What I propose in this article is application of existing dispute resolution practices that take place outside the courtroom to the negotiating that takes place between health providers and families when they try to reach agreement about the limits of medical care that arguably is futile. Specifically, I focus on a bargaining paradigm that is associated with divorce proceedings, and suggest how this paradigm is at work in the conflict about futile treatment. At issue are not the well-publicized aspects of (...) high profile cases, but the rather unpublicized bargaining that goes no further than the clinical setting.Physicians and families who disagree about the futility of medical treatments frequently engage in give-and-take exchanges about whether to start disputed treatments, about what period of time might comprise a reasonable trial period if a treatment is to be administered, and about when and how to transfer a patient to another facility if the dispute cannot be resolved. (shrink)

“There's glory for you!”“I don't know what you mean by ‘glory,’ ” Alice said.Humpty Dumpty smiled contemptuously. “Of course, you dont—till I tell you. I meant ‘there's a nice knock-down argument.’”“But ‘glory’ doesn't mean a ‘nice knock-down argument,” Alice objected.“When I use a word,” Humpty Dumpty said, in rather a scornful tone, “it means just what I choose it to mean—neither more nor less.”“The question is,” said Alice, “whether you can make words mean so many different things.”“The question is,” said (...) Humpty Dumpty, “which is to be master, that's all.”When applied bioethics confronts the topic of futility, the question of who is to be master turns out to be central. Indeed, much of the literature on futility has focused on exactly this question: who gets to define the terms of the debate? Who gets to decide that treatment is “futile” and therefore allowably withheld or withdrawn? (shrink)

“There's glory for you!”“I don't know what you mean by ‘glory,’ ” Alice said.Humpty Dumpty smiled contemptuously. “Of course, you dont—till I tell you. I meant ‘there's a nice knock-down argument.’”“But ‘glory’ doesn't mean a ‘nice knock-down argument,” Alice objected.“When I use a word,” Humpty Dumpty said, in rather a scornful tone, “it means just what I choose it to mean—neither more nor less.”“The question is,” said Alice, “whether you can make words mean so many different things.”“The question is,” said (...) Humpty Dumpty, “which is to be master, that's all.”When applied bioethics confronts the topic of futility, the question of who is to be master turns out to be central. Indeed, much of the literature on futility has focused on exactly this question: who gets to define the terms of the debate? Who gets to decide that treatment is “futile” and therefore allowably withheld or withdrawn? (shrink)

In this article I will argue that futile medical and nursing care is not only inefficacious but that it may be harmful to the patient and also to health professionals, who may be diminished both as clinicians and as persons if they are not able to give appropriate care to dying patients and their families. I discuss futile care in intensive care units because the opportunities and the temptation to provide futile care in these settings is higher than, for instance, (...) in internal medicine and nursing home care. I argue, following two nurse ethicists, Carol Taylor and Colleen Scanlon, that, even if nurses are not the initiators of futile care, they play an important role in its prevention because of their clinical expertise. They can do this by convening ‘patient care conferences’ when they recognize the need to bring together the various parties that have conflicting expectations. These conferences would then result in appropriate palliative care. The nurses providing this care would demonstrate their understanding of the process whereby living becomes the process of dying. (shrink)

In situations where experience shows that a particular intervention will not benefit a patient, common sense seems to suggest that the intervention should not be used. Yet it is precisely in these situations that a peculiar ethic begins to operate, an ethic that Eddy calls “the criterion of potential benefit.” According to this ethic, “a treatment is appropriate if it might have some benefit.” Thus, the various maxims learned in medical school instruct physicians that “‘an error of commission is to (...) be preferred to an error of omission,’ or ‘when in doubt, cut it out’ or ‘if but one patient is helped, then the treatment is worthwhile.’”. (shrink)

Ever since the 1960s, when medical science became capable of prolonging the dying process beyond bounds that many patients would find acceptable, people have sought “death with dignity,” or “a natural death,” or “a good death.” Once debilitation from a fatal affliction has reached a personally intolerable point, dying patients have sought to control the manner and timing of death via diverse techniques. Some sought the disconnection of life-sustaining medical interventions, such as respirators and dialysis machines. Beyond freedom from unwelcome (...) interventions, some patients intent on avoiding suffering sought access to pain relief medication—even in dosages posing some risk of hastening death. Other dying patients sought access to deep sedation, even knowing that they would never emerge from the resultant unconsciousness. Still other patients voluntarily refused to eat or drink or to accept artificial nutrition and hydration. (shrink)

Ever since the 1960s, when medical science became capable of prolonging the dying process beyond bounds that many patients would find acceptable, people have sought “death with dignity,” or “a natural death,” or “a good death.” Once debilitation from a fatal affliction has reached a personally intolerable point, dying patients have sought to control the manner and timing of death via diverse techniques. Some sought the disconnection of life-sustaining medical interventions, such as respirators and dialysis machines. Beyond freedom from unwelcome (...) interventions, some patients intent on avoiding suffering sought access to pain relief medication—even in dosages posing some risk of hastening death. Other dying patients sought access to deep sedation, even knowing that they would never emerge from the resultant unconsciousness. Still other patients voluntarily refused to eat or drink or to accept artificial nutrition and hydration. (shrink)