50 of benefit from it they are financially better off by choosing to do it.

I think any system which gives ordinary people such power is a totally flawed system.

And this flawed system is at the root of the dilemma faced by bunny's fiancee in at least some situations.

That is my point.

[bunny]

[ QUOTE ]
[ QUOTE ]
I meant more qualified to weigh evidence when making life-or-death decisions and more qualified to divorce herself from her own wants or prejudices and to consider what is best for the patient - just from experiencing death and related issues day-in-day-out.

[/ QUOTE ]

Has she ever asked a patient after he died whether it was the right decision or not? If not, then how could she know if she ever made a single correct decision (on the death issue)?

[/ QUOTE ]
You really havent understood what I meant. I did not mean more qualified to make the right decision - I meant more qualified to divorce emotion and her own personal issues from the decision at hand. I would also repeat that she has never made a decision (on the death issue). The ethical question is should she give advice to the family (who will then make the decision) or should she just leave them to struggle in a situation they are unused to dealing with (without all the information).

[Darryl_P]

Those nuances of whether she actually makes the decision or not when she persuades the family or "gives advice" pale in comparison to the key issue at hand, ie. is she qualified to form an opinion about death itself when she cannot possibly have a clue what it is like and therefore what weight should be assigned to it when compared with the other factors that I'm sure she knows very well.

All it takes is one of the numbers in a long sum to be unknown to make the sum itself unknown. I suppose you know that, though, so I'm not sure why you are focusing on the secondary issues of how strongly she persuaded people etc. when the philosophical question is much larger and more important IMO.

Giving advice on the issue is impossible without taking a side on the issue. Taking a side is wrong IMO. Do you not agree with this?

[DrewDevil]

At least in the United States, persons are free to draft a living will and/or directive to physicians to provide "clear and convincing evidence" about their wishes in these situations.

In the absence of evidence like this, I believe the doctor's responsibility is to "do no harm." (Yes, I think I read that somewhere.)

The idea of a family using financial considerations to justify killing off one of their own is at best abhorrent and at worst obscene.

[bunny]

[ QUOTE ]
Giving advice on the issue is impossible without taking a side on the issue. Taking a side is wrong IMO. Do you not agree with this?

[/ QUOTE ]
I dont really know - that was the point of the question. I guess my gut feeling is that the doctor should offer medical advice (obviously) but should also give advice as to quality of life post-procedure, including subjective issues like dignity. This is not what either my fiance or the rest of the medical fraternity actually do though - she feels this is an abrogation of responsibility through fear of legal action (ie that families of patients are being asked to make decisions far beyond their experience or knowledge and that doctors will no longer provide any guidance in case they get sued). Of course I am not claiming that doctors will always get it right, nor that they should be vested with the power to "make the call". However, I do think they have a role in assisting the family with the decision (and a role which is broader than just providing medical information on rates of success, side-effects, etc)

[bunny]

[ QUOTE ]
Those nuances of whether she actually makes the decision or not when she persuades the family or "gives advice" pale in comparison to the key issue at hand, ie. is she qualified to form an opinion about death itself when she cannot possibly have a clue what it is like and therefore what weight should be assigned to it when compared with the other factors that I'm sure she knows very well.

[/ QUOTE ]
I dont think the point is that the doctor knows best with regard to death. I think the point is that a relative may not want to be responsible for making the final decision, even if it is in the patient's best interests. In other words, they will not condone "giving up" but the motivation for that is their feelings and wants rather than those of the patient's. A doctor is just as clueless with regard to death and possibly less knowledgeable about what the patient would have wanted (although again, there are situations where the relatives are basing these decisions on the patient as they remember them several years ago, rather than in their current state) - they are better at maintaining a rational rather than an emotive perspective though (that would be my claim, anyhow).

[Darryl_P]

[ QUOTE ]
I think the point is that a relative may not want to be responsible for making the final decision, even if it is in the patient's best interests. In other words, they will not condone "giving up" but the motivation for that is their feelings and wants rather than those of the patient's.

[/ QUOTE ]

So basically we have a situation where the family is irrational, not too intelligent or informed, couldn't truly give a crap about the relative, and doesn't like accepting responsibilities, while the doctor has the opposite of these qualities.

Does all this justify the doctor getting involved in questions beyond his/her expertise? I still say no.

Once you get into subjective areas like dignity for example, you are going into personal territory where you have no place. They may live their lives in an extremely primitive way and you might have 1000 ideas as to how to make it better, but as a doctor it is not your role to get involved in that. For them dignity might mean hanging turds from the ceiling in a certain way. That kind of information will never get out into the open, and IMO it is in the interest of their dignity that it doesn't.

They may not be able to process all of the info. from the doctor correctly, but that still doesn't give the doctor the right to influence how they choose to live their lives.

It's with noble intentions that your fiancee wants to help them but let's not forget that over 99% of the time someone f's things up for someone else it's with good intentions.

If you had a relationship with these people on the side then that might be different.

Basically I'm repeating myself here and the question is subjective to be sure, but this is where I come out. I am strongly opposed to any of society's representatives getting involved in people's personal lives even if it is to "help" them. I suppose this is correlated to my political views but it's probably best if we don't go there in this thread. If your political views are different, then maybe it makes sense to think about what course of action by your fiancee is most consistent with those.

[Darryl_P]

[ QUOTE ]
In the absence of evidence like this, I believe the doctor's responsibility is to "do no harm." (Yes, I think I read that somewhere.)


[/ QUOTE ]

OK but this is a rather subjective way to put it (probably deliberately) and so the question at hand is: what does it mean to "do no harm" in certain situations?

[ QUOTE ]
The idea of a family using financial considerations to justify killing off one of their own is at best abhorrent and at worst obscene.

[/ QUOTE ]

Trouble is that, if a procedure costs a lot of money, then there is no getting around "using financial considerations". Financial considerations are not there because I'm a jerk. They are there because they are there, plain and simple.

You either use your own money or you get it from someone else. If you get it from someone else, then you either steal it or get it from voluntary donations. The way the current system is set up, they are able to steal it without repercussions. I'm not OK with this, but if you are, then why not just come out and say it?

[DrewDevil]

I would say "do no harm" pretty clearly means "do not kill your patient."

I agree that financial considerations are always present, but we're not talking about a life-saving procedure, we're talking about assisted suicide.

Saving the family money is not a reason to support allowing assisted suicide. That's what I mean by obscene.

[Darryl_P]

Are you sure it's as clear cut as you make it sound?

Patient A needs a $10 treatment to survive. Choosing not to do it would obviously be assisted suicide.

Patient B needs to be placed on machines which cost $200k per year to operate to survive, and even then his mental state will never be more than vegetative.

Would someone choosing not to use those machines be committing assisted suicide?

Would the doctor be breaking the "do no harm" rule?

If it were your call, would you have him connected to the machines for 20 years at a cost of $4 million if the patient were:

a) a random person
b) a close friend or relative
c) yourself

?

Just curious...

[bunny]

Thanks for your answers. Just to clarify - my fiance insists that I explain that although she believes doctors should be involved as more than providers of medical facts, she doesnt go against accepted practise (I had misunderstood her) and just grits her teeth, disagreeing with some of the decisions she sees being made. My apologies to her for mistating her position (especially to those of you here who know her directly or indirectly) /images/graemlins/frown.gif

[Darryl_P]

No problem. It was good of you to make this thread for the reality elements make it very interesting.http://www.runemasterstudios.com/graemlins/images/thumbsup.gif

FWIW I don't think you misrepresented her at all. Your formulations were general enough to be interpreted lots of ways.

[DrewDevil]

[ QUOTE ]
Are you sure it's as clear cut as you make it sound?

Patient A needs a $10 treatment to survive. Choosing not to do it would obviously be assisted suicide.

Patient B needs to be placed on machines which cost $200k per year to operate to survive, and even then his mental state will never be more than vegetative.

Would someone choosing not to use those machines be committing assisted suicide?

Would the doctor be breaking the "do no harm" rule?

If it were your call, would you have him connected to the machines for 20 years at a cost of $4 million if the patient were:

a) a random person
b) a close friend or relative
c) yourself

?

Just curious...

[/ QUOTE ]

I'm getting a little lost in all the doublespeak here.

Assisted suicide is an affirmative act where the doctor actually kills the patient (by injection or whatever).

Not giving a patient treatment is not assisted suicide, and certainly it is not "doing harm." By that tortured logic, any time a doctor stops treatment on a dying patient would be assisted suicide.

[Darryl_P]

[ QUOTE ]
Assisted suicide is an affirmative act where the doctor actually kills the patient (by injection or whatever).


[/ QUOTE ]

OK, at least I know more about your position on the issue.

Do you believe there is such a thing as a "sin of omission"? If not, then you are at least consistent, but then be aware that there is plenty of high-level logic that can be used to argue about such a thing not only existing, but being equally wrong as sins of commission.

If so, then if a sin can be committed without an affirmative act, then why couldn't assisted suicide?

[DrewDevil]

Because death is an inevitability in a world of finite resources. As I said, your interpretation would mean that every time a patient died, it would be assisted suicide, because the doctor failed to exhaust all possible resources to save the patient.

[Darryl_P]

[ QUOTE ]
As I said, your interpretation would mean that every time a patient died, it would be assisted suicide, because the doctor failed to exhaust all possible resources to save the patient.

[/ QUOTE ]

Not at all! My interpretation says it depends on the cost/benefit of the stuff that needs to be done. It effectively puts a price on a life which, as I understand, you find repulsive.

Note that I'm not the creator of this price-for-life concept. Rather, it is what I observe in other peoples' behavior around me and I take it as a natural part of the world, much like the oxygen content of our atmosphere.

I was under the impression that you would want to expend the world's resources to save a life, but I suppose I misunderstood. Instead, it looks like you are arguing for euthanasia under the proviso that there is no active involvement from anyone else.

In this case, I'd argue that doing nothing when the something you could do is very trivial and extremely beneficial is equivalent to active involvement. It's the classic sin of omission vs. sin of commission argument.

I should say that I'm for euthanasia even WITH active involvement (if certain conditions are present) but that's tangential to the point we're discussing.

Finding out your beliefs and challenging their logical consistency is much more interesting for me, even if the beliefs are different from mine.

[DrewDevil]

It's certainly not a black and white issue, but you are misunderstanding what I think is repulsive.

a) Withdrawing medical treatment because the patient is in great suffering and has no hope of recovery is humane.

b) Withdrawing medical treatment because the patient's medical care could be a drain on family's resources is obscene.

I am not sure how I feel about how assisted suicide (affirmatively killing the patient) enters into all this.

[Darryl_P]

Your point a) seems sensible enough.

Your point b) OTOH is inconsistent with the notion that there is a price for life. Whatever this price is, if the procedure costs more, then the rational decision would be to reject it. If it costs less, then it should be accepted. I don't see how such a natural and self-explanatory situation could be considered obscene.

If OTOH you are not OK with the concept of a price for life, then why don't you just come out and say it?

[Darryl_P]

Rereading my post I think the last line is unduly confrontational. I have a bad habit of sounding like that sometimes. Sorry about that.

I guess I'm just asking where you stand on the price-for-life issue, ie. is there some price for a life-saving procedure below which it's correct to perform it and above which it's correct not to? Assume the person in question is not suffering and doesn't want to die. If it depends on who is footing the bill, does the price still exist in all cases but varies according to the bill-payer or are there some bill-payers for whom a price doesn't exist?

My only purpose for asking is to find logical consistency in your views, nothing more and nothing less. I believe at least one of us (probably both of us) can learn from such an exercise and there's really no downside, so it looks like a good deal...

[vhawk01]

[ QUOTE ]
I would say "do no harm" pretty clearly means "do not kill your patient."

I agree that financial considerations are always present, but we're not talking about a life-saving procedure, we're talking about assisted suicide.

Saving the family money is not a reason to support allowing assisted suicide. That's what I mean by obscene.

[/ QUOTE ]

If the phrase 'do no harm' were really as clear cut as you make it out to be, there wouldn't be medical ethics review boards. Also, to be fair, the Hippocratic Oath, while something that most medical students are forced to give lip service to, and some physicians may be familiar with, is not a legally binding contract. You should read the entirety of it sometime. There are some truly outdated concepts in there which would most certainly NOT be legally acceptable by today's physicians.

[vhawk01]

[ QUOTE ]
It's certainly not a black and white issue, but you are misunderstanding what I think is repulsive.

a) Withdrawing medical treatment because the patient is in great suffering and has no hope of recovery is humane.

b) Withdrawing medical treatment because the patient's medical care could be a drain on family's resources is obscene.

I am not sure how I feel about how assisted suicide (affirmatively killing the patient) enters into all this.

[/ QUOTE ]

Perhaps I am putting words in your mouth, but it seems to me that what you find obscene is a differential standard of care. It isnt abhorrent or obscene that at some point the expenditure of resources needs to be curtailed, its that this 'point' is different for people for different economic status.