Download service of intensive care to patients

INTENSIVE CARE AND FUTILITY
A Summary of
“Ethical Issues raised by Intensive Care”
(B. A. BRODY)
by
Chiu Bit Shing, Abraham, ofm
INTRODUCTION
In the conclusion of the article “Ethical Issues raised by Intensive Care,” B. A. Brody states
that too much attention is devoted to the fighting against the technological imperative and
the legitimacy of limiting care. He continues to say, the data of neonatal studies and
APACHEIII, on the contrary, shows that there are also cases where intensive care is of
great benefit and should be encouraged. Finally, he insists that we need to make sure that
ours of ICU care is a balanced casuistry, one has to recognize its benefits as well as its
cost.
STATE OF THE QUESTION
What is the purpose of intensive care? For the treatment of patients, intensive care is not
an end but a means. This means is to relieve suffering, regain health and control the
disease of the patients.
It is difficult to balance between requirement and providence of intensive care. Whenever
we give advice to the patients who require ICU service, the responsibility for and morality
of providing the best treatment for them are necessary. On the other hand, ICU service
requires money and human resources. Concerning money, patients have to opt according
to the price level. Regarding human resources, physicians serve as a gatekeeper to the
ICU.
Are the physicians morally free to take this single-minded approach to promote the
interests of the individual patient? Is anyone of us ever morally free to attend to only a
single set of considerations? Is the concept of physiological futility an attempt to do
precisely that the quality of life is the basis of the judgment?
Those are the questions we are concerned with the distributions of cost and human
resources to the patients in ICU, specifically, the futile patients.
SERVICE OF INTENSIVE CARE TO PATIENTS
Everyone is a subject, even though he/she is in the stage of futility. He/she is a subject of
his/her body, society, history, and the world. Every individual is unique and a part of the
society. In short, there is nobody in the world can take another's place. No one is an
island. In the sense of community, we investigate the service of intensive care.
Death happens to all of us. We need a set of principles to decide what we must do,
particularly, for futile patients. In the Christian era, this idea first developed in the sixteenth
century.
In 1536, Francisco Vittorio discussed the question of whether a person always needed to
use food to preserve life. This idea points out part of the very nature of our humanity. We
are bonded to one another on certain basic loyalties or obligations, viz., the loyalty of
watching, waiting, keeping company, standing by, and giving care to one another as we
go toward our deaths. We are sharing the same human rights and duties.
Concerning human rights, Thomas Aquinas had a fairly positive notion of the
responsibility of government to enhance human dignity. Up to the twentieth century, the
Roman Catholic Church is encountered with the social dimension since the issue of the
famous encyclical “Rerum Novarum.”
The encyclical minds us of the common good. The definition of the common good is that
there exists a good for society as a whole and the society is respected more important
than the good of any individual. In the intensive care service, there may be an awareness
of fostering the common good.
Common good is closely related to justice. Justice opens us up to go beyond the
individualist orientation. Justice, moreover, is about duties and responsibilities. Building
the good community is our common responsibility.
In the concrete case of providing ICU service, Brody points out that the technological
imperative is not a moral imperative. Decision made by the patient is in light of the
patient's values. The role of the physician is to assess accurately the patient's condition
and prognosis, viz., the available treatment options and information have to be provided to
the patient or the patient's family.
There is one important survey of ICU: OTA (1984) indicates that the payment of an ICU
bed is three times more than that of other patients who require ordinary service. If the
human resources remain constant, there will be 20-30% of the patients receiving routine
physician services. The other 30-70% of patients will receive one or more stabilizing
interventions but do not require constant physician involvement.
This leads us to another question: how to define or affirm that the physician can withdraw
the ICU treatment from the patient while the patient is physiologically futile?
FUTILITY OF PATIENTS
Some of the current definitions of futility maintain "social in-convenience." Social
inconvenience is not the reason. Human person is adequately considered for any moral
judgement. How does the physician determine the futility of the patient in order that he/she
is discharged from the ICU, e.g., the vegetative patients?
Firstly, their situations are strong enough to claim the judgment of futility. Moreover, The
Task Force on Ethics of the Society of Critical Care Medicine affirms such a position: "A
healthcare professional has no obligation to offer, to begin, or maintain a treatment which,
in his or her best judgment, will be physiologically futile." On the other hand, in case of
meta-static cancer, Faber-Langendoen, 1991, recently reviews that there is no survival to
discharge of such patients. Is that transient survival sufficient to make the treatment nonfutile or is this still a case of physiological futility?
Faber-Langendoen argues that this treatment is still futile because "a treatment that
transiently prolongs life in the hospital, particularly, the life of a patient dying of an
irreversible disease, is without benefit with respect to regaining health, controlling the
effects of disease, or relieving suffering."
Supported by Truog, Brett and Frader (1992, p.1561), Brody proposes that "patients or
family members may value the additional hours of life differently." He maintains that
unless there is objective theory for the judgment of the patient or family about the value of
the extra hours of life, otherwise the decision of futility can be dismissed as irrelevant and
mistaken (Brody, 1992).
CONCLUSION
We provide the ICU service on the basis of human common good, or more concrete,
human rights and justice in a social dimension. The service, thus, is not based on wealth
and authority. In a just society, people enjoy equal human rights of survival. Both the rich
and the poor have the same opportunity to request ICU service if they are in necessities.
Nobody should increase his/her affluence until everybody has his/her essentials.
ICU service is always related to futility cases. Regarding the heavy financial burden of
ICU, we need to decide the providence of ICU, according to the common good. Even if the
rich can afford the huge amount of treatment charges, we have to consider whether the
patient is futile or not.
We must be aware of the case that the wealthy people might abuse the ICU services only
because of their wealth. On the contrary, the poor people who are in necessities of ICU
services, however, under their poor situation and the violation of ICU services by the rich,
there will not be adequate providence for them.
In the case that the patient is very close to death, the lack of ICU treatment will not cause
any lack of comfort and the dignity of the patient. We might suggest the appropriateness
of removing or not starting the ICU treatment.
For some futile patients, e.g., vegetative patients, ICU treatment may increase
unnecessary pain to the patients in their extra hours of life. They also occupy other
patients' opportunities of having ICU services in emergencies. It is immoral to treat every
human being unequal according to the basic human rights.
Consequently, regardless of the heavy financial burden of ICU, the decision of beginning,
maintaining and terminating the treatment of patients is not an obligation of physicians. It
is more preferable to form a committee which includes physicians, patients (if they are
able to give opinions), patients' families, hospitals' chaplains, pastoral, and social workers.
Thus, we will have a more objective, human, just and moral decision for the requests from
the futile patients.