Biomedical ethics: just a question of money?

When a patient’s wishes conflict with the doctor’s, or families disagree with medical teams about the treatment of a loved one, biomedical ethicists are often called in to help resolve the issues. Recent examples that made headlines include the case of Sophia Park, a twenty-five year old grad student, married and pregnant, who became comatose and was diagnosed brain-dead when her doctors failed to diagnose her tuberculous meningitis. The husband and family begged that she be kept on life support so that her fetus, then 10 weeks, could gestate long enough to become viable. Unfortunately, she died shortly after life support was removed.

Another example occurred when the ICU team at the SMBD-Jewish General Hospital wanted to disconnect the respirator of a Mr. Herman Krausz, who had a terminal lung disease. The family insisted that the respirator be kept, that this was the patient’s own wish, and sued the hospital and the doctors involved when the respirator was disconnected and the patient died.

What gives doctors the right to disconnect life support in these circumstances? The reason given is usually medical futility – the chances of the treatment being helpful are considered negligible. But even when the outlook is entirely negative, is it necessary to be so peremptory in unplugging life support? I submit that it’s not.

In Québec, the law requires that doctors be paid from the public health insurance plan only for services which are medically necessary. In the above cases, if the medical team agrees that continuing life support is not medically indicated (ie is futile) then the doctors cannot legally be paid for their services in providing life support when there is no hope of improvement. Most people would not insist that doctors work for free, and the law permits doctors to charge patients (or families) directly for such care which is not medically indicated. Because there is no obligation for the doctor to provide futile treatment, he or she could either agree to provide care for which the patient or family agrees to pay out of their own pocket, or he or she could refuse to provide such care, and direct the patient to other care providers, for instance in the U.S. or in Mexico. Similar provisions operate for the health care institutions in which care is rendered. If the patient or family has a difficult time deciding whether to accept an offer of treatment at the family’s own costs, a reasonable time period could be provided before services are discontinued.

A similar situation frequently arises when elderly patients suffering from Alzheimer’s Disease and other forms of dementia deteriorate to a point where they can no longer swallow properly (ie food intake by mouth may result in aspiration which can lead to pneumonia and even death). Family members may ask that a feeding tube be placed so that nutrition can be given with more safety.

While inserting a feeding tube is a relatively simple procedure, physicians and institutions may object on the grounds of futility – while it will possibly prolong life, there is little hope that it will improve the dementia or the swallowing problems. When this attitude conflicts with, for example, a religious belief that everything possible must be done to preserve life, bioethicists and even the courts may be asked to intervene.

Again, if the proposed treatment is futile, the physicians and institutions may choose to do it, but they cannot legally request to be paid for it out of the publicly funded health insurance. This leaves the option open for families to pay; it also creates an opportunity for a new kind of health insurance to cover futile medical acts!

Physician-assisted suicide, also known as active euthanasia, is clearly against the law in Canada, although other jurisdictions are softening their stance. There are well-known court cases of patients insisting on their right to die and to be provided with the mechanisms to take their own lives. But why are these appeals directed towards physicians? Why, indeed, is it called “physician”-assisted suicide? Because physicians are the only individuals permitted by law to prescribe substances which would result in a quick and pain-free death. Why only physicians? How did this situation come about?

In the middle ages, terminally ill individuals wanting to end their suffering could ask the village wise woman, knowledgeable in the use of herbs, to dispense a poison. Because this happened behind closed doors, because it took place at the wish of the dying individual, because the patient’s family or friends were typically part of the decision, such activity was rarely called into question. However, if there were any suspicion of foul play, the laws against murder or assault then, as well as now, would be utilized. But physicians and pharmacists, wishing to have an exclusive market and restrict the competition, applied to the authorities to grant them exclusive rights or charters. The argument that has traditionally been used to justify this type of monopoly is the protection of the consumer. But clearly, a skilled practitioner of herbal medicine could do much more to relieve suffering than physicians with their leeches, purgatives, and bloodletting. Now, not only has the competition been driven away, but also the knowledge of the wise woman has disappeared.

The evolution thus has been: wishing to improve their income, physicians (and pharmacists) sought for and obtained from governments, a monopoly on the prescription and dispensation of medicinal substances. To protect consumers in this monopoly situation, limits needed to be placed on physician autonomy by governments. Once again, a dilemma which arose because of economics. One solution? Deregulate the prescribing and dispensing of medications. Radical, to be sure, but consider the benefits: health care consumers would quickly begin to share information about which health care practitioners to seek out, and which ones to avoid.
In this essay, I have demonstrated how some common and frequent biomedical ethics dilemmas are, in essence, economic issues, and that frameworks other than ethics exist to arrive at solutions.

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