decides when care is ‘futile’?
WESLEY J. SMITH
Increasingly, when it comes to end of life care, patient
autonomy is a one-way street toward death. This heads-I-win,
tails-you-lose philosophy is known generically as Futile Care
Theory. If patient autonomy is to have any meaning other than
providing a veneer of respectability for a “duty to die,” the
futile care movement must be stopped. Our lives and dignity —
and that of those we love — depends on it.
Imagine your husband is in a hospital, struggling against a debilitating
or life-threatening disease. If something goes wrong, you tell the
doctor to do what he can because your husband wants to live. But the
doctor says no, he does not believe that the quality of your husband's
life is worth doing as you ask. Indeed, he is so adamant, he puts a Do
Not Resuscitate (DNR) order on your husband's medical chart over your
objections, meaning that if he suffers a cardiac arrest or some other
life threatening event, he plans to stand by idly and watch your husband
Frightening stuff. Unfortunately, it is also true. This is close to
what befell Andrew Sawatzky, 79, of Winnipeg, a resident at the
Riverview Health Centre since May. Sawatzky has had strokes and has
advanced Parkinson's disease. Helene, his wife, says her husband can
communicate (this is disputed by doctors) and wants to live as long as
he can. Moreover, their religious faith requires continued care.
If Sawatzky has a heart attack, Helene wants him to have CPR. But she
was told by Riverview that they won't do it, that CPR would he “futile.”
Over Helene's objections, a DNR order was entered upon his medical
chart. She sued to require his own doctors to treat him in a medical
emergency. On Nov.11, she won a victory. But it is only temporary,
pending court proceedings.
In a similar case, a Quebec man didn't survive long enough to take
his doctors to court. Earlier this year, Herman Krausz, 76, was admitted
to Montreal Jewish General Hospital, in respiratory distress from a lung
infection. At first, he improved; then he developed pneumonia and had to
be put on a respirator.
According to his family, Krausz, who was not unconscious or
incompetent, knew he would probably last only a few weeks. Still, he
wanted to continue to receive respiratory support so he could spend his
remaining time with his family. According to Krausz' family, that did
not sit well with the intensive care medical director who ordered the
respirator turned off against his patient's and the family's wishes.
Krausz died 15 hours after he was taken off the respirator. The matter
is now set for a coroner's inquest.
Ironically, most people are more worried about being “hooked up to
machines” against their will than of being denied wanted medical care.
That is because in too many cases, doctors used to keep people alive
regardless of their desires. But that danger faded substantially after
medical ethicists successfully argued that patients should be allowed to
refuse unwanted medical treatment even if ceasing care would lead to
death. As a result, patient autonomy became a mainstay ethic of
Under the principle of patient autonomy, if Sawatzky wanted a DNR
order placed on his chart, that was his right. Similarly, if Krausz had
wanted his respirator turned off, that would have been done. So, one
would suppose that these men had a similar right to receive treatment.
Autonomy is autonomy, right?
Not necessarily. Increasingly, when it comes to end of life care,
patient autonomy is a one-way street toward death. If a patient refuses
care, the decision is sacrosanct. But if the patient's “choice” is for
treatment such as CPR, antibiotics, ventilator, feeding tube, or blood
transfusion in order to stay alive, we are told by some doctors, medical
ethicists, and health care cost utilitarians that autonomy has its
limits. Treatment requests they view as “inappropriate” will be refused.
This heads-I-win, tails-you-lose philosophy is known generically as
Futile Care Theory. To fully comprehend the wickedness at work here, it
is important to understand how medical ethicists have turned the
traditional concept of medical futility on its head. A futile
intervention used to be defined as one that had no possible
physiological benefit. To use an extreme example to illustrate the
point, if you asked your doctor to remove your appendix to cure an ear
infection, the doctor should refuse because the surgery could not
benefit you medically and would harm you.
In contrast, futile care (also called “inappropriate care”) is about
subjective value judgments by medical professionals rather than
physiological outcomes. Sawatzky's involuntary DNR order was imposed not
because CPR would have no physical benefit, but because it might.
Similarly, Krausz's respirator was turned off against his will not
because it wasn't benefiting him — but because it was. Thus, it isn't
the proposed treatments that were deemed futile in these cases but the
patients. Bluntly stated, Sawatzky and Krausz were seen as people who
Throughout Canada and the U.S., hospitals and medical associations
are quietly adopting formal futile care policies with which to browbeat
families and patients who want “inappropriate” care and to convince
courts to permit doctors' and medical ethicists' values to prevail over
patient and family decision making. This is nothing less than the modern
equivalent of exposing unwanted infants on hills and abandoning the
infirm and elderly by the side of the trail.
A case in Spokane, Wash., demonstrates just how dangerous all of this
really is. On Oct. 27, 1994, Baby Ryan was born prematurely at 23 weeks
gestation. He was put on dialysis, but the doctors determined that
continuing treatment was “futile” and they halted it over his parents
objections. Ryan would have died, but his parents' obtained a court
order to continue his treatment. Administrators and doctors fought the
parents in court swearing under oath that “Ryan's condition is
universally fatal” and that the infant had “no chance” for survival,
contending that Ryan's continued treatment was a violation of their
integrity, values and ethics. The court never decided who had ultimate
say over Ryan's care — his parents or the hospital — because he was
transferred to Emanuel Children's Hospital in Portland, Oregon, where he
was soon weaned off dialysis and survived. Had his original doctors
successfully imposed their values on their patient, Ryan would be dead
today, Instead, he is a living four-year old child.
If patient autonomy is to have any meaning other than providing a
veneer of respectability for a “duty to die,” the futile care movement
must be stopped. Our lives and dignity—and that of those we love—depends
Wesley J. Smith, “Who decides when care is 'futile'?” National
Post, (Canada) 23 November, 1998.
Reprinted with permission of the National Post.
Wesley J. Smith is a senior fellow at the
and an attorney and consultant for the
International Task Force on Euthanasia and Assisted Suicide. He is
an international lecturer and public speaker, appearing frequently at
political, university, medical, legal, bioethics, and community
gatherings across the United States, Canada, Great Britain, and
Australia. Wesley J. Smith is the author or co/author of 9 books.
Most recently his revised and updated
Forced Exit: The Slippery Slope From Assisted Suicide to Legalized
Culture of Death: The Assault of Medical Ethics in America, and
Power Over Pain.
Copyright © 1998