Correspondence |


Jeffrey P. Burns, MD, MPH; Robert D. Truog, MD
Author and Funding Information

Harvard University Boston, MA

Correspondence to: Robert D. Truog, MD, Harvard University, Department of Anesthesiology, Childrens Hospital, 300 Longwood Ave, Boston, MA 02115; e-mail: robert_truog@hms.harvard.edu

The authors have reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/misc/reprints.shtml).

Chest. 2008;134(4):888-889. doi:10.1378/chest.08-1613
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To the Editor:

We thank Pope and Waldman for their thoughtful response to our recent article in CHEST (December 2007)1 and acknowledge that they made several excellent observations about the limits of mediation as a general strategy for resolving disputes. As applied to the problem of medical futility, however, the validity of their critique hinges entirely on the penultimate word of their letter, “inappropriate.” They claim that providers need “a clearly defined statutory safe harbor to unilaterally refuse requests for inappropriate treatments,” thereby implying that the word “inappropriate” has a commonly understood meaning or agreed-on definition. The truth is that no such meaning or definition exists.

Consider, for example, that while some requests for life-sustaining treatments are certainly the results of denial, delusion, or magical thinking, others emerge from genuine commitments to fundamental values. For example, some people believe that judgments about “quality of life” from neurologic disability should not be a factor in making decisions about the withdrawal of life support. While this belief is not popular, it is not irrational. Our country is (or at least should be) committed to protecting the rights of people to hold and to act on minority viewpoints. While we do not guarantee that these views will always prevail, they certainly deserve legal protection.

The Texas law, as we understand it, circumvents these protections in at least two ways. First, it grants hospital ethics committees the sole authority to determine the meaning and definition of the word “inappropriate.” While acknowledging that these committees are composed of thoughtful, compassionate, and well-meaning individuals, the members are typically physicians, nurses, social workers, and other employees of the hospital, many of whom have unavoidable financial and psychological connections to the hospital, creating untenable conflicts of interest. Even the so-called community members of the ethics committee are often individuals who have chosen to serve because of the positive regard they have for the hospital. It is difficult to imagine a group more predisposed to agree with the clinicians in their judgments about what constitutes inappropriate care.

Second, at the same time that the Texas law grants this sweeping authority to ethics committees, it precludes any possibility of an appeal to the judicial system. Judges are authorized only to grant extensions of the decision (and even then only if necessary to find an alternative care provider); judges are not authorized to question or to overturn the decision itself. In our view, the Texas law appears to be at odds with one of our most cherished legal traditions by denying access to due process to those with unpopular values.

Finally, while agreeing that clinicians have positive obligations to promote good stewardship of scarce health-care resources, the data cited in our article show that only a surprisingly small amount of money could be saved by eliminating treatments judged to be medically futile. This counterintuitive claim is possibly explained by the fact that the vast majority of disputes over life-sustaining treatments are resolved through negotiation, as they should be. But, regardless of the reason, the fact remains that legislation like that in Texas cannot be justified as an effective approach to cost control. In sum, while the claims of Pope and Waldman may be relevant in general, they do not apply to medical futility and the Texas legislation.

Burns JP, Truog RD. Futility: a concept in evolution. Chest. 2007;132:1987-1993. [PubMed] [CrossRef]




Burns JP, Truog RD. Futility: a concept in evolution. Chest. 2007;132:1987-1993. [PubMed] [CrossRef]
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