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Point and Counterpoint |

Rebuttal From Dr VeatchRebuttal From Dr Veatch 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):1458-1459. doi:10.1378/chest.15-0276
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Dr Hutchison,1 supporting physician recommendations, cites ambiguous data implying French and Canadian surrogates prefer physician participation and > 40% of Americans prefer no recommendations. He claims physicians should make recommendations based on their beliefs about patients’ authentic values.

No rational person opposes physician participation. Physicians need to provide diagnosis, prognosis, and treatment options, so the French and Canadian data seem meaningless. Even if surrogates want recommendations, confusion may exist about physician expertise.

Surely physicians are expert on medical facts (ie, diagnosis, prognosis, and treatment options). The real problem is the widespread assumption that physicians also have expertise on value judgments needed to determine the best treatment option. Evidence is lacking, however, that such expertise exists; in fact, physicians appear systematically skewed in their value judgments. We know that physicians vary widely on what they would recommend,2 and no mechanism exists for determining which recommendations are correct. If recommendations are made, patients will suffer random variation among practitioners. There is no basis for believing consensus value judgments are correct.

Consider Dr Hutchison’s scenarios. First, if surrogates ask for recommendations, this could be mere failure to understand that recommendations will necessarily incorporate physician values. It fails to realize what (admittedly old) data show—that surrogates are better at estimating patient preferences than physicians.3 Asking “What would you do if this were your loved one” foolishly assumes that what doctors would do (based on their values and knowledge of loved ones) is somehow relevant for patients. Conversely, physicians should not base recommendations on patients’ “authentic values,” since doing so requires assessment beyond the physician’s capacity, and also could require physicians to endorse grossly immoral or illegal options, turning them into mere patient lackeys.

Dr Hutchison’s second scenario poses an even more serious problem. We know that minorities of both patients and physicians believe in preserving life to the end. It is, for example, a position of many Orthodox Jews (patients and doctors). Thus, if surrogates reflect patient values opposing aggressive treatment, they may get paired with providers favoring it. If one believes the correct solution is to go with the patient’s values, the recommendation will be wrong. On the other hand, if somehow we knew that aggressive support were appropriate, patients paired with most physicians will receive incorrect recommendations (as would patients paired with physicians aggressively favoring euthanasia).There is simply no reason to believe that physician recommendations are better than surrogate decisions.

Dr Hutchison’s suggestion to take into account scarce resources poses an even more serious dilemma. Historically, physicians have been advocates for their patients, not society’s cost-containment agents. If recommendations incorporate societal interests, at least surrogates must be told this (and recommendations should be suitably discounted). Preferably, society should set limits so physicians would have no choice but to say these treatments are unavailable, thus freeing physicians to show uncompromising patient loyalty.

Physicians have no basis for making recommendations because their values would necessarily get incorporated and they have little basis for knowing what patients would prefer. If recommendations incorporate societal interests, recommendations are even more inappropriate.

References

Hutchison PJ. Point: do physicians have a responsibility to provide recommendations regarding goals of care to surrogates of dying patients in the ICU? Yes. Chest. 2015;147(6):1453-1455.
 
Fox E, Stocking C. Ethics consultants’ recommendations for life-prolonging treatment of patients in a persistent vegetative state. JAMA. 1993;270(21):2578-2582. [CrossRef] [PubMed]
 
Uhlmann RF, Pearlman RA, Cain KC. Physicians’ and spouses’ predictions of elderly patients’ resuscitation preferences. J Gerontol. 1988;43(8):M1115-121.
 

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References

Hutchison PJ. Point: do physicians have a responsibility to provide recommendations regarding goals of care to surrogates of dying patients in the ICU? Yes. Chest. 2015;147(6):1453-1455.
 
Fox E, Stocking C. Ethics consultants’ recommendations for life-prolonging treatment of patients in a persistent vegetative state. JAMA. 1993;270(21):2578-2582. [CrossRef] [PubMed]
 
Uhlmann RF, Pearlman RA, Cain KC. Physicians’ and spouses’ predictions of elderly patients’ resuscitation preferences. J Gerontol. 1988;43(8):M1115-121.
 
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