February 15, 2011 | Posted By Sheila Otto, MA, BSN

I have a family member who is 88 yrs of age with acute on chronic problems ranging from diabetes to heart failure to debilitating shingles that have kept her bedbound over the last several weeks. She has gone from a spirited, independent survivor of loss (husband and two children), to someone who reluctantly moved into her daughter’s home and who is now in an ICU to manage her unstable blood sugars, new sepsis, and a blood clot. Her daughter is upset at her worsening condition and holds out hope that she will just “fight” a bit harder, try to do more for herself, and undergo rehab so she can return to her baseline.  When I suggested that maybe her mother was simply exhausted and nearing the end of her life, and that comfort care might be in her best interest, the daughter looked at me as if I had four heads. She responded that she didn’t have anyone else, that her mother was the last of the family.

As a critical care nurse, I saw many families respond this way. I must admit feeling sorry for her, a bit annoyed at what I perceive as her selfishness, and finally a bit cautious that my message was not well received. “This is not about you, but about her,” I wanted to say. Where is it written that each of us has the moral obligation to live out every last second, regardless of cost, pain, or suffering, so that our families can delay the inevitable? Modern medicine has provided multiple solutions to complex problems, yet in the end, we will all die. Why is talk of comfort care, without ICU admission and without pulling out all of the bells and whistles, still regarded as somehow shortchanging the patient (or is it the family)?  In a nation undergoing drastic health care changes which are controversially expensive, will we ever have the backbone to recognize that some resources are just not worth the enormous cost? There, I’ve said it. Note that I did not say my family member was not worth the money, but I did say that providing expensive high tech care for marginal to no benefit was not worth it.  As an ethicist, I know that “benefit” is defined by the patient/family, but as a realist, I also know that limits are needed for the public good. The same political voices that don’t want to expand coverage to all citizens because of the expense are also the first to discount my argument as discriminatory, anti-religious, or anti-individual. Guilty as charged.  At some point, we need to face the reality that care without limits costs all of us.

1 comments | Topics: End of Life Care , Patient Autonomy


Richard R. Pesce MD, MS

Richard R. Pesce MD, MS wrote on 03/03/11 3:53 PM

Dan Callhan as discussed this issue over the years and his take is that medicine requires value recommendation for treatment consideration, that there is a limit to life, that health care really is not a right but a need that really does not exceed the needs of food and shelter but is coequal among the necessities but not superior to them. In the book "Can a Heallth Care system be moral?" Mary Mcdonough surveys callahan's viewpoints as well as others. She does take the Catholic viewpoint of person interdependence vs capitalism and/or socialism as well. But the underlying thrust is toward that which callahan favors as being close to what Catholic ethics teaches. But this requires that it is understand by practitioners and the public that technology is not always the answer and the struggle to prolong life, especially when one lives long enough to have chronic disabling problems is beneficial to no one, especially the patient. As you say in your situation teh marginal costs are not worth it.

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BIOETHICS TODAY is the blog of the Alden March Bioethics Institute, presenting topical and timely commentary on issues, trends, and breaking news in the broad arena of bioethics. BIOETHICS TODAY presents interviews, opinion pieces, and ongoing articles on health care policy, end-of-life decision making, emerging issues in genetics and genomics, procreative liberty and reproductive health, ethics in clinical trials, medicine and the media, distributive justice and health care delivery in developing nations, and the intersection of environmental conservation and bioethics.