Giving up the increasingly troubled distinction between “experiment” and “treatment” would make it easier to focus on informed consent and harder to beg questions about uncertainty and shared decisionmaking in medicine.

This commentary examines the ethics and law in the United States as they relate to the foregoing of life sustaining treatment when such treatment is deemed medically inappropriate. In particular the article highlights the procedural approach when there is disagreement between physicians and surrogates or patients as exemplified in Texas Law. This approach, although worthy in concept, may in practice invite opposition and dissatisfaction as it may be perceived as coercive and pitting the weak against powerful adversaries and interests, in (...) addition to discouraging the exercise of professional virtues. Too inflexible an approach erodes trust, and furthermore the Texas law allows hospital ethics committees to move from an advisory non judgmental role to a quasi legal court with real legal power but no credentialing or oversight. (shrink)

There is a broadly held view that neonatologists are ethically obligated to act to override parental nontreatment decisions for imperiled premature newborns when there is a reasonable chance of a good outcome. It is argued here that three types of uncertainty undercut any such general obligation: (1) the vagueness of the boundary at which an infant’s deficits become so intolerable that death could be reasonably preferred; (2) the uncertainty about whether aggressive treatment will result in the survival of a reasonably (...) healthy child or, alternatively, the survival of a child with intolerable deficits; and (3) the inability to determine an acceptable ratio between the likelihoods of those two outcomes. It is argued that the broadly held view accords insufficient weight to the fact that newborn intensive care increases the likelihood of harm to the child by effecting survival with intolerable deficits. Though treatment may offer a reasonable chance of a good outcome, it is argued that there are situations in which neonatologists should nonetheless defer to parental nontreatment decisions. (shrink)

Life saving or life sustaining treatment may not be instigated in the clinical setting when such treatment is deemed to be futile and therefore not in the patient’s best interests. The concept of futility, however, is related to many assumptions about quality and quantity of life, and may be relied upon in a manner that is ethically unjustifiable. It is argued that the concept of futility will remain of limited practical use in making decisions based on the best interests principle (...) because it places such high demands on the individual responsible for decision making. This article provides a critical analysis of futility (in the context of the best interests decision-making principle), and proposes an ethically defensible notion of futility. (shrink)

Rarely do ethics consults focus on genuine moral puzzlement in which people collectively wonder what is the right thing to do. Far more often, consults are about conflict. Each side knows quite well what is “right.” The problem is that the other side is too blind or stubborn to recognize it. And so the ethics consultant is called, perhaps in the hope that s/he will throw the weight of ethics toward one side and end the controversy so everyone can get (...) on with other business. Perhaps the greater problem in these scenarios is that even if one side “wins” by gaining the power to dictate what happens next, the toxicity permeating the relationships often markedly worsens and other conflicts erupt, major and minor. (shrink)