Ethics in medicine: is it a futile exercise?

In this issue of the MJA, we are launching a new occasional series of articles discussing current controversies and challenges in medical ethics. This first trio of articles addresses the provision of apparently futile treatment at the end of life. Koczwara, a medical oncologist, describes a difficult, but unfortunately all-too-common, case involving conflict between health professionals and family members about the appropriateness of life-prolonging treatment. Complementary clinical, ethical and legal perspectives follow.

There are two main groups of ethical challenges facing Australian health professionals in the 21st century. Some of them, like that of “futile” medical treatment, are questions that have been asked for a long time but remain unresolved. These contentious questions often involve conflicts between different ethical principles; for example, between the need to respect the patient’s autonomy and the need to allocate limited medical resources to those most able to benefit from them. It can sometimes appear that ethical debate on these questions is futile, since the arguments are intractable, values incommensurable, and solutions elusive. However, even if there is no single right answer to many ethical questions, there are often some answers that are clearly wrong, and can be rejected. Recent Australian work suggests the possibility of progress in the specific area of medical futility.1 Advance care planning significantly increases the chance that patients’ own wishes are known and respected at the end of life.2 This is likely to reduce the provision of unwanted and inappropriate treatment and may reduce disputes. Legal attention has shifted from attempts at defining futility to delineating a clear and fair process for resolving disputes when they occur.3,4

Other ethical challenges are new; for example, those arising from novel medical technologies and procedures. In forthcoming issues, the Journal will look at questions related to direct-to-consumer genetic testing, and umbilical cord blood storage and use. Both of these exemplify the challenge of regulating medical technologies and diagnostic tests that are available in both the public and private sectors. The problem for regulators is partly the speed of technological development; however, it is also the real difficulty of restricting access to direct-to-consumer testing in an age in which such testing can be simply arranged online or through the post and performed offshore.

One issue that has been a major source of debate in the medical ethics literature in the past decade and is likely to face practitioners in the near future is medical enhancement — drugs and technologies that are used to improve normal function rather than to treat illness or infirmity.5,6 In recent surveys, a small proportion of Australian adults have admitted to use of prescription medicines in the absence of a medical diagnosis to improve concentration or alertness.7 Should such enhancements be proscribed? Should students be tested for evidence of enhancers before sitting exams? As with performance enhancement in sport, could such an approach be futile, and should we accept that enhancement will occur despite any attempts to prevent it? If so, it may be better to focus attention on harm minimisation and education.

Finally, value pluralism creates an extra challenge for medical ethics in Australia, with our diversity of Indigenous and immigrant cultures.8,9 Without a shared set of values it may seem fruitless to even embark on ethical debate. It may be possible, though, to draw on higher-order principles that transcend religious and philosophical differences. First, we could seek universalisable solutions to ethical problems — could we apply to ourselves what we are proposing to do to others? This involves applying a version of the Christian “golden rule” or the Kantian categorical imperative shared by most philosophies.10 Second, we should be consistent in our ethical judgements and decision making. If our approach differs between cases, are there ethically relevant factors to justify that difference? (The philosopher Hare argued that the very language of ethics demands such consistency.11) This is a particular challenge in countries like Australia, where the legal framework for end-of-life decisions can differ significantly between states. Third, where there is a range of viewpoints that could reasonably dictate our actions, we should be guided by the wishes and values of the individual most affected by a decision, and avoid imposing on them the values of others, unless this would harm others.12 This approach recognises the diversity of values and beliefs held in our society. We respect this diversity by accepting that we will not all agree about contentious questions.

If the principles seem straightforward, their application is not — particularly when it comes to developing policy or legal solutions. As the articles in this issue illustrate, we have some way to go before our approach to conflicts about end-of-life treatment is universalisable, consistent and respectful of different values.