This is a rewrite, because I realized that my last attempt at this topic did not come off exactly the way I wanted it to. That was my own fault, and after thinking about it for the last couple days, I decided to just rework the entire entry to see if I could come out better. I apologize in advance to those who commented on my original entry.
There are dozens upon dozens of illnesses and conditions that we as humans face with some regularity, whether it be in the news, in our families, or in the families of our friends. Many of these are life-threatening. The two most people are familiar with are cancer and prematurity in babies. While they start very differently, and can vary significantly, in general both require a great deal of treatment, and sometimes the treatment is successful and the patient lives, while other times, the treatment is not so successful and the patient dies.
Sometimes, in the course of this treatment, the quality of life of these patients plummets. At times, it may seem as if they were better off dead than alive, because they are being tortured so much through these treatments. Every effort is made to save some of these people, to the point where it simply doesn't make sense to continue anymore.
With that in mind, I present my question: at what point does the quality of life take precedence over the duration of the life?
The easy answer that some have tried to say is that it's the patient's decision. Which it is, don't get me wrong. The patient has the right to choose whether to pursue rigorous treatment, or whether to stop treatment all together. And that would be the answer anyone in a professional position to do so would tell you.
But it doesn't answer my question. Ethics does extend beyond professionalism, and discusses what's right, and what's wrong (and often cannot come to a definitive answer one way or the other). So, for the sake of this question, please consider that the patient is in no condition to make his or her own medical decisions, and has no family to make the decisions for them. Consider this patient as completely without a choice to be made, remove that consideration from the puzzle entirely, and then try to answer my question.
Consider a premature baby. He did not develop an abdominal wall (skin holding in your insides), and his intestines were all tangled and dying. He required surgery after surgery to attempt to fix these intestines, and a plastic shield was used to hold the insides in. Each surgery, this had to be cut off, leaving raw edges where the shield was stitched on each new time. Little progress, if any, is made in each new surgery, but there is nothing else that can be done.
On the other hand, consider a woman diagnosed with late stage breast cancer. Chemotherapy will help her very little if at all (and because the FDA mandates a certain type of chemotherapy for all breast cancer patients opting for chemo, she cannot be given a chemotherapy that might help), and surgery isn't a viable option. Chemo would make her sick, with her hair falling out and her body rejecting the poisons being pumped into her body. The cancer would continue to attack, and the chemo would do little to stop it and would probably make things worse.
At what point in these therapies does enough become enough? Doctors are bound by the Hippocratic Oath, part of which says that the physician will do no harm. Isn't pursuing these plans of treatment at times doing harm, the thing they are sworn against doing? At what point do we say 'stop now... it's doing more harm than good'?
I honestly don't know the answer to this one. I'd like to say that we should face the inevitable at some point, that everyone should move onto the acceptance stage of grief. But, that doesn't happen. And I can't honestly say I wouldn't try whatever I could to stay alive. Besides, with the advances medicine has made just within the past 20 years, there seems to be so much hope out there, even when some treatments are still rudimentary. Maybe one day we'll conquer our own mortality enough to do away with suffering.
But that, of course, opens up a whole other can of worms....
You can access the other parts of this series at the following links: Part 1, Part 2, Part 3, and Part 4.
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I believe it is always a health care provider's job to promote wellness in their clients, and that the end result of wellness is an improvement in quality of life. So, the ultimate goal for me in health care is to increase quality of life.
Maybe some people would be ok living each of their days not being able to leave their beds because they're in so much pain, because they at least know they're alive. I'm not one of them.
Determining quality of life is such a individualized thing, so I don't know when I would be able to draw a line and switch from curative to palliative care. However, in a completely hypothetical situation, if someone were completely unable to make a decision for themselves, and had no family, and curative treatment was not working and causing suffering, I would probably not hesitate to stop treatment and work on providing relief.
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The more obvious one is the one that you mention specifically...
With that in mind, I present my question: at what point does the quality of life take precedence over the duration of the life?
...and while you may feel "it's the patient's decision" to be the "easy answer," I will still contend that this is the ONLY answer of any relevance to that particular ethical question.
The second ethical question that your blog presents is implied by this answer, and would I propose be properly framed by asking, when a patient cannot make his or her own determinations, who will step in and make that decision for them?
If a patient is incompent, and has made no provisions to establish whom they trust to make that kind of decision for them, then someone has to step in and make that decision for them. This is where the real "meat" of the ethical sandwich lies in these situations. I really don't think that it matters WHO makes the decision in cases like this, so long as the person doing so does their best to make the decision that the patient would make for themselves if they could. Unfortunately, there probably isn't any hard-and-fast guide to apply to direct such a decision. The core question of self-determination combined with deciding what is "best" for someone else is too subjective a tangle to expect any cut-and-dried answer to unravel. The point of ethical concern is for the surrogate decision maker to separate his or her own motivations as much as is humanly possible from the imputed desires from the wants of the patient.
TTFN,
Blackout
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Yes, I've changed my username from "percivale" to "Blackout." Go here if you want to know why.
You are right. This is a tricky issue. I think Blackout is right too, but what does one do when no one is available to speak for the patient? It's really hard too when it comes to babies. Especially babies who are born and rejected by their mother's.
I do think sometimes that modern medicine, while for the most part is an amazing and wonderful thing, gets a little too much reverence.
I have had the thought, "What is so wrong about letting nature take it's course? Why do we feel so ethically bound to always intervene to the bitter end with manmade, modern medicine?" Which is why I am a huge advocate of hospice care.
It's at the point where if a medical professional doesn't impose efforts to save someone's life who seems to already be dead, or is already so damaged or ill that it seems that survival will bring a new life of pain and suffering, that person could actually prosecuted for murder.
The last time I took ACLS, the teacher, a paramedic, said that while ACLS and first responders are often times able to resuscitate someone, the person often ends up dying once admitted to the emergency room. She said this to point out the inaccuracies of reports of emergency response deaths vs resuscitations.
It is a question I can't answer and I hope it persists in society until we get it right.
"Consistency is not a human trait" - Maude, from Harold and Maude