Ethics and Medically Ineffective Treatment I

Probably the most common ethics consult we get is one surrounding perceived, potential, or proven medically ineffective treatment. At least in California, physicians are not required to provide care that is not beneficial. Sometimes this is called futile care, but that doesn't go well with the public and policymakers, so we instead call it medically ineffective care. I think the phrase stirs up emotions about rationing care, death panels, and the like, but it's really not meant to be that. Antibacterials do not work for the common cold. High dose vitamins do not work for brain cancer. An endotracheal tube does not cure decompensated liver failure. Physicians are not obligated to and should not do things that they do not believe will work.

In practice, this gets muddy very quickly. We consulted on a pediatric patient who was started on a treatment by a community physician that has no evidence or even biologic plausibility for working (the disease is neurologic and the drug does not cross the blood-brain barrier). After being admitted to the hospital, the parents requested continuation of the drug, which the pediatrician believed was ineffective. Since the drug has side effects on the liver and kidneys (risks) with no benefit, we sided with the physician and found it ethical to stop that drug.

On the other hand, we had a similar pediatric case where the family was requesting a treatment that was not felt to help the child, but had few side effects or risks. Here, we said that it was ethically permissible to go either way - either to give the drug or to stop it. In looking at the ethical principles of beneficence of maleficence, we did not think the child would be harmed, and because the benefit was questionable, we left it up to the treating team to decide what was best. As with any other consultation service, we make recommendations of varying insistence. Sometimes, we find things ethically necessary, other times we find them simply ethically permissible.