Ethics of Acute Care Surgery

Laurence B. McCullough

INTRODUCTION

Trauma care is undertaken in order to save the lives and protect the health of patients who have experienced injuries. The ethical obligation to provide trauma care, however, is not unlimited. Sometimes it becomes ethically justified to set limits on the medical or surgical management of trauma, especially on the basis of clinical judgments of futility.

In general terms, futility means that a clinical intervention is reliably expected not to have its usually intended outcome. The clinical applicability of this general notion of futility requires that the outcome be clearly specified. Otherwise, clinical discourse among physicians or with patients and their families is at high risk of gridlock from unnecessary confusion about what is meant by saying that an intervention is “futile.”

Ethical challenges involved in setting limits on clinical management of patients’ diagnoses have been recognized in medical ethics since ancient times. In The Art, for example, the Hippocratic writers define medicine to include refusing to “treat those who are overmastered by their diseases, realizing that in such cases medicine is powerless.”¹ More recently, the issue of setting limits has arisen in the context of critical care and how physicians should respond to requests for inappropriate continuation of life-sustaining interventions such as mechanical ventilation, provision of fluids and nutrition, and pharmacologic support of cardiac function. Issues concerning setting limits now arise routinely in the postoperative setting, and futility is sometimes invoked as a justification for setting limits.² The purpose of this chapter is to identify four major concepts of futility that have been developed in the bioethical and medical literature and to incorporate these concepts with definitions of terminal and irreversible conditions into an algorithm that can be used to set ethically justified limits on the medical and surgical management of trauma patients.

FOUR CONCEPTS OF FUTILITY

The first three concepts of futility appeal to the ethical principle of beneficence as the basis for the requisite specification. This ethical principle obligates the physician and other healthcare professional to seek the greater balance of clinical goods over clinical harms to the patient. The key component of beneficence for clinical judgments of futility is that for an intervention to be reasonable to offer and perform in patient care, it must hold out the prospect of at least a modicum of potential clinical benefit.³

Tomlinson and Brody introduced the first beneficence-based concept of futility, physiologic or strict futility.⁴ An intervention is judged to be futile in this first sense when it is reliably expected not to produce its usually intended physiologic outcome. For example, cardiopulmonary resuscitation that continues for such a prolonged period of time that restoration of spontaneous circulation is no longer reasonably expected is properly judged physiologically futile, because there is at this point no reliable expectation, based on outcomes data, to support a clinical judgment that the outcome of resuscitation can be achieved.

Brody and Halevy introduced the second beneficence-based concept of futility, imminent demise futility.⁵ An intervention is judged to be futile in this third sense when it is reliably expected that the patient will die before discharge and not recover consciousness beforehand. For example, two large case series have shown that for patients who arrested in the field but were not successfully resuscitated upon arrival in the emergency department (ED) all were dead at discharge and with rare exceptions never recovered consciousness.^6,7

Schneiderman et al. introduced the third beneficence-based concept of futility clinical or overall futility.⁸ An intervention is judged to be futile in this second sense when it is reliably expected not to result in maintenance of any ability by the patient to interact with the environment and continue to develop as a human being. For example, a patient diagnosed to be a permanent vegetative state according to accepted criteria or who has suffered severe and extensive head trauma resulting in neurologic devastation has irreversibly lost the capacity to interact with the environment and continue to develop.⁹ Although interventions such as provision of nutrition and fluids continue to be physiologically effective, these interventions do not alter the outcome: irreversible loss of the capacity to interact with the environment.

The fourth concept of futility appeals to the ethical principle of respect for autonomy. This ethical principle obligates the physician to seek the greater balance of goods over harms to the patient as those goods and harms are defined from the patient’s perspective, which can range far beyond the relatively narrow scope of clinical goods and harms.

Tomlinson and Brody introduced the fourth concept of futility, quality-of-life futility.¹⁰ An intervention is judged to be futile in this fourth sense when it is reliably expected that the patient’s quality of life (engaging in life tasks and gaining satisfaction from doing so) will be unacceptable to the patient. This can occur when it is reliably expected that the patient will not be able to either engage in valued life tasks or derive sufficient satisfaction from doing so. The patient retains the ability to interact with the environment and develop, but judges the outcomes of doing so to be unacceptable. This concept does not appeal to an observer’s rating of the patient’s quality of life, because such external evaluation of quality of life is unreliable.¹¹ Using this concept of futility requires

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