Thorough Exam of Medical Ethics : Hospitals Addressing Patient Autonomy, Other Principles
The health care community is increasingly focusing on the ethics of medical treatment, especially in light of the rapid spiral in America’s aging population.
Yet, according to Dr. Kenneth Brummel-Smith, co-chief of clinical gerontology services at the county’s Rancho Los Amigos Hospital, “most doctors have no idea what (medical) ethics is all about.”
Few Are Taught Ethics
By that, he meant that few medical schools teach ethics and that most doctors therefore have little formal training in ethics.
But the establishment of hospital ethics committees is experiencing a “clearly rising trend,” according to Dr. Daniel A. Lang, medical director of the National Health Foundation, who estimated that the number of hospital ethics committees has increased “70% to 75% just in the past five years.”
Brummel-Smith concurred, referring to data showing only 26% of hospitals with ethics committees as recently as two years ago.
An assistant professor of family medicine at the USC School of Medicine, he addressed the ethical problems of health care at a seminar recently on “Medical Ethics and the Elderly” at Verdugo Hills Hospital, which sponsored the program in conjunction with the American Society on Aging.
He summarized the principles of ethics as applied to medicine, the most important being autonomy: the right of a competent adult to choose medical care, to what degree to pursue it--or to discontinue it altogether.
“In our society, autonomy is considered the overriding principle in ethics,” Brummel-Smith said. “In almost every court case the decision has been made toward the patient’s autonomy.”
He listed other ethical points as beneficence, the intention to do good--to treat illness and pain and to immunize; non-malfeasance, to not do harm, which was the overriding principle in Hippocrates’ time; justice, what is right for people or for society (“But,” Brummel-Smith said, “right is a difficult value judgment to make”); equity, what’s fair, equal, the distribution of resources; and double-benefit, treatment if the person wants it and it’s good for him.
Beneficence has special interest currently, Brummel-Smith said, because medicine is in a transitional state.
“From 1800 to about 1965, doctors did their best and always made the medical decisions,” he said. “After 1965 Medicare allowed people to purchase their medical care. That ended in 1983 when DRGs and ‘parsimonious paternalism’ came in.” (DRGs, or Diagnosis Related Groupings, are a Medicare formula to limit a patient’s hospital stays and services, thus reducing hospital fees.)
Tough Decisions
Brummel-Smith explained particular ethical points, illustrating equity with the hypothetical case of two patients needing CPR (cardiopulmonary resuscitation), one an 85-year-old in ill health and the other 45 in good health.
“Which one do you go to first? Which one is more likely to survive? What’s fair is flipping a coin,” he said.
Ethical decisions differ for the elderly largely because the decision-making of the older person is different from that of the younger.
“Younger people want the problem fixed--the broken bone healed, the disease cured,” Brummel-Smith said. “That doesn’t work for the older patient where a combination of biological, sociological and psychological factors operate. Here it is a matter of functional approach, to promote the ability to function, to live independently.
“The younger adult is not usually dependent on other people. In treating the older person every decision has to be looked on as to how it affects dependency and those who give it.
“Older people have wisdom; they understand that other things (than themselves) have primacy in life. They understand the finite aspect of life that younger people don’t, that people have to adapt--including that life is going to end someday. And it’s not depression, it’s wisdom. It’s being willing to die versus wanting to die.”
Brummel-Smith said that efficacy of treatment is more dependent on good health than on age, noting that survival after CPR does not differ between young and old if heart, pulmonary or kidney problems are not present: “Age is not ever the reason for treatment or no treatment. Health is.”
Medical Facts
The patient’s ethical workup begins with medical facts, he said: “There is no duty to offer futile medical care. We have no duty to do an appendectomy for a headache.”
The ultimate decision on medical treatment depends on human issues: What does the patient want or not want? What does his family want?
“Ultimately,” Brummel-Smith said, “these are the basis of ethical decisions. And what do other care providers, others involved besides the doctors, think? Their opinions are important.”
He discussed a variety of court cases that decided who should determine medical care, especially in instances in which the patient is no longer competent to do so for himself.
Both Brummel-Smith and the National Health Foundation’s Lang cited the Karen Ann Quinlan case in which the 21-year-old woman lapsed into a coma from which she was not likely to recover. The court’s ruling that Quinlan’s right to privacy gave her the right to die has become a landmark decision, they said.
“It was the first time that bioethics received a judicial blessing,” Lang said, adding that the case helped stimulate the growing interest in ethical committees.
It also contributed, Lang said, to “the recognition on the part of the public that the hospital and the physician can help the family wrestle with the problems of patient care, within the patient’s wishes if he is competent.”
Tools of Caring
Brummel-Smith spoke of the tools of caring for the elderly--withdrawing care, feeding, withholding care, allocating scarce resources.
“Feeding is ordinary care so it could never be stopped,” he said. “But the courts decided that feeding by tubes is extraordinary. If it is not beneficial, it can be stopped.”
He differentiated between withdrawing care and withholding care and spoke of nursing home policies that identify patients as “DNR--do not resuscitate; DNT--do not treat, and hospitalize. The nursing homes have the authority to speak for the patient if no one else does, but the ideal solution is to involve the family in the decision.”
In terms of scarce resources, Brummel-Smith said that 12% of the population older than 65 uses 33% of all health care dollars and that 6% of those older than 65 uses 28% of health care dollars.
He also said that it was a myth that earlier generations kept their elderly at home to care for them.
“In America we never did that,” he said. “People were immigrants and their parents lived in Europe. I heard a woman say that all her grandparents died at home--but they didn’t live as long. . . . The nursing home industry is a reasonable phenomenon for our country.”
In speaking of the legal tools governing care of elderly patients, Brummel-Smith brought up living wills and durable power of attorney.
A Living Will
“A living will is a piece of paper that doesn’t do anything except get people to talk to each other; it does not assure any kind of treatment,” he said. “It allows the patient to state his desires and wishes on a legal form but the form is ambiguous. What does artificial mean? What’s dependence--not having a visiting nurse three times a week, or going to a nursing home?
“Durable power of attorney is effective, a specific legal form that allows anybody to specify what they want and who can decide for them if they become incompetent. Power of attorney becomes ineffective if you become incompetent, but durable power of attorney means someone can make decisions for you, can consent to or refuse treatment ‘consistent with the person’s desires or in his best interests.’ ”
