When Families Demand Treatment the Physician Believes Inappropriate: New Challenges in End-of-Life Care
On March 24th, John Paris, Professor of Ethics in the Theology department at Boston College, spoke on the ethical problems that arise when, at the end of life, families enter and demand treatment that the physician believes to be inappropriate.
Paris spoke of two distinct eras in end of life debates. From the time of the Hippocratic Oath until 1960, there was little change in what medicine could provide to the dying other than palliative care. In the 1960’s, dramatic innovations in medical technology resulted in the ability to sustain life for longer and longer periods of time. Between 1960-1990, we also saw the emergence of third party payment, which Paris says was “like giving people an American Express Gold card”, feeding a tremendous expansion in the demand for medical treatment. Two values also emerged at this time, which Paris sees as originating in a culture of autonomous rights and rampant selfinterest. These values are that 1) cost should not be a consideration in medical treatment, and 2) everyone should have equal access to the medical treatment they need. This has resulted in what Paris sees as an untenable system in which people expect the best quality of medical care for everyone but are unwilling to pay for it. These issues are illuminated at the end of life when families, unwilling to let go of loved ones, demand that doctors do everything in their power to extend the life of the patient, regardless of cost or outcome. This raises an ethical dilemma, namely, “Who gets to decide what to do in this case?” Plato and Hippocrates argued that the doctor is in the best position to exercise the moral judgment necessary. The courts have decided that in judgments of value between doctors and patients, patients will always win. The economist Lester Thurow argued that society must collectively decide what is bad medicine, or else the market will control these decisions through one’s economic ability to pay.
The timing of Paris’ talk followed almost immediately on a recent statement from the Vatican which Paris incorporated into his talk in a critical fashion. Until recently, the Vatican’s “Declaration on Euthanasia” (1980) stated that account should be taken of the “reasonable wishes of families” and the “judgment of doctors.” This view has been revised however by an address by the Pope to a conference of the World Academy of Catholic Medical Associations and the Pontifical Academy of Life on March 20th of this year stating that: “The sick person in a vegetative state, awaiting recovery or a natural end, still has the right to basic health care (nutrition, hydration, cleanliness, warmth, etc.), and to the prevention of complications related to his confinement to bed…I should like particularly to underline how the administration of water and food, even when provided by artificial means, always represents a natural means of preserving life, not a medical act. Its use, furthermore, should be considered, in principle, ordinary and proportionate, and as such morally obligatory, insofar as and until it is seen to have attained its proper finality, which in the present case consists in providing nourishment to the patient and alleviation of his suffering” ~ John Paul II, March 20 2004