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UniversityofMiamiInternationalandComparativeLawReviewUniversityofMiamiInternationalandComparativeLawReviewVolume14Issue2Volume14Issue2(Fall2006)Article510-1-2006CommunicatingPastTheConflict:SolvingTheMedicalFutilityCommunicatingPastTheConflict:SolvingTheMedicalFutilityControversyWithProcess-basedApproachesControversyWithProcess-basedApproachesBryanRowlandFollowthisandadditionalworksat:https://repository.
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L.
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COMMUNICATINGPASTTHECONFLICT:SOLVINGTHEMEDICALFUTILITYCONTROVERSYWITHPROCESS-BASEDAPPROACHES'BryanRowland*Introduction272I.
DefiningFutility276A.
WhyDefineFutility277B.
WhatFutilityisNot278C.
AttemptsatDefiningFutility.
2801.
PhysiologicalFutility2812.
QualitativeFutility2823.
QuantitativeFutility2824.
HybridQuantitativeandQualitativeFutility.
.
.
283II.
FutilityintheU.
S.
&U.
284A.
TheUnitedStates2871.
TheRighttoSayNo.
2882.
TheRighttoDemandTreatment292B.
TheUnitedKingdom2971.
Withdrawing&WithholdingLifeProlongingTreatmentintheU.
2982.
HumanRightsAct.
301III.
CommunicatingPasttheConflict304A.
MovingTowardsaProcess-BasedApproach.
305B.
LegalizingtheWithholdingorWithdrawalofFutileCareintheU.
S308Conclusion309Forsakeofbrevity,"medicalfutility"willbereferredtoas"futility.
"*J.
D.
candidate2006,UniversityofTulsa,CollegeofLaw,Tulsa,Oklahoma;B.
S.
,1990,OralRobertsUniversityinTulsa,Oklahoma;M.
S.
,1992,OurLadyoftheLakeUniversityinSanAntonio,Texas.
IwouldliketoexpressmygratitudetoKerry,ourdaughter,Chloe,myparents,andfamilyforalloftheirpatience,loveandsupport.
ThanksalsotoProfessorMargueriteChapmanandJanSlaterAndersonfortheirwisdom,guidance,andencouragement.
U.
MIAMIINT'L&COMP.
L.
REv.
INTRODUCTIONMr.
Jisa75-year-oldmalewho,becauseofapreviouslegamputationandtheneedforchronicdialysis,livedwithandwascaredforbyhistwosons.
.
.
.
Hesuffersfromcomplicationsofdiabetesandisadmittedtothehospitalforamputationofhisotherleg.
Approximatelyfivedayspost-amputation[ofhissecondleg],Mr.
Jsufferedarespiratoryarrest,wasresuscitatedandtransferredtotheICU.
ThisbeganMr.
'sfivemonthodysseyofmultipletransfersintoandoutofallthreeadultICUsasaresultofmultipleresuscitations.
Becausethesonsrefusedtoacceptanythinglessthanamiraculoushealingfortheirfather,theyadamantlyrefusedtoagreetoDNR[DoNotResuscitate]status.
Ononeoccasiontheydemandedthattheresuscitationbecontinued,resultingina55minuteresuscitativeeffort.
Theyviewedeachsuccessfulresuscitationas"minormiracles"thatwouldresultinafinal"majormiracle"(Mr.
Jbeingabletoleavethehospitalandgivetestimonytohiscure).
AnEthicsRapidResponseconsultapproximatelythreemonthsintohishospitalstayacknowledgedtheimpossiblenatureofthedilemmafacedandadvocatedanemphasisonmeetingMr.
J'ssymptommanagementneedsforthedurationofhishospitalstay.
Thechasmbetweenthephysicians'perspectiveoffutilecareandthesons'perspectiveofmiracleswidenedanddeepenedoverthefive-monthperiod.
Thephysiciansstruggledwithbeingputinanuntenablepositionofviolatingtheethicalprinciplesofbeneficence,non-malfeasance,andjustice(bothpersonalanddistributive)whilethesonsstoodfirmontheirlegalsurrogatedecisionmakingrole,viewingthemselvesasprotectingtheirfather'sautonomybymakingdecisionsforhimthattheybelievedtobeinhisbestinterest.
Mr.
Jdiedonthe147thdayofhishospitalstay,surroundednotbyfamily,butratherbytheCodeBlueteamwhoattemptedonefinal,butfutile,resuscitationeffort.
22Sr.
JulieMantemach,Chaplain,ATaleofanEnd-of-lifeJourney,AddressattheProjectofCompassionateHealthCareandResponsibleStewardship,Aug.
26,2005.
Patientandfamily'sidentificationhavebeenchangedforconfidentialitypurposes.
[VOL.
14:2272COMMUNICATINGPASTCONFLICTMr.
Jisbutoneexampleofpatientsexperiencingprolongedpainduetotechnologicaladvancesandraisedexpectationsofpatientsandtheirfamilies.
3Manypatientsexperienceextendedperiodsofsufferingduringthedyingprocessduetopatientorfamilymembers'desirestodoeverythingpossible.
Modemmedicaltechnologyhasproducedagroupof"half-waytechnologies"thatallowphysiciansto"maintainthephysiologicbasisoflifebutnotreversepathologicprocesses.
"5Oftenthesetreatmentsprovenon-beneficialandevenharmful.
6Shouldaphysicianbeallowedtowithdraworwithholdcontinuedtreatment,evenovertheobjectionsofacompetentpatientortheirrepresentativeOrshouldthepatientortheirrepresentativedictatetreatmentregardlessoftheirphysician'sclinicaljudgmentorthecostofthedemandedtreatmentThesearesomeofthequestionsthemedicalcommunity7hasbeengrapplingwithsincethemid1980s.
8Thesecasesdifferfromthetraditionalright-to-diecasesinwhichthepatientorproxyrefusestreatment.
Intheearlyright-to-diecases,e.
g.
KarenQuinlan9andNancyCruzan,patientsortheirfamiliesrefused3SeegenerallyHealthCouncilofSouthFlorida,Inc.
,TheMedicalFutilityGuidelinesofSouthFlorida,4,(2000),availableathttp://www.
healthcouncil.
org/publications/futility.
html.
4SeeGayMoldowetal.
,WhyAddressMedicalFutilityNow,MINN.
MED.
,(June2004),availableathttp://www.
mmaonline.
net/publications/MNMed2004/June/Moldow.
html(lastvisitedMar.
21,2006).
5Id.
6id.
7"Medicalcommunity"referstothehealthcaresystems:physicians,otherclinicians,ethicists,hospitaladministratorsandattorneys.
8PaulR.
Helftet.
al,TheRiseandFalloftheFutilityMovement,343NEwENG.
J.
MED.
293,293(2000),availableathttp://content.
nejm.
org/cgi/content/full/343/4/293maxtoshow=&HITS=20&hits=20&RES.
9Yetthisearlyright-to-diecasebegan"thisnationonacourseawayfrommedicalpaternalism,andtowardafutureinwhichthewishesofpatientswouldprevail.
Patientautonomyis.
.
.
thegoldstandardforethicaldecision-makingwhenrecommendedcareconflictswithapatient'swishes.
"JerryMenikoff,DemandedMedicalCare,30ARIZ.
ST.
L.
J.
1091,1091(1998).
20061U.
MIAMIINT'L&COMP.
L.
REV.
medicaltreatment.
'0Theseright-to-diecasesestablishedpatients'rightstorefuselife-sustainingtreatmentordemanditswithdrawal.
"Theconceptsofprivacy,patientautonomy,andinformedconsentestablishedthatpatients(nottheirphysicians)shouldmaketreatmentdecisions.
12Paradoxically,thebattletodaybetweenphysiciansandpatientsisnotlikelytoregardpatientsandphysiciansdisagreeingovercarethatphysiciansrecommend.
Rather,thebattleconsistsofpatientsortheirsurrogatesdemandingcarethattheirphysiciansbelieveisfutileormedicallyinappropriate.
13Hastherighttorefusetreatmentbeenextendedtoencompassapositiverighttodemandmedicaltreatmentregardlessofcostorphysicians'clinicaljudgment14Doeslegalprecedentestablishapatient'srighttodemandtreatmentoraphysician'srighttorefusetreatmentdeemedfutileThiscommentwillsuggestthatthesolutiontotheconflictbetweenphysiciansandpatientsregardingfutilecareisaprocess-basedapproachtodecidingend-of-lifedecisions.
'5PartIofthiscommentwill'oSeegenerallyInreQuinlan,355A.
2d647(N.
J.
1976);Cruzanv.
Director,Mo.
Dep'tofHealth,497U.
S.
261(1990).
1KeithShiner,Note,MedicalFutility:AFutileConcept,53WASH.
&LEEL.
REV.
803,805(1996).
QuinlanandCruzanareoftencitedasthebeginningofpatient/surrogaterightstodemandthewithdrawalorwithholdingoflife-sustainingtreatmentbasedonapatient'srighttoprivacy.
PhilipG.
Peters,WhenPhysiciansBalkatFutileCare:ImplicationsoftheDisabilityRightsLaws,91Nw.
U.
L.
REV.
798,798(1997).
12SeeShirleyE.
Sanematsu,TakingaBroaderViewofTreatmentDisputesbeyondManagedCare:AreRecentlegislativeeffortsthecure,48UCLAL.
REV.
1245,1254-55(2001);MatthewS.
Ferguson,EthicalPosturesofFutilityandCalifornia'sUniformHealthCareDecisionsAct,75S.
CAL.
L.
REV.
1217,1217(2002).
13Menikoff,supranote9,at1091.
14Inhealthcaredecisions,a"positive"rightistherighttobefreetomakeanyhealthcaredecisionsonedesires.
ALANMEISEL&KATHYL.
CERMINARA,THERIGHTToDIE:THELAWOFEND-OF-LIFEDECISIONMAKING,§13.
06(3ded.
Supp.
2004).
15"Theemphasisofthe[dueprocess]approach.
.
.
isonfairprocessbetweenpartiesratherthanon.
.
.
definition.
.
.
oftheparties.
Professionalstandards.
.
.
patientrights,intentstandards,andfamilyorcommunityinvolvementusuallyshouldbeaccommodatedintheprocessofdeliberation.
"AMACouncilon274[VOL.
14:2COMMUNICATINGPASTCONFLICTbeginwithareviewofthevariousattemptsatdefiningfutility,includingidentifyingwhatisnotfutility.
Itwillrevealthefutilityofthesearchforanabsolutedefinitionofmedicalfutility"sinceitisinherentlyavalue-ladendetermination.
"''6PartIIwillreviewtheevolutionofaddressingfutilecareintheUnitedStates(alternatively"U.
S.
")andGreatBritain(alternatively"U.
K.
").
Thissectionwillfocusonthemajorcasesthathaveprovidedpatientsandtheirfamiliesthelegalrighttodie17andtheprogressionofpatientsandtheirfamiliesmovingawayfromthe"paternalistic"physician18towardsdemandingtreatmentthatphysiciansandfacilitieshavedeemedfutileintheU.
S.
.
'9FurtheranalysisoffederalandstatestatutorylawswillbereviewedtodeterminethecurrentlegalstatusoffutilityasapositiveornegativerightintheU.
S.
.
ContrastedwiththestatusoffutilityintheU.
S.
willbethereviewoffutilityintheU.
K.
that"merelifeforitsownsakeisnotworthspendingmoneyonifthereisanopportunitycostforthoseresourcesthatcouldotherwisebespentprovidingdefinitebenefitsandhighprobability.
'20TheBritishNationalHealthSystemhascourt-appointedauthoritytorationcarebasedon"clinicalguidelinesthatblendefficacyofoutcomes,qualityoflifejudgments,andeconomics.
",21ThiscommentwillalsoreviewBritishCaseLaw,whichhasestablishednodutytoEthicalandJudicialAffairs,MedicalFutilityinEnd-of-LifeCare,281JAMA937,942(1999)availableathttp://www.
icampus.
ucl.
ac.
be/medoc/jama.
htm.
16Id.
at941.
17InreQuinlan,355A.
2d647(N.
J.
1976);Cruzanv.
Director,Mo.
Dep'tofHealth,497U.
S.
261(1990).
18AnneFederwisch,Medicalfutility:Whohasthepowertodecide,Nurseweek,July2,1998,http:www.
nurseweek.
com/features/98-7/limits.
html(lastvisitedMar.
21,2006).
'9Seee.
g.
,InRe:TheConservatorshipofHelgaM.
Wanglie,7ISSUEsL.
&MED.
369(1991-92).
(includeaparenthetical)20HowardBrody&RaananGillon,FutileCareTreatment:PerspectivesfromtheUnitedStatesandUnitedKingdom,75U.
DET.
MERCYL.
REv.
529,540(1998).
21Id.
at543;WesleyJ.
Smith,TheEnglishPatient,TheWeeklyStandard,May30,2005,availableathttp://www.
weeklystandard.
com/Utilities/printer_preview.
aspidArticle=5645&R=C6DB31.
2006]275U.
MIAMIINT'L&COMP.
L.
REV.
continuelife-prolongingtreatmentevenifthepatientmaydesireit.
22FurtherattentionwillbepaidtotherecentsagaofLeslieBurke23intheU.
K.
andhissuitagainsttheGeneralMedicalCounsel(GMC)regardinghiscontentionthatthewithholdingofartificialnutritionagainsthisdesireswouldbeaviolationofhishumanrightsundertheEuropeanConventionofHumanRights(ECHR).
24PartIIIofthiscommentwillconcludewiththeargumentforestablishingprocess-basedapproachestoaddressmedicalfutilityasanestablishedcommunicationstandardfromwhichphysiciansandpatientsorfamiliesmaysuccessfullyaddressfutility.
Process-basedapproachesintheU.
Swillbeidentifiedandthe"legality"oftheprocess-basedapproachwillbeexplored.
Finally,theevolutionoftheTexasAdvancedDirectivestatute,theonlycodifiedprocess-basedapproachtofutilityintheU.
S.
,willbediscussedanditsramificationonpatientsinTexaswillbereviewed.
25I.
DEFININGFUTILITY"IshallnottodayattemptfurthertodefinethekindsofmaterialIunderstandtobeembraced.
.
.
.
[b]utIknowitwhenIseeit.
.
.
.
,,26ThesewordsillustratetheSupremeCourt'sfrustrationinitsfifty-yearstruggleatdescribingobscenity.
27Thisreactiontoanattemptatdefining"obscene"issimilartotheconfusionandcontroversysurroundingattemptstodefine"medicalfutility.
2822InreJ,[1992]3W.
L.
R.
507(Fam),[1993]Fam.
15(Eng.
).
23LeslieBurke,anEnglishcitizen,suffersfromadegenerativebrainconditionandwasfearfulthatartificialnutritionmightbewithheldfromhim.
24TheUKenactedtheEuropeanConventiononHumanRightsActof1998onOct.
2,2000.
25SeeTEX.
HEALTH&SAFETYCODEANN.
§166.
046(Vernon2003).
26Jacobellisv.
Ohio,378U.
S.
184,197(1964).
FamousquotefromJusticePotterexemplifiesthestruggletheSupremeCourthashadintheirattemptsatdefiningwhatspeechqualifiesas"obscene.
"27id.
28AnneFederwisch,MedicalFutility.
WhohasthePowertoDecide,NurseWeek,July2,1998,http://www.
nurseweek.
com/features/98-7/limits.
html.
276[VOL.
14:2COMMUNICATINGPASTCONFLICT"Numerousdefinitionsoffutilityhavebeenproposed,butnonehavebeenuniversallyaccepted.
,29Somedefinitionsoffutilityappearunderinclusive,othersoverinclusive,whileothersappearbothunderinclusiveandoverinclusive.
30TheAmericanMedicalAssociation's(AMA)CouncilonEthicalandJudicialAffairshasstated,"[F]utility.
.
.
cannotbemeaningfullydefined.
"'3'Theissuewithdevelopinga"standard"clinicaldefinitionoffutilityisthatitcontainsvaluejudgmentsaboutthecharacteristicsofaparticularpatient'slife.
32Consequently,whatonephysicianmightconsiderfutilemaynotbeconsideredfutilebythepatientorherfamilyorevenotherphysicians.
33A.
WhyDefineFutilityThereareseveralreasonsforclearlydefiningwhatfutilitymeansanddetermininghowtomanagemedicalcareinthosesituations.
First,oneshouldqueryatwhatpointcareorinterventionisfutileinlightoftheexistenceof"half-waytechnologies"permittingphysicianstomaintaincertainbiologicalsystemsevenwhencognitivehumanlifeisnotevident.
34Second,modemdaymedicinerelatedtolife-sustaininginterventionsisexpensive.
35Eventhoughphysiciansareinstructedtodoeverythingwithintheirpowertobenefittheirpatients,theAMA's29AscensionHealth.
org,HealthCareEthics:Futility,http://www.
ascensionhealth.
org/ethics/public/issues/futility.
asp(lastvisitedMar.
25,2006).
30MarkStrasser,TheFutilityofFutility:OnLife,Death,andReasonedPublicPolicy,57MD.
L.
REV.
505,514(1998).
31AMERICANMEDICALASSOCIATION,CODEOFMEDICALETHICS:CURRENTOPINIONSWITHANNOTATIONSE-2.
035(2004),availableathttp://www.
ama-ssn.
org/ama/pub/category/8389.
html.
32LanieOlmstead,MedicalFutility,http://www.
wramc.
amedd.
army.
mil/departments/Judge/futility.
htm(lastvisitedMar.
25,2006).
33Id.
34Moldowetal.
,supranote4.
35SeeGilmeretal.
,TheCostsofNonbeneficialTreatmentintheIntensiveCareSetting,HEALTHAFF.
,July-Aug.
2005,at962(statingthatintheUnitedStates,servicesprovidedintheICUaccountsfor20percentofinpatientcosts,currently0.
9percentoftheannualgrossdomesticproduct).
2006]277U.
MIAMIINT'L&COMP.
L.
REv.
CouncilonEthicalandJudicialAffairsCodeofMedicalEthicsdoallowphysicianstoreviewethicallyappropriatecriteriarelatedtocostwhendeterminingtreatmentfortheirpatients.
36Third,dilemmasrelatingtofutilityhaveresultedinhigh-profilecourtcases,suchasthoseofGilgunn,Burke,BabyK,andWangile.
37Patientsandhealthcaresystemswouldbenefitifthemedicalcommunitycouldresolvefutilityissuesoutsidethearenaofthecourtroom.
Finally,medical-decisionauthorityhasmovedawayfromthemorepaternalisticmodelofphysiciansdeterminingthecourseoftreatment,withlittleornoinputfromthepatientandtheirfamily,towardsthepatientandfamilyhavingmoredecision-makingpower.
38Acleardefinitionoffutilitywouldbehelpfultopatientsandtheirfamilywhenassertingtheirauthorityinthefaceofaphysician'srefusaltoprovidecare.
B.
WhatFutilityisNotPerhapsonecanbetterunderstandtheconceptof"futility"byexamininghowfutilityisnotdefined.
Futilitydoesnotrefertopatientsortreatmentsinageneralsense.
Futilityappliestothetreatmentbeingperformedorconsideredonanindividualpatientataparticularpointin36AMERICANMEDICALASSOCIATION,CODEOFMEDICALETHICS,supranote30,atE-2.
03,availableathttp://www.
ama-assn.
org/apps/pf~new/pf~onlinef_n=resuitLink&doc=policyfiles/HnE/E-2.
03.
HTM&st=allocation+of+limited+medical+resources&catg=AMA/HnE&catg=AMA/BnGnC&catg=AMA/DIR&&nth=1&&st_p=0&nth=1&.
31InreBaby"K,"823F.
Supp.
1022(E.
D.
Va.
1993),aff'd16F.
3d590(4thCir.
1994);RobertJ.
Dzielak,PhysiciansLosetheTugofWartoPullthePlug:TheDebateAboutContinuedFutileMedicalCare,28J.
MARSHALLL.
REv.
733,748(1995);PatientLosesRight-to-FoodCase,BBCNews,July28,2005,http://newsvote.
bbc.
co.
uk/mpapps/pagetools/print/news.
bbc.
co.
uk/2/hi/health/4721061.
stm(lastvisitedMar.
25,2006);SistersofCharityofLeavenworthHealthSystem,CatherineGilgunn,http://www.
sclhsc.
org/about/missionvision/ethicalissues/catherinegilgunn.
htm(lastvisitedMar.
25,2006).
38Dzielak,supranote37,at733.
278[VOL.
14:2COMMUNICATINGPASTCONFLICTtime.
39Thetreatmentbeingperformedorconsideredcanonlybeconsideredfutileifitdoesnotorwillnotachievemedicine'sgoalsofbenefitingthatparticularpatient.
4aFutilityisnotrationinghealthcare.
4Futilityinvolvesdecisionsregardingthebenefitofmedicaltreatmenttothepatient,whilerationing2explorescostconsiderationandtheavailabilityofparticularresourcesinrelationtotheproposedtreatment.
43RationingisthereforeaderivationofDistributiveJustice.
4Asthepatient'sadvocate,aphysicianshouldprovidecareregardlessofcost.
45Iftheinterventionisdeemed39LAWRENCEJ.
SCHNEIDERMAN&NANCYS.
JECKER,WRONGMEDICINE:DOCTORS,PATIENTS,ANDFUTILETREATMENT8(1995)[hereinafterWRONGMEDICINE].
40id.
41Seeid.
at79.
42Anexampleofmedicalrationingreasoning:[Dr.
Vincent]finallyblurtedout.
"Look,theguyisalreadyinhis80s.
Ijustdon'tthinkit'srighttobespendingtensorwhatcouldbeevenhundredsofthousandsofdollarsonhimwhenthebestwecandoisgivehimmaybeayearortwomoreofpoorqualityoflife,ifthatmuch.
Meanwhilelookatalltheotherpeople-kids,particularly-whohavetheirwholelifeaheadofthem-they'retheoneweshouldbegivingthistreatmentto.
"TheotherdoctorschimedintheiragreementId.
at66.
43Shiner,supranote11,at826.
44"Principlesofdistributivejusticearenormativeprinciplesdesignedtoallocategoodsinlimitedsupplyrelativetodemand"Plato.
stanford.
edu,DistributiveJustice,athttp://plato.
stanford.
edu/entries/justice-distributive/(lastvisitedMar.
25,2006).
45"Aphysicianhasadutytodoallthatheorshecanforthebenefitoftheindividualpatient.
.
.
.
Physicianshavearesponsibilitytoparticipateandtocontributetheirprofessionalexpertiseinordertosafeguardtheinterestsofpatientsindecisionsmadeatthesocietallevelregardingtheallocationorrationingofhealthresources.
"AMERICANMEDICALASSOCIATION,CODEOFMEDICALETHICS,supranote30,atE-2.
03,availableathttp://www.
ama-assn.
org/apps/pfnew/pfonlineffn=resultLink&doc=policyfiles/HnE/E-2792006]U.
MIAMIINT'L&COMP.
L.
REv.
futile,however,thephysicianorfacilityisnotethicallyboundtocontinuetreatmentnomatterthecost(eveniftheresourceischeapandabundant).
46Palliativecareshouldnotbeconsideredfutile;47infact,futility48disputescouldactuallybeconsideredtheantithesisofpalliativecare.
Infutilecare,physiciansaregivingtreatmentthatmayonlyresultinpainandothersymptomswithoutanyhopeofsignificantbenefit.
49Conversely,"palliativecareimprovesthequalityofapatient'slife,eveniftheinterventionmaynotprolongthelengthofsurvival.
"5°C.
AttemptsatDefiningFutilityToaddressfutilityappropriately,themedicalcommunitymustreachaconsensusaboutadefinitionorseeksomeotherprocessfromwhichtoaddresstheproblem.
51Severalattemptsatdefiningfutilitywarrantmention.
2.
03.
HTM&st=allocation+of+limited+medical+resources&catg=AMA/HnE&catg=AMA/BnGnC&catg=AMA/DIR&&nth=1&&stp=0&nth=1&.
46"Physiciansarenotethicallyobligatedtodelivercarethat,intheirbestprofessionaljudgment,willnothaveareasonablechanceofbenefitingtheirpatients.
"Id.
atE-2.
035,availableathttp://www.
ama-assn.
org/apps/pfnew/pfonlinef_n=resultLink&doc=policyfiles/HnE/E-2.
035.
HTM&st=allocation+of+limited+medical+resources&catg=AMA/HnE&catg=AMA/BnGnC&catg=AMA/DIR&&nth=1&&st_p=O&nth=2&.
47Id.
48JosephJ.
Fins,PrinciplesinPalliativeCare:AnOverview,RESPIRATORYCAREJ.
(2000),athttp://www.
rcjoumal.
com/contents/11.
00/11.
00.
1320.
asp(lastvisitedMar.
25,2006).
49Id.
50Olmstead,supranote32.
"ERICHH.
LOEWY&ROBERTASLOEWY,TEXTBOOKOFHEALTHCAREETHICS297(2ded.
2004).
[VOL.
14:2COMMUNICATINGPASTCONFLICT1.
PhysiologicalFutility52Physiologicalfutilitycanbedescribedastreatmentthatwillnotachieveitsphysiologicalgoalandthereforewillaffordnophysiological53benefittothepatient.
Anexampleofphysiologicalfutilitywouldbeaphysicianprescribinganantibiotictotreataviralinfection.
Sinceantibioticscombatbacteriatheywouldbeineffectiveintreatingviralinfections.
54Althoughphysiologicalfutilitymaybetheeasiestdefinitionoffutilitytoanalyzeinpractice,anapproachthatonlyaccountsforpsychologicalfutilityhasseveralproblems.
55First,suchadefinitioncouldeasilyprohibitphysiciansfromproperlydeterminingatreatment'sfutility,becausethetreatmentwouldmaintainabiologicalfunctionofthebodyeventhoughthepatientmaybepersistentlyunconsciousorterminallyill.
56Furthermore,thevalueofaninterventioncannotbejudgedbyphysiologicaloutcomealone.
Physiologicaloutcomesoftenvary,andphysiciansareoftenunabletodeterminewhenaninterventionmaybeoflittleornophysiologicalbenefit.
57Caselaw,however,doessupportthepositionthatwhenapatientreceivesnophysiologicalbenefitfromatreatment,aphysicianhasnolegalobligationtoprovideorcontinuethatcourseoftreatmentregardlessofpatientauthorization.
5852Physiologicalisa"characteristicoforappropriatetoanorganism'shealthyornormalfunctioning"MERRIAM-WEBSTER'SCOLLEGIATEDICTIONARY888(9thed.
1991),availableathttp://www.
m-w.
com/dictionary/physiological.
53TheMedicalFutilityGuidelinesofSouthFlorida,supranote3,at6.
54EricM.
Levine,ANewPredicamentforPhysicians:TheConceptofMedicalFutility,thePhysician'sObligationtoRenderInappropriateTreatment,andtheInterplayoftheMedicalStandardofCare,9J.
L.
&HEALTH69,74(1994-1995).
55Menikoff,supranote9,at1095.
56TheMedicalFutilityGuidelinesofSouthFlorida,supranote3,at6.
57SeeRalphCohen-Almagor,LanguageandRealityattheEndofLife,28J.
L.
MED.
ÐICS267,270-71(2000).
58MEISEL,supranote14,at13-15.
2006]U.
MIAMIINT'L&COMP.
L.
REv.
2.
QualitativeFutilitySomecommentatorsdeemqualitativefutilityasthemostcontroversiali9SchneidermanandJeckerdefinethequalitativefeatureofmedicalfutilityas:"[i]fapatientlacksthecapacitytoappreciatethebenefitofatreatment,orifthetreatmentfailstoreleaseapatientfromtotaldependenceonintensivemedicalcare.
"60Inotherwords,isthepatient'squalityoflifesodiminished(e.
g.
permanentunconsciousness)thatitcouldbeconsideredfutiletocontinuethepatient'slife61Determiningthequalityofapatient'slifeinrelationtoagiventreatmentthereforebecomesavaluejudgment,onethatphysiciansareillqualifiedtodeterminealone.
62Thequalitativeviewoffutilitydirectlyclasheswiththenotionofpatientautonomy.
63Courtshavemovedawayfromthepaternalisticphysicians'model(underwhichthephysicianscoulddeterminethebenefitsofatreatmentforagivenpatient)towardstheprincipleofpatientautonomy.
64"Nowthey[doctors]cansustainlifebeyondourwildestformerexpectations,butoncepatientsrealizethehollownessofsuchmechanicallife,thosepatientswhowanttodie[orintheoppositecase,theproxywhowantseverythingpossibledone]suetheirdoctors.
'653.
QuantitativeFutilityShinercharacterizesquantitativefutilityasa"atreatment[that]hasprovedineffectiveinthelastonehundredcases,"66thatis,theprobabilityofagiventreatment'ssuccessdropssolow,thatonecould59Menikoff,supranote9,at1096.
60WRONGMEDICINE,supranote39,at17.
61Bythisdefinition,continuedmedicaltreatment(e.
g.
respiratororfeedingtube)inapersistentlyunconsciouspersonwouldbeconsideredfutilesinceitsimplymaintainsthepatient'schronicvegetativestate.
62Menikoff,supranote9,at1097.
63Shiner,supranote11,at830.
64Id.
at832.
65BrianC.
Kalt,Death,Ethics,andtheState,23HARV.
J.
L.
&PUB.
POL'Y487,501(2000).
66Shiner,supranote11,at828.
[VOL.
14:2282COMMUNICATINGPASTCONFLICTconsideritfutile.
67AnexampleofthiskindoffutilityisprovidingCPR68toanelderlypatientwithmetastatic69cancer.
70Asmoretherapeuticoptionshavebecomeavailable,thisstrugglewithuncertaintycanleadtoaparalysisofaction.
71Ifaphysiciancanneverbeonehundredpercentsurethatatreatmentwillfailorsucceed,istherenotamoralobligationtodoanythingthatmightwork72Thissituationisyetanotherinstancewhereforindividualvalueswillpredominatedecisionmaking,whichagaincannotbeadequatelyaddressedbyphysiciansalone.
4.
HybridQuantitativeandQualitativeFutilitySchenidermanandJeckercombinethedifferentaspectsofquantitativeandqualitativeintotheirgeneraldefinitionoffutility:Medicalfutilitymeansanyefforttoprovideabenefittoapatientthatishighlylikelytofailandwhoserareexceptionscannotbesystematicallyproduced.
[emphasisintheoriginal].
.
.
[T]hisdefinitionhasaquantitativecomponent("highlylikelytofail")andaqualitativecomponent("benefittothepatient").
.
.
[T]hefocusoftheeffortisthepatient(derivedfromtheLatinwordfor'tosuffer'),notsomeorganorphysiologicalfunctionor67Menikoff,supranote9,at1098.
68Contrarytopopularbelief,"[O]nlyabout15%ofhospitalizedpatientsinwhomresuscitationisattemptedwillsurvivetodischarge.
.
.
.
Patientsover70yearsofagewhohavesepsisormetastaticcarcinoma,orwhosearrestlastsmorethan15minutesareunlikelytosurvive.
"HealthcareEthics,CardiopulmonaryResuscitation(2005),http://www.
ascensionhealth.
org/ethics/public/issues/cardio.
asp(lastvisitedMar.
24,2006).
69Metastaticcanceriscancerthathasspreadormetastasizestootherareasofthebody.
70Olmstead,supranote32.
71WRONGMEDICINE,supranote39,at14.
72Id.
at14-15.
2832006]U.
MIAMIINT'L&COMP.
L.
REV.
bodysubstance.
.
.
[W]hatisprovidedisabenefit,notaneffect.
73SchenidermanandJeckerstresstheprovisionof"benefit"over"effect,"duetotheenormousrangeofeffectsthatmodemmedicinecanproduceonthehumanbody.
74Physicianscancreateorcausemultipleeffectsonevenanunconsciouspatient,yetiftheseactionshavenobenefit,theauthorsarguethetreatmentisfutile.
75Althoughthesedefinitionshavebeenhelpfulinframingthefutilityargument,theyhavebeenunsuccessfulindeterminingadefinitivedefinitionoffutility.
76Eventhosewhoaccepttheconceptsofquantitativeandqualitativefutilitydisagreeonhowtodrawthedividinglinebetweenfutileandnon-futilecare.
77II.
FUTILITYINTHEU.
S.
&U.
K.
IntheU.
K.
,CharlotteWyattwasbornprematurelyrequiringventilationformostofherfirstthreemonths.
Shesuffersfromseverebrain,kidney,andlungdamage.
Asaresult,BabyCharlotte,asshecametobeknown,is:[B]lind,deafandincapableofvoluntarymovementorresponse.
Itisveryhighlyprobablethatshewillduringthiswintersuccumbtoarespiratoryinfectionthatwillprovefatal.
Thatsaidtheunanimousmedicalevidencealsorecognizesthatinthisareathereisnosuchthingascertaintyofprognosisorsurvival.
7873Id.
at11-12.
74Id.
at12.
75Someexamplesoftheseeffectsinclude:"addingandsubtractingbodychemicals,increasingandreducingcirculatingbloodcells,destroyingcancercells,restoringtheheartbeat,replacingkidneyfunction,killingbacteria,subduingvirusesandfungi.
.
.
.
"Id.
76Menikoff,supranote9,at1099.
77Id.
78PortsmouthNHSTrustv.
Wyatt&Ors,[2004]EWHC(Fam.
)2247(Eng.
).
[VOL.
14:2284COMMUNICATINGPASTCONFLICTABritishjudgeheldthatdoctorsdonothavetoattemptresuscitationofCharlotteifshestopsbreathing.
79Nowthatshehassurvivedpasthersecondbirthday,Mr.
JusticeHedleyhas,inturn,dischargedhisyear-oldrulingonOctober21,2005whichstated"thatdoctorswouldnotbeactingunlawfullyiftheydecideditwasnotinthechild'sbestintereststoartificiallyventilateherinalife-threateningsituation.
"80Yet,doctorsatStMary'sHospitalinPortsmouthclaimthattheystillhavethefinaldecisionindeterminingthebesttreatmentforCharlotte:"[I]fthereisafuturedisagreementwehaveaverycleardirectionfromthecourt.
.
.
doctorsarenotrequiredtoventilateCharlottewhenitisnotinherbestinteresttodoso.
',8IIntheU.
S.
,BabyKwasborninananencephalicstate.
2Shewastransferredtoanursinghomeforongoingcarewithanagreementthatthehospitalwouldreadmitherifsheagaindevelopedrespiratorydistress.
83Afterseveralre-admissionsforrespiratorydistressrequiringventilatortreatment,thehospitalsought"declaratoryjudgmentabsolvingthehospitalofliabilityundertheEmergencyMedicalTreatmentand79Id.
at9.
80Timesonline.
co.
uk,BabyCharlottewinsreprieveonhersecondbirthday,http://www.
timesonline.
co.
uk/article/0,,2-1836900,00.
html(lastvisitedMar.
25,2006).
81id.
82Anencephalicstate:Anencephalyisacongenitaldefectinwhichthebrainstemispresentbutthecerebralcortexisrudimentaryorabsent.
Thereisnotreatmentthatwillcure,correct,orameliorateanencephaly.
BabyKispermanentlyunconsciousandcannothearorsee.
Lackingacerebralfunction,BabyKdoesnotfeelpain.
BabyKhasbrainstemfunctionsprimarilylimitedtoreflexiveactionssuchasfeedingreflexes(rooting,sucking,swallowing),respiratoryreflexes(breathing,coughing),andreflexiveresponsestosoundortouch.
BabyKhasanormalheartrate,bloodpressure,liverfunction,digestion,kidneyfunction,andbladderfunctionandhasgainedweightsinceherbirth.
Mostanencephalicinfantsdiewithindaysofbirth.
IntheMatterofBabyK,832F.
Supp.
1022,1025(E.
D.
Va.
)(1993).
83Id.
2006]U.
MIAMIINT'L&COMP.
L.
REV.
ActiveLaborAct(EMTALA)84ifthehospitalrefusedtoprovideventilatortreatmentwhenBabyKnextexperiencedrespiratorydistress.
85ThecourtruledthattheplainlanguageofEMTALArequiredthatrespiratorytreatment(life-savingtreatment)begiventoBabyK.
86EMTALA,aU.
S.
Federallaw,requiresthatlife-sustainingtreatmentbegiventoanyindividualwhocomestoanemergencyroomrequiringemergencytreatment.
87Somecommentatorsarguethatthereasoningof84EmergencyMedicalTreatmentandActiveLaborAct(EMTALA),42U.
S.
C.
§1395dd(2000).
85Strasser,supranote29,at507.
86id.
87Hospitalswithemergencymedicaldepartmentsmustprovideanappropriatemedicalscreeningtodeterminewhetheranemergencymedicalconditionexistsforanyindividualwhocomestotheemergencyroomseekingtreatment.
42U.
S.
C.
§1395dd(e)(1)(2000).
Thestatutedefinesan"emergencymedicalcondition"asincluding:[A]medicalconditionmanifestingitselfbyacutesymptomsofsufficientseverity(includingseverepain)suchthattheabsenceofimmediatemedicalattentioncouldreasonablybeexpectedtoresultin(i)placingthehealthoftheindividual.
.
.
inseriousjeopardy,(ii)seriousimpairmenttobodilyfunctions,or(iii)seriousdysfunctionofanybodilyorganorpart.
42U.
S.
C.
§1395dd(e)(1)(A)(i)-(iii)(2000);TheCourtdeterminedthatintheapplicationofEMTALAtoBabyK:[T]heHospitalconcedesthatwhenBabyKispresentedinrespiratorydistressafailuretoprovide'immediatemedicalattention'wouldreasonablybeexpectedtocauseseriousimpairmentofherbodilyfunctions.
See42U.
S.
C.
§1395dd(e)(1)(A).
Thus,herbreathingdifficultyqualifiesasanemergencymedicalcondition,andthediagnosisofthisemergencymedicalconditiontriggersthedutyofthehospitaltoprovideBabyKwithstabilizingtreatment.
.
.
[s]incetransferisnotanoptionavailable.
.
,theHospitalmuststabilizeBabyK'scondition.
BabyK,832F.
3dat594.
286[VOL.
14:2COMMUNICATINGPASTCONFLICTthecourtinBabyKregardingEMTALAis"flawed.
88Asaresultofthedecision,BabyKliveduntilshewastwoandone-halfyearsold.
89ThesetwocasesarerepresentativeofthefutilitydebatesinboththeU.
S.
andU.
K.
.
TheBritishcourtsusuallysupportrationalmedicaldecision-makingtowithholdorwithdrawfutilecare.
90Ontheotherhand,litigatedcasesintheU.
S.
usuallydisallowphysiciansfromwithholdingorwithdrawinglife-sustainingmedicaltreatmentwithouttheconsentofthepatientorsurrogate.
9'A.
TheUnitedStatesIntheU.
S.
,"thewithholdingandwithdrawaloflifesupportislegallyjustifiedprimarilybytheprinciplesofinformedconsentandinformedrefusal,bothofwhichhavestrongsupportinthecommonlaw.
92Patientsortheirsurrogatescaneitherapprovetheproposedtreatment(informedconsent)orrefuseanyandalltherapies(informedrefusal).
93Withthisemphasisonpatientautonomyhascometheevolutionofpatientsdemandingnotonlythatcarebediscontinued,but88MEISEL,supranote14,at13-30;Strasser,supranote30,at508-09.
ButtheU.
S.
CourtofAppealsdidnotconsiderotherfederallaws(Section504oftheRehabilitationActandSection302oftheAmericanswithDisabilitiesAct)orVirginiastatelaw(VirginiaMedicalMalpracticeAct)asobligatingtheHospitaltoprovidecaretoBabyK,sinceitdeterminedthatEMTALArequiredtheHospitaltorenderstabilizingtreatment.
BabyK832F.
3dat592.
89Answers.
com,ThecaseofBabyK,http://www.
answers.
com/topic/baby-k(lastvisitedMar.
26,2006).
90SeeLEHagger,TheHumanRightAct1998andmedicaltreatment:timeforre-examination,89ARCHIVESOFDISEASESINCHILDHOOD460(2003)availableathttp://adc.
bmjjournals.
com/cgi/content/full/89/5/460#otherarticles(lastvisitedMar.
26,2006).
91See,e.
g.
,IntheMatterofBabyK,832F.
Supp.
1022(E.
D.
Va.
)(1993).
Seealso,42U.
S.
C.
§1395dd;Wanglie,supranote19,at372(Hospitaldeniedguardianship);MEISEL,supranote14,at13-6,17.
92JohnM.
Luce&AnnAlpers,LegalAspectsofWithholdingandWithdrawingLifeSupportfromCriticallyIllPatientsintheUnitedStatesandProvidingPalliativeCaretoThem,162AM.
J.
RESPIR.
CRIT.
CAREMED.
2029(2000).
93Seeid.
at2029(statingthatphysiciansareallowedtoprovidetreatmentwithoutconsentinemergencysituations).
2006]287U.
MIAMIINT'L&COMP.
L.
REv.
alsothattreatmentbeprovidedevenwhenaphysiciandoesnotrecommendit.
94Yet,sincenodefinitivedefinitionoffutilityhasbeendeveloped,thesecommonlawproclamationsregardinginformedconsentandinformeddenialprovidenolegalconsensusabouthowfutilitycasesshouldbeaddressedintheU.
S.
95Instead,avarietyofconflictingcommonlawandstatutoryapproacheshavedevelopedregardingfutilecare.
TheonlyconsensusregardingfutilecareintheU.
S.
regardsphysiologicfutility.
96Forexample,aphysicianisundernoobligationtocontinueventilationofaclinicallybrain-deadperson.
971.
TheRighttoSayNoIthasbeenalmostthirtyyearssincethelandmarkcaseofKarenQuinlan(InreQuinlan)inwhichthequestionofwithholdingorwithdrawinglife-sustainingtreatmentfromapatientwasfirstdetermined.
98Quinlanwaskeptalivebyaventilatoraftersheslippedintoapersistentvegetativestate(PVS).
99Herphysiciansandhospitalrefusedherfamily'srequesttoterminateventilatortreatment.
They94MEISEL,supranote14at13-8-9.
9'Seeid.
96SeediscussiononPhysiologicFutilitysuprapp.
277-78.
97SeeMEISEL,supranote14,at13-7.
98InreQuinlan,355A.
2d647,662-63(N.
J.
1976).
99PVSwasfirstconsideredadiagnosticentityin1972.
"Untilthe1970'sand'80sPVSpatientswererarelykeptaliveforlongperiodsoftime.
"WRONGMEDICINE,supranote38,at3.
MoreregardingPVS:Individualsinsuchastate[PersistentVegetativeState]havelosttheirthinkingabilitiesandawarenessoftheirsurroundings,butretainnon-cognitivefunctionandnormalsleeppatterns.
Eventhoughthoseinapersistentvegetativestatelosetheirhigherbrainfunctions,otherkeyfunctionssuchasbreathingandcirculationremainrelativelyintact.
Spontaneousmovementsmayoccur,andtheeyesmayopeninresponsetoexternalstimuli.
Theymayevenoccasionallygrimace,cry,orlaugh.
NationalInstituteofNeurologicalDisordersandStroke,ComaandPersistentVegetativeStateInformationPage,http://www.
ninds.
nih.
gov/disorders/coma/coma.
htm(lastvisitedMar.
26,2006).
288[VOL.
14:2COMMUNICATINGPASTCONFLICTrecognizedthat"Karen'spresenttreatmentservesonlyamaintenancefunction;.
.
.
therespiratorcannotcureorimproveherconditionbutatbestcanonlyprolongherinevitableslowdeteriorationanddeath.
"'100TheNewJerseySupremeCourtrecognizedarightofprivacyinwhichthe"individual'srighttoprivacygrowsasthedegreeofbodilyinvasionincreasesandtheprognosisdims.
"'0'ThisrighttobeleftaloneisacceptedbytheU.
S.
SupremeCourt.
102InallowingQuinlan'srighttoprivacy,thecourtrecognizedapatients'rightsmovementgivingpatientsortheirguardiansthe"righttorefusemedicaltreatment,evenifthatmeantdeath.
"'3Inessence,thefamilywasgiventheresponsibilitytodowhatKarenwouldhavewanted,andifherwisheswerenotknown,theyweregiventheauthoritytodecideasaproxyforherbestinterest.
14Karen'srespiratorwasremoved,andshelivedunaidedinherbreathingforanothernineyearsbeforesuccumbingtopneumonia.
105SevenyearsaftertheNewJerseySupremeCourtdecidedQuinlan,NancyCruzanlostcontrolofhercaronaroadinMissouriandwasthrownfromhervehiclefacedownintoawater-filledditch.
106ParamedicswereabletoresuscitateCruzan,butherinjuriesresultedinadiagnosisofPVS.
107CruzanwouldbethefirsttimethattheU.
S.
SupremeCourtwouldaddresstheissueofwithholdingorwithdrawinglife-supportingtreatment.
Afterthreeyearsofwitnessingtheirdaughter'sgrotesquephysicalchangesandwithaprognosisofPVSuntildeath,Cruzan's100Seediscussionof"half-way"technologiesinfrap.
2;Quinlan,supra,note98,at663.
o'Id.
at664.
102ARTHURS.
BERGER&JOYCEBERGER,ToDIEORNOTTODIECROSS-DISCIPLINARY,CULTURAL,ANDLEGALPERSPECTIVESONTHERIGHTTOCHOOSEDEATH131(PraegerPub.
)(1990).
103RobertM.
Veatch&CarolM.
Spicer,MedicallyFutileCare:TheRoleofthePhysicianinSettingLimits,18AM.
J.
L.
&MED.
15(1992).
104id.
105KarenAnnQuinlanHospice,History,athttp://www.
karenannquinlanhospice.
org/History.
htm(lastvisitedMar.
26,2006).
106Cruzan,497U.
S.
at266.
107id.
2006]289U.
MIAMIINT'L&COMP.
L.
REv.
parentshadrequestedthatherartificialhydrationandnutritionbeterminated.
108TheMissouriSupremecourtdeclaredthatthestatehadaninterestinlifethatwasunqualified;consequently,thecourtorderedthattreatment(artificialnutritionandhydration)mustbecontinuedaslongasCruzanwasalive.
109ThecourtstateditwouldonlyapprovetheremovalofCruzan'sfeedingtubeif"clearandconvincing"evidencecouldestablishedthatshewouldnotwanttobekeptaliveinaPVSstate.
"0TheCruzansappealedtheircasetotheU.
S.
SupremeCourt.
ButtheCourtupheldMissouri'sevidentiarystandardof"clearandconvincing"indeterminingapatient'swishesrulingthatdueprocesswasnotviolatedbysuchastandard.
'11TheCourtstated"[t]hechoicebetweenlifeanddeathisadeeplypersonaldecisionofobviousandoverwhelmingfinality.
WebelieveMissourimaylegitimatelyseektosafeguardthepersonalelementofthischoicethroughtheimpositionofheightenedevidentiaryrequirements.
"'"12Yetwhenthecasewasremandedtothetriallevel,thetrialcourtacceptedtestimonyfromNancy'sfriendsnotpresentedatanyoftheearlycourthearingsthatshehadstatedthatshewouldnotwanttoliveinavegetativestate.
Thetrialcourtacceptedthisadditionalevidenceas"clearandconvincing,"andthestateofMissourichosenottopursueanappeal.
113Nancy'smedicallyassistednutritionandhydrationwasremovedinDecemberof1990,andshediedtwoweekslater.
"14HerfamilymaintainedthatforthemNancyhaddiedbackin1983,theyearofherautoaccident.
"5UnlikeQuinlan,therighttorefuselife-sustainingtreatmentinCruzanwasfirmlygroundedbytheFourteenthAmendment'sguarantee'08Seeid.
,at265.
109Cruzanv.
Harmon,760S.
W.
2d408,423-24(1988).
11oSeeWRONGMEDICINE,supranote38,at2.
111Cruzan,497U.
S.
at282-83.
112Id.
at281.
"'WRONGMEDICINE,supranote39,at2.
114WESLEYJ.
SMITH,CULTUREOFDEATH(THEASSAULTONMEDICALETHICSINAMERICA)68-69(2000).
"'WRONGMEDICINE,supranote39,at2.
290[VOL.
14:2COMMUNICATINGPASTCONFLICTofpersonalliberty.
'6Additionally,"theSupremeCourt'sCruzanrulingsignificantlyextendedtheQuinlandecisionbyincludingartificialnutritionandhydration(tubefeedings)asmedicalcarethatmayberefusedordiscontinuedbythecompetentpatientorsurrogate.
"'"17Thustoday,competentpatientsortheirsurrogateshavealegallyprotectedrighttosay"no"toanytreatment,evenlife-sustainingtreatment.
18QuinlanandCruzanestablishedapatient'srighttorefuseordemandthewithdrawaloflife-sustainingtreatment.
Effectively,thisisa"negative"right.
19"Thisnegativerightofrefusalskewedmedicaldecision-makingpowerinfavorofpatients.
"'2°Thecommonlawdoctrineofinformedconsentprovidedyetanotherjustificationforapatient'srighttorefuselife-sustainingtreatment.
121Informedconsentmeansthat"priortoagreeingtoany116NancyCruzanhasalibertyinterestundertheDueProcessclauseofthe14thAmendment.
Cruzan,497U.
S.
at278.
117DavidB.
Waisel&RobetD.
Truog,TheEnd-of-LifeSequence,87J.
AM.
SOC'YANESTHESIOLOGISTS676(1997),availableathttp://gateway.
ovid.
com/ovidweb.
cgiT=JS&MODE=ovid&NEWS-n&PAGE=toc&D=ovft&AN=00000542-000000000-00000.
118id.
119"Negativeright"explained:Anegativerightembodiesthefreedomtodowhatonewantswithoutinterferencefromothers.
Therighttorefusemedicaltreatmentissucharight.
Itisarighttoliveone'slifewithoutbeingimposeduponbyphysicianswho,fortheirownreasonsandbasedontheirownvalues(howeverbenevolent),mightwishtocompelanindividualtoreceivetreatmentthat[the]individualdoesnotwant.
MEISEL,supranote14,at13-23.
120Dzielak,supranote37,at747.
121Id.
,"Undercommonlaw,apatientnormallymustconsenttomedicaltreatmentofanykind.
Consentisrequiredtomaintaintherightofpersonalinviolability.
"Keinerv.
Cmty.
ConvalescentCtr.
549N.
E.
2d292,297(1989).
Furthermore,JusticeCardozoviewingthisrightinthecontextofmedicaltreatmentstated:"Everyhumanbeingofadultyearsandsoundmindhasarighttodeterminewhatshallbedonewithhisownbody;andasurgeonwhoperformsanoperationwithouthispatient'sconsentcommitsanassault,forwhichheisliableindamages.
"Id.
(quotingSchloendorffv.
Soc'yofNewYorkHosp.
,105N.
E.
92,93(1914)).
2006]U.
MIAMIINT'L&COMP.
L.
REv.
touchingofone'sbody,anindividualmustbegiveninformationabouttheproposedtouching.
Judicialdecisions[generallyholdthat]underthisdoctrine,itisessentialforaphysiciantoobtainconsentfromapatientbeforestartinganyprocedureortreatment.
"122Patientsaretomakethetreatmentdecisionsbasedontheinformationprovidedbytheirphysician.
Thepatienthasalegallyprotectedrighttorefuseofferedmedicaltreatmentunderinformedconsent.
'23Therefore,theright-to-diedecisions(establishingprivacy,liberty,andinformedconsentformedicaltreatment)providedpatientsortheirsurrogatesintheU.
S.
therighttodemandorrefusethewithdrawaloflife-sustainingtreatment.
2.
ARighttoDemandTreatmentEmboldenedwiththerighttosay"no"tomedicaltreatment,patientsbegantodemandthatphysiciansprovidemedicaltreatmenteveniftheirphysicianbelievedthetreatmentwasinappropriate.
24Oftenthesedemandsforcontinuedcarecomeonbehalfofthepatientbytheirsurrogate.
25Althoughthesecasesdonotdirectlyaddressthefutilityissue,theydemonstratetheexpansionofpatients'rightsfromanegativerighttosay"no,"toapositiveright26todemandhealthcare(sanctionedbythecourt),regardlessofcostorphysicians'recommendations.
27122"Foraconsenttobevalid,thephysicianmustgivethepatientmaterialinformationaboutthecourseofactionproposed,therisksofdeathorharmtheproceduremayentail,thealternatetherapies,andtheproblemsthatmayariseduringtherecoveryprocess.
"BERGER&BERGER,supranote102,at132.
123Id.
124Dzielak,supranote37,at744.
125SeeInreWanglie,supra,note19,at371.
SeealsoInreBabyK,16F.
3d590(4thCir.
1994).
126Meiselonpositiveandnegativerights:Likeanegativeright,apositiverightenvisionsthatoneshouldbefreetodowhatonewants,butratherthanenvisioningafreedomfrom-specifically,freedomfrominterferencebyothers-itenvisionsafreedomto-specifically,freedomtomakethemostofone'slifewiththeresourcesthatonecanlegitimatelysuperintendwithoutentrenchingonother'sfreedomtobefreefromunwantedinterference.
Inthe[VOL.
14:2COMMUNICATINGPASTCONFLICTOneofthefirstcasestoaddresstheissueofa"positive"rightwasHelgaWanglie'scase,inwhichWangliesufferedacardiacarrestthatrenderedherpermanentlyunconscious.
128Afterseveralweeks,thephysicianstreatingWangliedeterminedthatcontinuedrespirationwasfutileandrecommendedthatcontinuedlife-sustainingtreatmentbestopped,butWanglie'shusbandrefusedtodiscontinuehercare.
'29Consequently,alawsuitensuedwhereWanglie'sphysicianattemptedtohaveaconservatorappointedtodeterminethebestinterestofWanglie.
'30Ultimately,thecourtappointedMr.
Wangliewho,itreported,wasinthebestpositiontoactonbehalfofhiswife.
13'Thecourtstated:NocourtordertocontinueorstopanymedicaltreatmentforHelgaWangliehasbeenmadeorrequestedatthistime.
Whethersucharequestwillbemade,orsuchanorderisproper,orthisCourtwouldmakesuchanorder,andwhetherOliverWanglie[Helga'shusband]wouldexecutesuchanorderarespeculativemattersnotnowbeforetheCourt.
32Inthisproclamation,thecourtseemstoinferadisregardforphysicianautonomy,showingrecognitionthatthecourt'sdecisionhadnotdirectlydeterminedmedicaltreatmentforWanglie,butinsidesteppingtheclashofvaluesbetweenWanglie'sphysicianandfamily,nonethelessensuredcontinuedcaredespitemedicalobjection.
133contextofmedicaldecision-making,itisthefreedomtohavewhatevermedicaltreatmentonemightwish.
MEISEL,supranote14,at13-23.
127ld.
128InreWanglie,supranote19,at374.
129Id.
at371.
130Id.
'"'Id.
at372.
132Id.
at377.
133JudithF.
Daar,MedicalFutilityandImplicationsforPhysicianAutonomy,21AM.
J.
L.
&MED.
221,224(1995).
2006]293U.
MIAMIINT'L&COMP.
L.
REv.
Patientsandtheirfamilieshavealsoinvokedfederalstatutorygroundstodemandtreatment.
Thefederalstatutesinvokedassourceofapositiverighttohealthcareinclude:EMTALA,34§504oftheRehabilitationActof1973,§302oftheAmericanwithDisabilitiesAct,andtheChildAbuseAmendmentof1984.
135Althoughallthesefederalstatutescanlogicallybedrawnintothedebateofpatientsdemandingmedicaltreatmentfromtheirphysicians,onlyEMTALAhasbeensuccessfullyinvokedtoimposealimiteddutytocontinuetreatment.
136TheRehabilitationActof1973andtheAmericanswithDisabilitiesActof1990(ADA)prohibitdiscriminationagainstthedisabled.
137ProponentsofapositivehealthcarerighthavecitedSection504oftheRehabilitationActof1973andSection302oftheAmericanswithDisabilitiesActof1990toprohibitattemptsatwithholdingorwithdrawinglife-sustainingtreatmentfromthehandicapped.
138Section504prohibitsdiscriminationagainstan"otherwisequalifiedindividualwithadisability.
.
.
solelybyreasonofhisorherdisability.
.
.
underanyprogramoractivityreceivingFederalfinancialassistance"'39(thisincludesanyhospitalreceivingMedicaidor134Supranote84.
135ErinA.
Nealy,MedicalDecision-MakingForChildren:AStruggleForAutonomy,49SMUL.
REv.
133,141-52(1995-1996).
SeegenerallyMEISEL,supranote14,at13.
06[c][1](coveringtheseveralfederalstatutory'positive'rights).
136SeeMEISEL,supranote14,at13-28;InreBaby"K,"16F.
3d590,594(4thCir.
1994).
SeealsoBryanv.
Rectors&VisitorsofUniv.
ofVa.
,95F.
3d349(4thCir.
1996).
CaserecognizedthatEMTALAisananti-dumpingstatute,notafederalmalpracticestatute.
EMTALAwascreatedtokeephospitalsfromturningawaypatientsthatneededemergentcare.
Oncethatpatientisstabilized,thedecisionsregardingongoingtreatmentisuptothediscretionofthefacilityandthetreatingphysicians.
Therefore,itwasnotaviolationofEMTALAforaphysiciantodeterminethatnofurtherlife-sustainingtreatmentshouldbeprovidedafter12daysoftreatment.
ThisdecisionisconsistentwithBabyK,becausethepatientinBabyKrequiredemergentcareforimmediatestabilization.
37Nealy,supranote135,at141-147.
1Id.
at146.
13929U.
S.
C.
§794(a)(2000).
SeeNealy,supranote135,at142-43.
294[VOL.
14:2COMMUNICATINGPASTCONFLICTMedicare.
)140Thepersonmustbeotherwisequalifiedtoreceivethecarefortheretobediscrimination.
41ThelineofreasoningusedtodenyclaimsofdiscriminationunderSection504isasfollows:"inspiteofthebirthdefect,heorshewas'otherwisequalified'toreceivethedeniedmedicaltreatment.
Ordinarily,however,ifsuchapersonwerenotsohandicapped,heorshewouldnotneedthemedicaltreatmentandthuswouldnot'otherwisequalify'forthetreatment.
"''42AfutilitydecisionbyaphysicianwouldonlyconstituteaviolationofSection504ifthepatientwas"otherwise"qualifiedtoreceivethetreatmentthephysicianrecommendswithholding.
43Thus,Section504doesnotmandateaphysicianhavingtoprovidefutilecare,evenifdemanded.
144Incontrast,Section302oftheADAappliestodiscriminationatallpublicaccommodations,ratherthanjustMedicaidorMedicarefundedfacilities.
145Additionally,Section302oftheADAdoesnotrefertoahandicappedindividualbeing"otherwisequalified"inregardstotheservicesinquestiontoqualifyfordiscriminatoryprotection.
146Section302oftheADAstatesthat:[D]iscriminationincludes--theimpositionorapplicationofeligibilitycriteriathatscreenoutortendtoscreenoutanindividualwithadisabilityoranycallofindividualswithdisabilities.
.
.
.
[u]nlesssuchcriteriacanbeshowntobenecessaryfortheprovisionofgoods,140MEISEL,supranote14,at13-31.
14'29U.
S.
C.
§794(a)(2000).
142Johnsonv.
Thompson,971F.
2d1487,1493(10thCir.
1992),cert.
denied,507U.
S.
910(1993).
Thisdecisionreferstoinfantsbornwithbirthdefectsandisinagreementwiththe"otherwisequalified"reasoninginUnitedStatesv.
UniversityHospital,StateUniversityofNewYorkatStonyBrook,729F.
2d144,156(2dCir.
1984)"[O]newouldnotordinarilythinkofanewborninfantsufferingfrommultiplebirthdefectsasbeing'otherwisequalified'tohavecorrectivesurgeryperformed.
"Id.
14SeeNealy,supranote135,at144-45.
144Id.
145SeeAmericanswithDisabilitiesActof1990,42U.
S.
C.
§12182(2000);MEISEL,supranote14,at13-32.
146InreBabyK,832F.
Supp.
1022,1028(E.
D.
Va.
1993).
2006]U.
MIAMIINT'L&COMP.
L.
REv.
services,facilities,privileges,advantages,oraccommodationsbeingoffered.
147Therefore,Section302oftheADAcarefullypermitseligibilitycriteriaformedicalservicestoescapethedefinitionofdiscrimination.
MesielandCerminarareportthat"[a]physician'smedicalassessmentdeemingtreatmentofapatienttobefutilemaybecharacterizedassuchaneligibilitycriterion"andthuswouldnotseemto"constitutediscrimination,"atleastnotontheirface,withoutadditionalevidencethatdiscriminatorymotivewasatwork.
148Furthermore,MeiselandCerminarareportthataCongressionalcommitteehasaddressedtheissueofeligibilitycriteriaandthatnothingintheADAwasintendedtoprohibitappropriatemedicaldiagnosing.
49OnlytheChildAbuseAmendmentsdonotprovideaprivatecauseofaction.
5°Theyonlyallowstatesthatreceivefederalgrantsforchildabuseandneglecttobringlegalactionthroughstatechildprotectiveservicesagencies.
'15Moreover,theBabyDoeamendmentstotheChildAbuseAmendmentscarrylanguagetoensurethatdoctorswouldnotberequiredtoprovidefutilecare.
152UndertheChildAbuse147AmericanswithDisabilitiesActof1990,42U.
S.
C.
§12182(b)(2)(A)(i)(2000).
148MEISEL,supranote14,at13-32;Treatmentdecisionsproperlyrelatetothenatureoftheconditionbeingtreated.
Indecidinghowtorespondtoaspecificclinicalsituation,physiciansconsiderthelikelyrisksandbenefitsofdifferentcoursesofaction.
AconstructionoftheADAthatdisplacesbonafidemedicaldecision-makingaltogetherisatwarwithclinicalmedicine.
Nealy,supranote135,at146.
149MEISEL,supranote14,at13-32,33.
150Nealy,supranote135,at147.
'5'Id.
at147-48.
152Thebillenacteddefined"withholdingormedicallyindicatedtreatment"as:[T]hetermdoesnotincludethefailuretoprovidetreatment(otherthanappropriatenutrition,hydration,ormedication)toaninfantwhen,inthetreatingphysician's(orphysicians')reasonablemedicaljudgment[VOL.
14:2296COMMUNICATINGPASTCONFLICTAmendment,"atreatmentshouldnotbeconsideredfutileifitwilldefinitelynotpreventdeathinthenearfuture.
'153Furthermore,severalstateadvancedirectivestatutesprovidenon-liabilityclausesforphysicianswhowithholdorwithdrawlife-sustainingtreatmentbasedontheirclinicaljudgment.
'54Withoneexception,thesestatutesprovidelittleguidanceinregardstothelimitingoftheobligationforphysicianstoprovideongoingcaretheybelievefutile.
55Thus,thedebateregardingfutilityandphysicianversuspatientautonomycontinuesintheU.
S.
B.
TheUnitedKingdom"Theyknowthereissuchathingasafreelunch.
HealthcarehereinBritainisabanquet,andeverybuggerinthiscountrythinkshe'sstarving.
"'156anyofthefollowingcircumstancesapply:(i)Theinfantischronicallyandirreversiblycomatose:(ii)Theprovisionofsuchtreatmentwouldmerelyprolongdying,notbeeffectiveinamelioratingorcorrectingalloftheinfant'slife-threateningconditions,orotherwisebefutileintermsofthesurvivaloftheinfant;or(iii)Theprovisionsofsuchtreatmentwouldbevirtuallyfutileintermsofthesurvivaloftheinfantandthetreatmentitselfundersuchcircumstanceswouldbeinhumane.
45C.
F.
R.
§1340.
15(b)(2)(2005).
153MEISEL,supranote14,at13-33.
154MEISEL,supranote14at13-35.
Seealso,CAL.
PROB.
CODE§4735(West2005);DEL.
CODEANN.
TIT.
16,§2508(f)(2005);HAw.
REV.
STAT.
§327E-7(f)(2004);SeeMd.
Op.
Att'yGen.
No.
00-029(Nov.
16,2000)(construingMaryland'sHealthCareDecisionsAct);ME.
REV.
STAT.
ANN.
TIT.
18A,§5-807(F)(Weil,2005);MISS.
CODEANN.
§41-41-215(6)(West2005);NEV.
STAT.
ANN.
§449.
670(West2004);N.
J.
STAT.
ANN.
§26-2H-62(d)(West2005);N.
M.
STAT.
ANN.
§24-7A-7(F)(West2005);TEX.
HEALTH&SAFETYCODEANN.
§166.
046(Vernon2005).
'55Mesiel,supranote14,at§13.
07.
Tex.
Health&SafetyCode§166.
046(Vernon2005)doesprovideaprocess-basedapproachtofutilityissuesthatwillprovidelegalprotectiontophysiciansandfacilitiesthatfollowthecodifiedfrocedure.
Seediscussioninfrapp.
45-46.
EricG.
Anderson,LessonsAmericaShouldLearnFromaLandof'Free'HealthCare,ManagedCare,(Jan.
1997),2006]297U.
MIAMIINT'L&COMP.
L.
REV.
IncontrasttotheU.
S.
'sfreeenterpriseapproachtomedicine,theU.
K.
hasincorporatedanationalizedhealthservice(NHS).
157FollowingthedevastationofWorldWarII,PrimeMinisterAneurinBevanestablishedtheNHSonJuly5th,1948,sothatthegovernmentcouldprovidehealthservicesfreeofchargetothepublic.
158DemandformedicaltreatmentintheU.
K.
rapidlyincreasedoncetheservicesbecame"free.
"Medicalrationingandprotractedtimeperiodsforhealthcarewerethenorm.
59In1951,BevanresignedfromhispositionasPrimeMinisterinprotestagainsttheNHSintroducingchargesfordentalcare.
16Justthreeyearsafteritsinception,oneofthemajorissuesthattheNHSstillstruggleswithtodayhadsurfaced:howtopayfornationalizedhealthcare.
1611.
WithdrawingandWithholdingLife-ProlongingMedicalTreatmentintheU.
K.
DefinitivecaselawregardingmedicalfutilityintheU.
K.
includesbothInreJandAiredaleNHSTrustv.
Bland.
162BabyJsufferedfromcerebralpalsy,microcephalia,blindness,andepilepsyasaresultofaseriousheadinjurysufferedattheageofonemonth;J'slifeexpectancywasshort.
163Hisphysicians,whoseviewwassupportedbyNHSandothermedicalopinion,consideredtheuseofmechanicalventilationinappropriate.
164Thetrialjudgeorderedthatlife-prolonginghttp://www.
managedcaremag.
com/archives/9701/9701.
lessons.
shtml(lastvisitedMar.
24,2006).
157id.
158SeeHistoricFigures,AneurinBevan,http://www.
bbc.
co.
uk/history/historicfigures/bevananeurin.
shtml(lastvisitedMar.
24,2006).
159DonaldIrvine,Thechangingrelationshipbetweenthepublicandthemedicalprofession,94J.
R.
SOC.
MED.
162.
(2001).
160HistoricFigures,AneurinBevan,supranote158.
161SeeIrvine,supranote159.
162RichardHamilton,TheLawonDying,95J.
R.
Soc.
Med.
565(2002);Brody&Gillon,supranote20,atn.
2.
SeegenerallyInreJ,[1992]3W.
L.
R.
507(Fam),[1993]Fam.
15(Eng.
).
163InreJ,supra,note162.
164Seeid.
298[VOL.
14:2COMMUNICATINGPASTCONFLICTmeasuresbeappliedpendingfurtherhearings.
65Onappeal,thecourtrefusedtorequirethatJ'sphysicianstreathimifthephysician'sclinicaljudgmenthaddeterminedthatitwasnotinhispatient'sbestinterest,evenifthepatient'sfamilywantedcontinuedtreatment.
'66"Itisimpracticable,andunlikelytobeinthepatient'sbestinterests,tocompeladoctortoexercisehisskillinaspecifiedmanneragainsthisprofessionaljudgment.
"'167AiredaleN.
H.
S.
TrustRespondentsv.
BlandisthefirstU.
K.
casetoaddressunderwhatcircumstancesaphysiciancanlegallywithdrawlife-sustainingtreatment,withoutwhichthepatientwoulddie.
168AnthonyBlandsufferedinjuriesasaspectatoratasoccermatchwhichresultedinhisPSVstate.
'69Threeyearsaftertheaccident,theAiredaleNHSTrust,withthesupportofBland'sparents,requestedadeclarationstatingthatwithdrawalofartificialnutritionandhydration,ventilation,andfurthermedicaltreatmentwouldnotbeunlawful.
70TheHouseofLordsacceptedthatartificialnutritionandhydration,whichtheydefinedasamedialtreatment,couldlawfullybewithdrawnonthebasisofBland's"bestinterest.
'7'TheHouseofLordsfurtherrequiredthatadeclarationfromthecourtmustbeobtainedinPVScases"thatcontinuedtreatmentandcarenolongerconferanybenefit"beforelife-sustainingtreatmentisremoved.
172BlandhasbeenappliedinseveralPVSandborderlinePVScasesintheU.
K.
173Ineveryinstance,thecourtshavereportedthatinmakingadecisiontowithdrawlife-sustainingtreatment"itisnotimposingdeathbutis,rather,nottakinganystepstoprolonglife.
"'174TheBritishMedicalAssociation(BMA)publishedguidelinesregardingthewithholdingorwithdrawingoftreatmentin1999,identifyingothernon-beneficialtreatmentsthatcourtsneednotreview165Id.
166Id.
167Id.
at4.
168AiredaleN.
H.
S.
TrustRespondentsv.
Bland[1993]A.
C.
789,797(Eng.
).
169id.
170Id.
at789.
171Id.
at896-899.
172Id.
at789.
173Id.
174Hamilton,supranote162,at565.
2992006]U.
MIAMIINT'L&COMP.
L.
REV.
forphysicianstoterminatetreatment.
'75Thus,physicianautonomyand"benefitingthepatient"bynotprolonginglifehavebeenparamountconcernsintheU.
K.
fromwhichthecourtshaveruledforthediscontinuanceofnon-beneficialcare.
Furthermore,boththeGeneralMedicalCounsel(GMC)andtheBMAhaveissuedguidelinesthatallowforthewithdrawaloftreatment"whenitisfutileinthatitcannotaccomplishanyimprovement,whenitwouldnotbeinthepatient'sbestinteresttocontinuetreatment(because,forexample,itissimplyprolongingthedyingprocess)orwhenthepatienthasrefusedfurthertreatment.
,''76TheGMCisastatutorybodyestablishedundertheMedicalActof1858to"protect,promoteandmaintainthehealthandsafetyofthepublicbyensuringproperstandardsinthepracticeofmedicine.
"'77TheMedicalActauthorizestheGMCtolicensephysicianstopracticeintheU.
K.
178TheguidanceprovidedbytheGMCforphysiciansonwithholdingandwithdrawingfutilecare'79createsnostatutorylegalobligation,althoughcourtshaverevieweditsguidanceincourtdecisions.
180175LaurenceOates,TheCourts'RoleinDecisionsaboutMedicalTreatment,321BRIT.
MED.
J.
1282(2000).
ForfurtherdiscussionregardingtheBritishMedicalAssociationseeinfrapp.
note181.
176EndofLifeDecisions-ViewsoftheBMA,athttp://www.
bma.
org.
uk/ap.
nsf/Content/Endoflife(lastvisitedMar.
27,2006).
177RoleoftheGMC[GeneralMedicalCounsel],athttp://www.
gmc-uk.
org/about/role/index.
asp(lastvisitedMar.
27,2006).
178id.
179GeneralMedicalCouncil,WithholdingandWithdrawingLife-ProlongingTreatments:GoodPracticeinDecision-Making(2002),athttp://www.
gmc-uk.
org/guidance/library/standards/witholdinglifeprolonging-guidance.
asp(lastvisitedMar.
27,2006).
180UKClinicalEthicsNetworkSectionD.
ProfessionalGuidelines,LawandEthics,athttp://www.
ethics-network.
org.
uk/reading/Guide/SectionD/sectionD.
htm(lastvisitedMar.
27,2006).
[VOL.
14:2300COMMUNICATINGPASTCONFLICTTheBMAisavoluntaryassociationofphysicians,withatotalmembershipofover137,000,includingover19,000medicalstudents.
81TheBMAproducesnumerouspublicationsregardingethicalissuesincluding,WithholdingandWithdrawingLife-ProlongingMedicalTreatment:GuidanceforDecisionMaking,whichliketheGMC'sguidelinesarenotlegallybinding,butcanbetakenintoaccountbythecourtsinaddressingspecificcases.
'822.
TheHumanRightsActof1998TheHumanRightsAct(1998)cameintoeffectOctober2,2000intheU.
K.
ItincorporatestheEuropeanConventiononHumanRightsandFundamentalFreedomsintoU.
K.
domesticlaw.
ThemainpurposeoftheConvention"istosafeguardhumanrightsandfundamentalfreedomsandtomaintainandpromotethevaluesofademocraticsociety.
"183AnyinconsistencybetweencurrentU.
K.
legislationandtheConventioncanbechallengedindomesticcourtsandalsointheEuropeanCourtofHumanRights.
Furthermore,publicauthorities(e.
g.
theNHSTrust,doctors)mustcomplywiththeConvention'sguidelinesformedicalcare.
'84TheArticlesoftheConventionthathavehadmajorimpactonhealthcareareArticle2(therighttolife),3(theprohibitionontortureandinhumanordegradingtreatment),5(therighttolibertyandsecurity),and8(therighttorespectforprivateandfamilylife).
NoneoftheserightsisabsolutebutArticle3representsanabsoluteprohibitionandcannotbeinterferedwithbytheStateunderanycircumstances.
Article2181BMA[BritishMedicalAssociation],AbouttheBMA,http://www.
bma.
org.
uk/ap.
nsf/Content/Hubaboutthebma(lastvisitedMar.
24,2006).
182UKClinicalEthics,supranote172.
183AshSamanta&JoSamanta,TheHumanRightsAct1998-WhyShoulditMatterforMedicalPractice,98J.
R.
SOC.
MED.
404(2005).
184DepartmentofHealth-HumanRightsAct1998FAQ,http://www.
dh.
gov.
uk/PolicyAndGuidance/EqualityAndHumanRights/EqualityAndHumanRightsArticle/fs/enCONTENTID=4054183&chk=QOxVM9(lastvisitedMar.
27,2006).
2006]U.
MIAMIINT'L&COMP.
L.
REV.
and5aresubjecttolimitedexceptions.
Article8isaqualifiedobligationthatrequiresabalancetobestruckbetweentheinterestsoftheindividualandthewiderinterestsofsociety.
Anylimitationorconstraintimposedbyapublicbodymustbejustifiedasbeing'proportionatetothelegitimateaimpursued.
185ECHRguidelineswillhavealastingeffectonthehealthcarepracticesintheU.
K.
TheECHRhasbeenactivelyinvolvedinissuesregardinglifeanddeath(e.
g.
,withholdingorwithdrawinglife-sustainingtreatment).
186Article2hasbeeninterpretedbyU.
K.
courtstoascontaininganegativerighttonotintentionallyandillegallytakealife.
'87InReA,"[t]heCourtofAppealstooktheviewthatArticle2imposedadutytoprotectthestrongertwinandnotjustanegativedutyofpreventingdeathfortheweakertwin.
''88Thesurgerytoseparatethetwinswasjustifiedbysavingthelifeofthestrongertwinandnot"intentionally"takingthelifeoftheweakertwin.
'89Furthermore,Article185Samanta&Samanta,supranote183.
186Id.
at405.
187id.
118Id.
at405.
189Rationalebehindthedecision:[Thepurposeoftheapplication]wastopreservethelifeofJandnottocausethedeathofM,itwasinappropriateintheuniquecircumstancestocharacteriseforesightofM'saccelerateddeathasamountingtocriminalintent;thattheprotectionofaperson'srighttolifeinarticle2oftheConventionfortheProtectionofHumanRightsandFundamentalFreedomsdidnotimportanyprohibition,additionaltothatunderEnglishcommonlaw,totheproposedoperation,and"intentionally"initsordinaryandnaturalmeaningappliedonlytocaseswherethepurposeoftheprohibitedactionwastocausedeath;that(perWardLJ)inessencetherewasnodifferencebetweenresortingtolegitimateself-defenceandthedoctorscomingtoJ'sdefenceandremovingthethreatoffatalharmtoherpresentedbyM'sdrainingherlifeblood;andthat,accordingly,theoperationcouldbelawfullycarriedout.
InreA,[2001]Fam147,2000WL1274054(CA(CivDiv)).
302[VOL.
14:2COMMUNICATINGPASTCONFLICT2'snegativerighthasbeeninterpretedtoauthorizethecontinuedremovalofartificialhydrationandnutritionbecause,theillness,notthetreatment(artificialnutritionandhydration),wouldbethecauseofthepatient'sdeath.
Additionally,withholdingandwithdrawinglife-sustainingtreatmentwouldnotviolateArticle3ifdoingsowouldbeinthepatient'sbestinterest.
190ButArticle3hasbeeninterpretedtoallowcourts,notphysicianstodeterminethepatient's"bestinterest"wheretherearedisputesaboutproposedtreatmentforincompetentpatients.
191However,theconfusionsurroundingtheECHRinU.
K.
courtsystemscontinuesasrepresentedbythecaseofLeslieBurke.
'92Mr.
Burke,whosufferedfromadegenerativebraincondition,wasafraidthatartificialnutritionandhydrationcouldbewithdrawnagainsthiswishesaccordingtotheGMC's"WithholdingandWithdrawingLife-ProlongingTreatments:GoodPracticeinDecision-Making"guidelines.
193TheHighCourtruledthatGMC'sguidancewasinviolationofArticles3and8oftheHumanRightsActof1998.
TheHonourableMr.
JusticeMunbyruledthatnotonlydopatientshavearighttodemandthewithdrawaloflife-sustainingtreatment,buttheyalsohaveapositiverighttodemandtreatmentincertaincircumstances.
JudgeMunbyacknowledgedthatinaddressingthisethicalissue,furtherimportantissuesoflimitedresourcesareinvolved.
194OnappealbytheGMC,theCourtofAppealruledthatMr.
Burkes'concernswereadequatelyaddressedbytheGMC'sguidelinesregardingwithholdingandwithdrawinglife-prolongingtreatment.
195TheCourtofAppealheldthatphysicianscannotdenycompetentpatients190Samanta&Samanta,supranote183,at405.
'9'Id.
at406.
192SeeBBCNews,PatientWinsRight-to-LifeRuling,http://news.
bbc.
co.
uk/l/hi/health/3938879.
stm(lastvisitedMar.
27,2006);BBCNews,PatientLosesRight-to-FoodCcase,supranote37.
193TomWoodcock&RobertWheeler,GlassvUnitedKingdomandBurkevGeneralMedicalCouncil.
JudicialinterpretationofEuropeanConventionRightsforpatientsintheUnitedKingdomFacingDecisionsaboutLife-SustainingTreatment,31INTENSIVECAREMED.
885(2005).
194Id.
195BBCNews,PatientLosesRight-to-FoodCase,supranote37.
2006]303U.
MIAMIINT'L&COMP.
L.
REV.
artificialnutritionorhydration,unlessduringthefinalstagesoftheirillnessesartificialnutritionandhydrationcouldnotprolongtheirlives.
196Thus,artificialnutritionandhydrationcanbewithdrawnfromMr.
Burkeonlyduringtheendstagesofhisillnesswhenhelapsesintoacoma;whenhecannolongerexpresshisdesireforlife-prolongingtreatment.
'97IV.
CommunicatingPasttheConflictThebasicproblemwithfutilityisthattheclinicalrealityoftheuniquenessofpatientsanddiseasesresultsinjudgmentsoffutilitythatarenoteasilyformulatedintoageneralsubstantivedefinition.
,98Futilityisavalueladenjudgment;itshouldbeseenasuniquetoeachpatientandfamily,andthusauniversalconsensusregardingfutilecareisunlikely.
Ratherthanrelyingonadefinitivedefinitionoffutility,severalorganizationshavemovedtowardsrecommendingaprocessthatwouldallowathoroughreviewofthefutilitydisputeinafairandopenenvironmentthatrequirescommunicationbetweenpatientsandtheirfamilies,doctors,andfacilities.
199Failuretocommunicateaboutdiagnosisandprognosisoftencausesincreaseddiscordamongstpatients,families,andphysicians;200thislackofcommunicationmayultimatelyleadtothecourtroom.
2°'Establishingeffectivecommunicationstandardsbetweenpatients,theirfamilies,andphysiciansleadstomutualunderstandingregarding196ClareDyer,CourtrulesinfavourofGMC'sguidanceonwithholdingtreatment,331BRIT.
MED.
J.
309(2005)(TheGMC'spresidentGraemeCattosaid,"[o]urguidancemakesitclearthatpatientsshouldneverbediscriminatedagainstonthegroundsofdisability.
Andwehavealwayssaidthatcausingpatientstodiefromanddehydrationisunacceptablepracticeandunlawful.
").
197Id.
198AmirHalevv&BaruchA.
Brody,AMulti-institutionCollaborativePolicyonMedicalFutility,276J.
AM.
MED.
Assoc.
571,571(1996).
'99Id.
at574.
200Fins,supranote48,at1322.
201IntheMatterofBaby"K",832F.
Supp.
1022(E.
D.
Va.
1993);Woodcock&Wheeler,supranote178.
304[VOL.
14:2COMMUNICATINGPASTCONFLICTtreatmentgoals.
202Furthermore,process-basedapproachestofutilecaremayevenprovidelegalprotectionforphysiciansorfacilities'decisionstowithdrawnon-beneficialcareagainstthedesiresofpatientsorfamilies.
203A.
MovingTowardsaProcess-BasedApproachRecognizingthe"futility"ofattemptingtodefinefutilecare,severalhealthcareorganizationsstarteddefiningaprocesstoaddresstheissueoffutilecarewithpatientsandtheirfamilies.
204Thesepoliciesweredevelopedtoprovidephysicians,patients,andtheirfamilieswithanavenuetocollaborativelyapproachthefutilitydecision.
Thisapproachallowedthedefinitionoffutilitytobemovedawayfromonephysicianorhospitaltreatmentteamtoafacilityethicscommittee.
Thisapproachmayalsoprovidedtheopportunitytocreateacommunity-wideapproachtofutility,whilerespectingtheinputofthepatientorfamily.
205Oneoftheearliestprocess-basedapproachescreatedwastheHouston(Texas)policy.
206TheHoustonpolicywasacollaborativeeffortofadiversetaskforcewhichincludedmostofHouston,Texas'hospitals.
TheHoustonpolicyallowedapatienttotransfertoanotherphysicianorfacilityifnoresolutioncouldbereached.
However,ifanotherphysicianorfacilitywouldnotacceptthetransfer,theattendingphysicianorfacilitywouldnotberesponsibleforcontinuedfutilecare.
202"[Ethics]consultationswereassociatedwithreducedhospitalstaysandtreatmentcostsandweredeemedeffectiveinresolvingconflictsthatwereblockingthewayofmoreappropriatecomfortcare.
"Gilmeretal.
,supranote35,at967.
203Seegenerally,TEX.
HEALTH&SAFETYCODEANN.
§166.
046(Vernon2003).
204Seegenerally,HealthCouncilofSouthFlorida,supranote3,at30-44.
205AmericanMedicalAssociation,MedicalFutilityinEnd-of-LifeCare,CEJAOp.
2.
037(June1997),availableathttp://www.
ama-assn.
org/ama/pub/category/8390.
html206AcommitteewasformedinAugustof1993withrepresentationfrommostofthemajorHoustonhospitals.
Aftertwoyears,"GuidelinesonInstitutionalPoliciesontheDeterminationofMedicallyInappropriateInterventions"werepresentedforinstitutionalapprovalatthevariousHoustonhospitals.
Halevy&Brody,supranote198,at571.
2006]305U.
MIAMIINT'L&COMP.
L.
REv.
Regardlessoftransferoptions,thepolicystatedthatpatientabandonmentisprohibited.
Onlyinterventionsthataredeemednon-beneficialcouldbeceased;othercarethatpreservedthecomfortanddignityofthepatientmustbecontinued.
2°7In1999,theAmericanMedicalAssociationCouncilonEthicalandJudicialAffairspublisheditsrecommendationforadueprocess-basedapproachtofutilitydeterminationsintheJournaloftheAmericanMedicalAssociation(JAMA).
2°8Theprocessincludesatleast4stepsaimedatdeliberationandresolutionincludingallinvolvedparties[physicians,patient,andfamily],2stepsaimedatsecuringalternativesandresolutionsincludingallinvolvedparties,2stepsaimedatsecuringalternativesinthecaseofirreconcilabledifferences,andafinalstepaimedatclosurewhenallalternativeshavebeenexhausted.
09Recognizingthatthereare"necessaryvaluejudgmentsinvolvedincomingtotheassessmentoffutility,"theAmericanMedicalAssociation's(AMA)processrequiresthatfutilityjudgmentsaccountforpatients'orproxies'input.
210Thisprocessutilizesthesameproceduresthathospitalethicscommitteeshavebeenusingforyears,withattemptstotransferthepatientifamutualagreementcouldnotbereachedregardingthepatient'scontinuedcare.
2'Ifnoalternativeprovidercanbefound,theCouncil'sguidanceallowsthefutileinterventiontobediscontinued(thatis,asdeterminedbytheprocessinvolvingthepatient/proxy,physicians,andinstitutionalcommittee).
207Id.
at572-73.
208AmericanMedicalAssociation,supranote15,at939.
209Id.
210id.
211RobertL.
Fine,MedicalFutilityandtheTexasAdvanceDirectivesActof1999,13BAYLORU.
MED.
CENTERPROC.
144(2000),availableathttp://www.
baylorhealth.
edu/proceedings/13_2/13_2_fine.
html.
[VOL.
14:2COMMUNICATINGPASTCONFLICTLegalconsiderationsareofparamountconcernwhendiscussingthediscontinuationofcare.
Althoughnoformalrecognitionofa"positive"righttodemandtreatmenthastakenplace,patientautonomyforhealthcaredecisionsmustbecarefullybalancedagainstphysicians'autonomytomakeclinicaldecisions.
212Litigationregardingfutilityhasremainedconstant,butlimited,sincetheearly1990s.
213Havingsetforththeirpolicy,theAMAdidnotelegalramificationsofwithholdingtreatmentareunknown.
214OnecaseintheU.
S.
thathasfoundinfavorofphysicianautonomytowithholdnon-beneficialcareisGilgunnv.
MassachusettsGeneralHospital.
215Thiscaseinvolvesaphysicianorderingado-not-resuscitate(DNR)orderwithoutthefamily's216consent.
Afterthepatientdied,thefamilysuedthehospitaland21721physician.
Thejuryruledinfavorofthephysicianandhospital.
218Yetthiscaseisnotprecedentsettingbecausethereasonsforthejuryfindingforthedefendantswasnotrecorded.
219Evenwithlegalprotectionunknown,processbasedapproachestofutilityissuesprovidebenefitstobothphysiciansandfacilities.
Theycanprovidetreatmentclarityandassistwithatransitionfromacurativetoapalliativemodelfreefromconflictbetweenpatient,families,andfacilities.
220Furthermore,onerecentstudyregardingethicsconsultsintheintensivecareunitreported"thatethicsconsultationsreducedhospitalspendingandhasteneddeathamongthosewhoultimatelydiein212MEISEL,supranote14at§13.
02.
213Id.
at13-5.
214AmericanMedicalAssociation,supranote15.
215JohnEllement,JurySideswithDoctorsonEndingWoman'sLifeSupport,BOSTONGLOBE,Apr.
22,1995,at18.
216id.
217id.
218id.
219StanleyA.
Nasraway,Unilateralwithdrawaloflife-sustainingtherapy:Isittime,29CRIT.
CAREMED.
215(2001),availableathttp://www.
ncbi.
nlm.
nih.
gov/entrez/query.
fcgicmd=Retrieve&db=PubMed&listuids=11200242&dopt=-Abstract.
220RobertL.
Fine&ThomasW.
Mayo,ResolutionofFutilitybyDueProcess:EarlyExperiencewiththeTexasAdvanceDirectiveAct,138ANNALSINTERNALMED.
,743,744-745(2003).
2006]U.
MIAMIINT'L&COMP.
L.
REv.
[the]hospitalafteraprolongedstay.
',2Infollow-upinterviewswithnurses,physicians,andpatients,morethan90percentofthehealthcareprofessionalsand80percentofpatientsorproxiesagreedthatethicsconsultationswereusefulindeterminingappropriatetreatment.
222IntheU.
K.
,theHumanRightsAct1998requiresthatphysiciansmustconsultwithpatientsandtheirfamiliesinmakingtreatmentdecisions.
223Additionally,beginninginApril2002,eachNHSintheU.
K.
isrequiredtohavePatientAdvocacyandLiaisonServices(PALS)advocatestoassistpatientsandfamilieswithmedicaldecisions.
224TheimplementationofPALSadvocatesrecognizestheneedfortheinclusionofthepatient'sviewindeterminationoftreatmentdecisions,eventhoughU.
K.
courts,unliketheU.
S.
courts,generallysidewiththedecisionsofthephysiciansregardingissuesofwithdrawingorwithholdingfutilecare.
225B.
LegalizingtheWithholdingorWithdrawalofFutileCareintheU.
S.
Onestatedoesrecognizetheabilityforphysiciansandfacilitiestowithholdorwithdrawfutilecare.
TheTexasAdvancedDirectivesActof1999notonlycombinedseverallawsdealingwithend-of-lifedecisionsintoasinglestatue,itprovidedadue-processapproachtofutilecarewhichprovideslegalprotectiontophysiciansandfacilitiesthatfollowthestatutoryguideline.
226Thisstatute,anevolutionoftheHoustonpolicy,wasenactedintoTexaslawshortlyaftertheAmerican221Gilmeretal.
,supranote35,at969.
222Id.
223AbhayK.
Das,TheValueofanEthicsHistory,98J.
R.
.
SOC.
MED.
262(2005).
224KayLurie,WithholdingandWithdrawingLife-ProlongingTreatments:GoodPracticeInDecision-MakingTheRoleofthePatient'sAdvocate,BametCommunityHealthCouncil,(June20,2001),athttp:www.
barnetchc.
org.
uk/scrutiny/withholding.
htm(lastvisitedMar.
25,2006).
225Id.
226Fine,supranote211;Seealso,TEX.
HEALTH&SAFETYCODEANN.
§166.
046(Vernon2003).
308[VOL.
14:2COMMUNICATINGPASTCONFLICTMedicalAssociationpublishedtheirmedicalfutilityinend-of-lifecarepolicy.
227FineandMayoinResolutionsofFutilitybyDueProcess:EarlyExperienceswiththeTexasAdvanceDirectivesActsstate:[T]hegreatestsignificanceofthelawishowitchangesthenatureofconversationsbetweenprovidersandpatients'familiesaboutfutile-treatmentsituationsbyprovidingconceptualandtemporalboundaries.
.
.
.
[I]tplaceslimitsonfamiliesandsurrogateswhorequesttherapiesthattheprofessionconsiderfutile.
Atthesametime,ifforcestheprofessiontothinkcarefullyabouttheconcept,forifanotherphysicianandfacilityarewillingtoprovidethefutiletreatment,thenthelawdoesnotallowwithdrawalofthattreatmentongroundsoffutility.
Thelawalsoprovidestemporalboundaries(12days)forresolvingdisagreementsoverfutiletreatment.
228TheyfurtherencourageotherstatestolookattheTexasfutilecareprocessasastartingpointforpossiblechangesinstatutoryregulationregardingmedicalfutility.
229CONCLUSION"Futility"isavalue-ladenconceptthatescapesdefinition.
Physicians,healthcarefacilities,andpatientsintheU.
S.
andU.
K.
havestruggledwithend-of-lifedecisionsregardingfutilecareduetothelackofadefinitivedefinitionoffutility.
Thesestruggleshaveoftenendedupinthelegalsystem,movingthedecisionofappropriatemedicalcareawayfromthephysiciansorfamilytothediscretionofajudgeorjury.
Withtheever-increasingcostofhealthcareandtheexplosionofmedicaltechnology,thestruggletodifferentiateappropriatecarefromfutilecarewillcontinue,increasingconflictamonghealthcare227TelephoneInterviewwithProfessorTomMayo,Director,CaryM.
MaguireCenterforEthicsandPublicResponsibility,SMU,Tex.
(Oct.
20,2005).
228Fine&Mayo,supranote220,at746.
229Id.
2006]U.
MIAMIINT'L&COMP.
L.
REv.
facilities,physicians,andfamilieswithpatient'scontinuedcarecaughtinthebalance.
23°Insteadoffocusingondefiningfutilescenarios,physiciansandhealthcarefacilitiesshouldfocusonprovidingappropriatecommunicationtoassistthepatientandfamilyinmakingend-of-lifedecisions.
Thisprocess-basedapproachtofutilecarewillestablishappropriateboundariesforpatientsandfamiliestoaddresstheissueofappropriatecarebyprovidingaprocessinwhichtheycancommunicatewithhealthcareprofessionals,aswellasestablishcollaborativegoalsfortreatmentaftertreatmentoptionsarereviewed.
Furthermore,thiscollaborativeapproachwilldecreasetheconflictbetweenphysiciansandpatients,leadingtoadecreaseinoverallhealthcarecostandpatient/physiciansatisfaction.
Byprovidingtheabilityforpatienttransfer,process-basedapproacheswillopenthedefinitionof"futility"toacommunity-widestandard,makinghealthcareprofessionalsthinkverycarefullyaboutdeemingatreatmentfutile,becauseacceptanceoftransferwillpreventtheremovaloftreatmentonthegroundsoffutility.
231Withdrawaloftreatmentisatreatmentoflastresort;whethermadebyapatient,physician,orapatient'sfamily,thedecisiondeemingcarefutileshouldonlybedeterminedaftercarefuldeliberationandconsultationwithallappropriateparties.
Clearly,definedprocessed-basedapproachesshouldprovidetheopportunityforcollaborationofphysicians,families,andpatients,thusallowingthepatient'sbestinteresttodeterminetreatment(whetheritispalliativecareorcontinuedtreatmentfortheillnessathand).
230Seegenerally,Gilmeretal.
,supranote35(surveyingtheincreasingcostofhealthcareintoday'sworld).
231Fine&Mayo,supra220,at746.
310[VOL.
14:2