Futility

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Futility Methods in Arguments NEJM June 15
July 5, 2007

• Mike Kroll
• PGY-1

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Rosiglitazone CV Side Effects
End point included Death, CHF, MI, UA, TIA,
amputation, etc.
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Rosiglitazone CV Side Effects
End point included Death, CHF, MI, UA, TIA,
amputation, etc.
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Why????

• -3rd line drug
• -meta-analysis wasnt that good of a study
• -studies arent convincing either way

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Also in the Journal

• Tackling Medical Futility in Texas by R.D.
  Troug, a professor in medical ethics and
  anesthesia at Harvard.

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GOAL

• To critically analyze Dr. Truogs perspective
  article in the same manner as the Rosiglitazone
  articles.

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Futility in primary care

• Prostate cancer screening?
• Mammograms/paps for a 100 yr old?
• Specialist referrals?

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Case

• Emilio Gonzales
• an 18 month old boy
• born with Leighs disease, a fatal neurometabolic
  disorder
• In the ICU for 5 months, when
• Hospital invoked the Texas Advance Directives
  Act, which authorized the withdrawal of life
  support.
• Mother, Ms. Gonzales, successfully obtained
  extension of deadline, but Emilio died regardless
  of this extension.

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Dr. Troungs goal

• To present a case example of futility,
• Discuss the ethics behind it
• Discuss the medical-legal aspects of the Texas
  Advance Directives Act.
• Conclude that in such futility cases, we must
• Protect minority rights
• Tolerate the choices of patients families
• Honor the values preferences of others

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Dr. Troungs conclusion

• Protect rights of minorities against the tyranny
  of the majority
• Values and preferences that have life-or-death
  consequencesshould be honoredwhenever possible
• We should seek to enhance our capacity to
  tolerate the choices of others, even when we
  believe they are wrong.

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My problem

• In this short Perspective article on futility
• 1) The conclusions made by the author do not seem
  to follow from his arguments.
• 2) His arguments are modeled on the idea of
  fundamental differences intractable
  conflict imply that there are no proofs in
  ethics.
• 3) Use of subjectivism/Cultural Relativism in
  ethics.

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What to discuss in futility cases?

• Practical matters
• breakdown of trust in the physician-patient
  relationship
• Poor communication
• Ethics
• Legal

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Argument 1 Values

• Format of argument??
• Utilitarian?
• No
• Sanctity of Life?
• No
• Rather he emphasizes the differences
  subjectively.
• Problem
• just because the physicians and family disagree
  on whether or not Emilio is in pain, this does
  not determine whether or not he in fact has pain
• Emilio either has pain or he does not

• Pain / Dignity
• Physician
• 1) unwarranted suffering
• 2) undignified death
• Family
• 1) neuro deterioration-actually less pain
• 2) Momno matter what, Emilios life is dignified
• fundamental differences in values

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Argument 2 Expense

• Excessive expense, so stop Tx
• But futility cases amount to a trivial amount of
  the total spent on health care

• Format
• Seems utilitarian
• Yet it seems his major point is
• High expense for an individual
• Low expense for society
• Therefore, one cannot use expense as an argument
  to withdraw care from Emilio

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Argument 3 Rights

• Premise 1 Doctor has the right to refuse
• violatemoral integrity
• Premise 2 But Mom has rights too
• Conclusion to deny Tx would be
• nothing more than an assertion that the
  values of the clinicians were correct while those
  of Ms. Gonzales were wrong

• Format
• Not utilitarian, does not weight all
  harms/benefits
• Major point
• In futility/end-of-life cases, the use of
  rights (like values) does not lead to a
  satisfying conclusion.

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Argument 4 Social

• Social issues
• Protect rights of minorities against the tyranny
  of the majority
• Values and preferences that have life-or-death
  consequencesshould be honoredwhenever possible
• We should seek to enhance our capacity to
  tolerate the choices of others, even when we
  believe they are wrong.

• Overall Format
• intractable conflict
• Values, Pain, ,Rights
• Futility cases are different one does not know
  what OUGHT to be done
• Goes on to discuss legal routes to deal with
  intractable conflict

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Problem 1 Is this consistent?

• 1) Are all futility cases based on intractable
  conflict?
• Anencephalic infant?
• no chance of personhood
• no meaningful interactions
• no possibilities
• must we respect a familys decision to continue
  care no matter what?
• Baby Theresa example if we must tolerate, honor
  respect others decisions in futility cases, we
  must allow apparently contradictory results in
  1987, this family wanted to use an anencephalic
  infant for organ donation

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Problem 2 Invalid argument

• Physician believes A ought to be done
• Patient believes B ought to be done
• A and B contradict each other
• Therefore, one cannot determine what what ought
  to be done.

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Problem 2 Invalid argument

• From the mere fact that 2 disagree, does this
  mean there is no objective truth?
• Geography Xworld flat, yworld round, is there
  no objective truth on the worlds shape?
• Rosiglitazone
• Article 1 increased risk CV SE
• Article 2 no increased risk CV SE
• Can we conclude that we cannot know the risk of
  CV SE??
• Does it follow there is no objective truth about
  the risk of CV SE????

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Problem 3 No proof idea

• Easy
• Murder is wrong
• High cholesterol is a risk factor for MI
• Hard
• Futility, abortion
• Rosiglitazone MI, prostate cancer screening

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Problem 4 Subjectivism Cultural Relativism in
Ethics

• Popular, but dead wrong
• From the mere fact that 2 disagree, does this
  mean there is no objective truth?
• 1) other societies can no longer be inferior
• Slavery
• Female genital mutilation
• 2) Societys standards morality
• Apartheid
• Anti-Semitism
• 3) No moral progress
• Civil rights movement

James Rachels The Elements of Moral Philosophy
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What is Dr. Troungs argument?

• The conclusion may still be right or wrong
• Yet the conclusion does not follow from the
  premises
• Ethical argument? Or just a legal argument?
• Regardless, when talking about futility, these
  are ethical arguments
• There are methods to these arguments

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Summary

• Articles on futility/ethics need to be analyzed
  with the same scrutiny that the Rosiglitazone
  articles have received.
• There are methods to analyze both
• 1) statistical analysis gives further insight
  into Rosglitazones risk profile
• 2) Analyzing ethical arguments shows
  counterexamples subjectivism/Cultural
  Relativism that are unacceptable

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Suggestions

• When an article reports relative risk, look at
  the Absolute risk, NNH and if the end points used
  are narrow
• When an article discusses futility/ethics, the
  arguments must
• be valid
• not use subjectivism Cultural Relativism