Process II
Michael A. Gillette, Ph.D.

Last month in "Practical Ethics" I presented a five step procedure for approaching medical ethics cases that instructed us to Review, Respond, Reduce, Recast, and Resolve. This month I will apply that process to the following case:

Review the background information:
Ms. A is a 75 years old resident of a long term care facility who has been diagnosed as having severe dementia secondary to Alzheimer's.

Ms. A is presently being treated for numerous decubitus ulcers on her legs and buttocks. She is minimally responsive to verbal cues and is cognizant of pain. Ms. A occasionally indicates desires when questioned and is presently fed by gastrostomy tube. Her ulcers are serious but are now beginning to heal. A recent neurological exam shows that Ms. A is not in a persistent vegetative state. Her family, however, requests that the feeding tube be removed as they feel that her quality of life is not worth living any longer.

Staff at the facility feel that continued tube feedings are appropriate and that Ms. A will recover from her ulcers and return to a quality of life that is equal to that when the family agreed to place the feeding tube initially.

Should the facility grant the family request that feeding be discontinued, refuse to grant the request and seek patient transfer, or refuse the request and seek guardianship through the courts to block further family action?

Respond by listing arguments:
1. Cost Containment (Hospital Reimbursement & Social Resources): Is the fact that continued care for Ms. A is expensive a good reason to withdraw treatment?

2. Futility of Care: If the care being offered does no good for Ms. A then why continue to provide it?

3. Quality of Life: Even if the care works, is Ms. A's life worth living?

4. Family Authority: Doesn't the family have the right to make these types of choices, period? 5. Facility Standard of Care: Can the family force the facility to provide care that it feels is sub- standard?

Reduce the arguments to those that are most central:

Eliminate Cost Containment:
Although this is an important biomedical ethics issue, it is not an appropriate clinical ethics issue. Our society is not yet ready for physicians to deny care in order to save money. Money should not count yet.

Combine Futility with Quality of Life
In this case continued feeding does work physiologically. Therefore, a judgment of futility is based on an evaluation of the benefit to be achieved by continued treatment, not on an objective standard of futility. This becomes a quality of life issue.

Eliminate Quality of Life as being redundant:
This argument is based on divergent value judgments and is therefore not a question of quality of life, but of whose values prevail. This reasoning reduces the quality argument to one of authority to make decisions for the patient.

Recast the conflict based on the central issue

This step of the procedure requires that we pursue the discussion now on the truly central point which is the conflict between family authority and the facility standard of care: Whose judgment should prevail in this case?

Resolve the Conflict
There are some important assumptions to consider in resolving this conflict. First, since families can normally make important medical decisions for their incapacitated loved-ones, the burden of proof initially rests with the facility. The family has the right to make such decisions, all other things being equal, so it is up to the facility to show that all other things are not equal in this case.

Second, although family authority is powerful, its power is not absolute. Family authority does not include the power to force an individual or facility to fall below its standard of care and it does not permit a family to act negligently or abusively. In order to settle this dispute, it becomes necessary to carefully consider the conflicting claims involved. Unless the facility can reasonably show that the decisions of the family are abusive or negligent toward Ms. A, it is in no position to interfere with that authority.

This does not mean that the family can force the facility to follow their wishes. If the facility is ideologically opposed or medically unequipped to withhold tube feedings and manage the dying process from that point on, it may refuse to do so and demand that the family seek alternate placement in a more appropriate setting (e.g. hospice).

On the other hand, if the facility can show that the family's choice is contrary to what the patient would have wanted, or if it can show that the patient's quality of life is high enough to constitute a benefit, on balance, to the patient, then it may claim that the family is acting negligently and may seek judicial relief in this matter by suing for guardianship.

Although we began with five possible arguments in this case, we have successfully reduced that list to one issue. Either the facility must be prepared to show negligence, or it must allow for transfer of the patient.