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Point and Counterpoint |

COUNTERPOINT: Do Physicians Have a Responsibility to Provide Recommendations Regarding Goals of Care to Surrogates of Dying Patients in the ICU? NoRecommend Care to Surrogates of the Dying? No FREE TO VIEW

Robert M. Veatch, PhD
Author and Funding Information

From the Kennedy Institute of Ethics, Georgetown University.

CORRESPONDENCE TO: Robert M. Veatch, PhD, Kennedy Institute of Ethics, Georgetown University, Healy Hall, 4th Floor, Washington, DC 20057; e-mail: veatchr@georgetown.edu


FINANCIAL/NONFINANCIAL DISCLOSURES: The author has reported to CHEST that no potential 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. See online for more details.


Chest. 2015;147(6):1455-1457. doi:10.1378/chest.15-0275
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At first, it seems that physicians might have a responsibility to recommend goals of care for dying patients in the ICU. I suggest this is mistaken. Not only do physicians usually have no such responsibility to recommend goals, it is even a mistake if they do. Usually, the next of kin or other surrogate is the decision-maker in such cases, but regardless of whether it is a still-competent patient or a surrogate, many bad things can happen if physicians try to recommend treatment goals. If surrogates decide, they should pursue what the patient would have wanted, if known, and otherwise what is in the patient’s best interest.

Traditional, professionally generated medical ethics was committed to having the physician strive to do what is best for the patient. That might seem to include recommending treatment goals. That ethic, symbolized most vividly in the Hippocratic Oath,1 is now widely rejected as ethically erroneous. Physicians cannot be expected to know what is best for the patient, not even what is medically best. Even if they could know this, patients should have the right to pursue their own goals and fulfill their own duties, which sometimes are not the same as what is in the patient’s best interest. However, medical lay people, usually mistakenly, think they should do what experts recommend. Hence, their decisions will be distorted. The conclusion is that physicians have no basis for recommending treatment goals and, even if they did, they would tend to distort the decision-maker’s perspective.

Of course, lay people should rely on physicians for information about diagnosis, prognosis, and treatment alternatives. Occasionally, physicians are wrong, and, even less frequently, patients may know something that their physician does not, but normally it is only reasonable to presume the physician is the authority on diagnosis, prognosis, and treatment alternatives. These are matters of medical fact. Physicians’ professional education and experience should make them authoritative on these matters.

Choosing treatment goals, however, can never be based solely on medical facts. Logically, one cannot get to the conclusion that one ought to do something solely based on facts. The choice of goals always must incorporate an evaluative judgment. That evaluative framework will be based on the decision-maker’s religious or philosophical system of beliefs and values.2 There is no reason to assume that the physician’s beliefs and values are the same as the patient’s or that those who are experts in some technical area, such as medicine, are also experts on the value judgments needed to pick a goal. For example, once one knows a patient is permanently unconscious from a head injury, it takes more than all the relevant medical facts to know whether it is better to withdraw life support and let the dying progress continue or to ventilate on the grounds that human life is to be preserved. Jack Kevorkian3 may choose one goal; the devout Orthodox Jew, the other.4 Neither is factually in error. Endorsing goal recommendation means patients will arbitrarily get different goals recommended depending on the views of the clinician.

Assuming the physician is the expert on the medical facts of the case, it should be clear that picking a goal of treatment requires, in addition to imposing value judgments, some important nonmedical facts about which physicians also cannot be presumed to be expert. Picking a goal must occur in the context of whether the patient has completed life projects and is ready to die or, alternatively, has projects yet to accomplish. Patients may want to survive to see the birth of grandchildren or even to see relatives arrive for final goodbyes. Patients may want to preserve economic resources for important family uses. They may have religious concerns—having last rites administered, for example—totally unknown to the physician.

The good of the patient is plausibly made up of several spheres of well-being: psychologic, social, familial, legal, economic, and religious, as well as medical.5 Facts related to all these areas will be needed to pick goals for medical treatment. There is no reason to assume physicians should know the relevant nonmedical facts. In fact, experts in any one of these areas are likely to overemphasize their sphere of expertise at the expense of the other spheres. Lawyers will predictably advise their clients incorrectly when it comes to setting goals involving legal matters. Accountants will advise their clients incorrectly when it comes to setting goals involving financial matters. When it comes to setting goals, experts in a domain of well-being should not be able to pick the values upon which those goals are set. They should not even be expected to know all the relevant facts, let alone the values that laypeople (patients or clients) would want expressed in the goals. Just as lawyers cannot be expected to advise clients whether to take a long-shot, expensive try at winning in a trial or settle for a smaller, but more certain sum, so physicians cannot be expected to advise clients whether to fight to the last gasp or avoid suffering and withdraw life support.

Physicians, of course, can be expected to know what they would do in particular situations and share their opinion with the patient or surrogate, especially if asked. It should be obvious, however, that what the physician would want in the patient’s situation has little relevance for the patient, who can be expected to hold different values and confront different nonmedical facts. If a physician is asked, “Doctor, what would you do in my situation?” the responsible answer is to first make sure that the patient or surrogate realizes how the physician’s answer will be dependent on the physician’s factual circumstances and religious and philosophical world view, and how irrelevant that answer may be to the patient. A physician might well respond by saying, “Well, I am a member of the ___ Church, am an old man with no further family responsibilities, and no particular desire to continue living, so I would… If you have similar values, affiliations, and life circumstances, you might consider doing likewise.” What seems foolish is for physicians to recommend goals they themselves would pursue in the patient’s medical condition. Even if physicians tried to replace their own life circumstances with the patient’s before recommending a goal of treatment, the result would be, at best, a vicarious conjecture on the physician’s part.

Finally, even if we could somehow expect to determine not only the medical and nonmedical facts, but also the proper values to incorporate into the goals for treatment, we must recognize the possibility that patients, in some cases, may rationally not want to pursue their best interest (medical or otherwise). Many ethical theories recognize that people have duties, even if fulfilling them diverges from what is best for the individual.6 Patients, in particular, may perceive obligations to family, to fellow sufferers from the same disease, or to the next generation. Patients may be duty bound to preserve resources for their children, volunteer as research subjects for studies of their condition, or simply move out of the way to benefit the next generation. None of these goals would be appropriately recommended by physicians; none would be consistent with physicians pursuing patients’ best interests. Yet, they may be fitting goals for some patients.

Physicians should not be able to know the relevant nonmedical facts needed to recommend treatment goals; they should not be able to pick the values needed to recommend goals; they have no business conveying that patients should sacrifice their own interest for some duty to others. Physicians might, if asked, tell patients what they would want in the patient’s situation, but should do so only if they are satisfied that the patient or surrogate realizes how irrelevant that communication would be.

Edelstein L. The Hippocratic Oath: text, translation and interpretation.. In:Temkin O, Temkin CL., eds. Ancient Medicine: Selected Papers of Ludwig Edelstein. Baltimore, MD: The Johns Hopkins Press; 1967:3-64.
 
Veatch RM. Patient, Heal Thyself: How the New Medicine Puts the Patient in Charge. New York, NY: Oxford University Press; 2009.
 
Kevorkian J. Prescription Medicide: The Goodness of Planned Death. Buffalo, NY: Prometheus Books; 1991.
 
Bleich J. The obligation to heal in the Judaic tradition: a comparative analysis.. In:Rosner F, Bleich JD., eds. Jewish Bioethics. New York, NY: Sanhedrin Press; 1979:1-44.
 
Veatch RM. The Basics of Bioethics.3rd ed. Upper Saddle River, NJ: Pearson; 2012.
 
Macklin R. Moral concerns and appeals to rights and duties. Hastings Center Report. 1976;6(5):31-38. [CrossRef] [PubMed]
 

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References

Edelstein L. The Hippocratic Oath: text, translation and interpretation.. In:Temkin O, Temkin CL., eds. Ancient Medicine: Selected Papers of Ludwig Edelstein. Baltimore, MD: The Johns Hopkins Press; 1967:3-64.
 
Veatch RM. Patient, Heal Thyself: How the New Medicine Puts the Patient in Charge. New York, NY: Oxford University Press; 2009.
 
Kevorkian J. Prescription Medicide: The Goodness of Planned Death. Buffalo, NY: Prometheus Books; 1991.
 
Bleich J. The obligation to heal in the Judaic tradition: a comparative analysis.. In:Rosner F, Bleich JD., eds. Jewish Bioethics. New York, NY: Sanhedrin Press; 1979:1-44.
 
Veatch RM. The Basics of Bioethics.3rd ed. Upper Saddle River, NJ: Pearson; 2012.
 
Macklin R. Moral concerns and appeals to rights and duties. Hastings Center Report. 1976;6(5):31-38. [CrossRef] [PubMed]
 
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