Medical Care at the End of Life: A Catholic Perspective

Glossary

150 Chapter 8 resistance to governmentally mandated single-payer universal coverage, exacerbated by televised political warnings of the horrors of government interference, makes such an alternative unlikely in the near future. 2. Private insurance companies, medical care organizations, preferred provider organizations, HMOs, and the like may also rightly refuse to pay for these treatments, though the legal implications of hospitals refusing to treat would be unclear without federal or state statutory indemnification. But because private insurers are ethically and legally required to tell their clients what treatments they will and will not pay for, and because health insurance in the United States is largely private and highly competitive, insurance companies are unlikely to refuse to cover inappropriate treatments. If one insurer told potential clients it would not pay for treatment that another covered, the former might be at a disadvantage in a market in which clients want access to all possible medical care. 3. Hospitals could establish public policies rejecting specific treatments in certain situations. A hospital might say, ‘‘We do not treat patients who are in a persistent vegetative state, because we believe the resources should go to our well-baby clinic instead.’’ That is not a medical policy in the strict sense; rather, it is a social and ethical decision based on a wide range of factors including, but not limited to, the strictly medical. But hospitals are unlikely to take this approach, given possible damage to public relations in a competitive environment. Attempts by hospitals to establish ‘‘futility policies’’ are unlikely to define exactly which procedures will be unilaterally denied in which cases, and thus hospitals are likely to fall back on a policy that asks for better communication with patients (Wear et al. 1995) or a policy that admits of exceptions when, despite all attempts, families insist on continuing treatment (Saint John’s Hospital 1995). 4. Hospitals or individual physicians can always go to court to find a guardian who will agree to forgo the inadvisable treatment. A judge is unlikely to rule in the hospital’s or physician’s favor, Medical Futility 151 however, unless it can be shown that either the surrogate is unfit because of a conflict of interest or the treatment is not only unreasonable but hurtful to the patient, which, with proper pain relief, should never be the case.5 5. Early review can often be helpful in reducing the number of cases of inappropriate treatment. If primary care physicians take the time to speak with their patients about these issues, many of these patients will opt against inappropriate treatment and perhaps leave advance directives that can help forestall such treatment later on. In this context, it is important to note that physicians act ethically when they advise patients and surrogates against procedures that offer little benefit. Health care providers are rightly expected by patients to give such advice. They are not supposed to behave as neutral observers who simply offer a list of options. 6. Time spent with the family can be of great help. It takes time for families to let go. Hospital personnel should try to keep families well informed of the deteriorating condition of patients. If the ICU attending physician tells a family on Monday that he hopes a series of diagnostic procedures will suggest a solution to an illness or injury, even though he knows that in this case a favorable prognosis is highly unlikely, and then the physician who comes in on Tuesday tells them that in this case there is no hope for recovery, it is hardly surprising that they are unable to let their loved one die. They want the Monday doctor back. 7. General education of the public is important. I am convinced that the medical community does significant harm with its competitive advertising. People are continually told only about the miracles that occur in hospitals. They naturally expect that another miracle is possible. And there is the problematic fact that medicine is not and can not be an exact science. The popular media is full of stories about patients whose cases were seemingly hopeless but who survived and even thrived. People naturally want that chance for themselves and their loved ones. 8. Living wills and durable powers of attorney may help families follow the expressed wishes of dying patients to forgo unreasonable 152 Chapter 8 life-sustaining treatment. These documents, as we have seen, are most helpful in assuaging...