Thoughts on medical futility
5 MINUTE READ
from Luke’s Journal Dec 2018 | Vol 23 No 3
As many people have noted, medicine has become the victim of its own success.
Over the last hundred years, conditions which once were inevitably fatal (ranging from systemic infection to malignancy) have become amenable to effective curative treatment. While changes in social infrastructure and living conditions have contributed more to human longevity than have advances in medical treatment, there is no doubt that countless people are alive because of modern medicine. And that’s no bad thing. But it does bring new problems to the fore. Amongst them are questions regarding futile medical treatment at the end of life. And medicine is struggling to know how to answer them.
There are many factors that have contributed to this: traditional training has focused on curative treatment and neglected questions of end of life care; doctors tend to be concerned about ‘success’, measured in terms of reduced morbidity and mortality; as a society we no longer know how to talk about death, and many have never experienced another person’s dying; our society is obsessed with beauty and youth and control in ways that make intractable illness, suffering and the inevitable encroaching of death horrifyingly offensive. And here’s another: the very efficacy of modern medicine gets in the way of talking about dying and recognising when it’s time to stop ‘fighting death and disease’.
Let me explain…
Twenty years ago Gerald McKenny wrote an important, if rather neglected, analysis of medicine as a technical enterprise driven by a Baconian imperative – the use of science and technology to free human beings from their bondage to fate.1 He states, ‘One of the most characteristic features of technological medicine is the confidence among its practitioners that the elimination of suffering and the expansion of human choice, in short, the relief of human subjection to fate or necessity, are (so long as abuses in implementation are avoided) unambiguous goods whose fulfilment is made possible by technology.’2 To put it a little more crudely: modern medicine uses science to cure disease and fight death. If that’s the case, then whenever medicine comes to the end of its technical resources, it confronts failure.
“…as a society we no longer know how to talk about death, and many have never experienced another person’s dying…”
This is exacerbated by one of our great cultural myths, one that modern medicine sadly perpetuates: the delusion that ‘we can get out of life alive’.3 If death is ‘defeat’ and if it can, in some way, by whatever desperate measures, be indefinitely forestalled, then so it must. But the result is all-too inhuman. People are subjected to treatment on the off-chance that it might prolong their life just that little bit, with no thought that perhaps we’re simply prolonging their dying. And so they endure a death in which they and their families are pushed out of their own experience of dying by technicians and their machines. This is not just medical futility, it is medical harm.
“Modern medicine uses science to cure disease and fight death. If that’s the case, then whenever medicine comes to the end of its technical resources, it confronts failure”.
It should come as no surprise in a social and medical culture such as this, that ‘medical assistance in dying’ has become as prominent and popular as it is. For it allows us to extend our (sense of) technical control into the domain of death and dying, while simultaneously exorcising the spectre of frailty and mortality from our midst.4 These aren’t radically new observations – any palliative care physician or geriatrician worth their salt has come to grips with them – but they bedevil the practice of medicine in late modernity.5
How should we address them as Christians?
First, doctors need to look more carefully at the nature of medicine and its goals. We need to shift our perspective away from viewing medicine as technical mastery towards seeing it as a form of care for vulnerable people. This would enable us to acknowledge the inherent frailty and finitude of the human condition (we are all vulnerable creatures, bound to die), recognise the great privilege of being agents of a society’s care for its vulnerable members, and discern the appropriate forms of that care. Often that care is best expressed by seeking to overcome the limitations imposed by disease or disability or disaster, and return people to a reasonable level of functioning as persons and in relationship. But sometimes, it takes the form of standing in solidarity with someone as we care for them in their frailty and dying, rather than abandoning them to it. A shift from (in these circumstances) futile curative therapy to palliative care would not be seen as an admission of defeat, but an expression of the right kind of care for this person at this time.6
Secondly, we need to talk more openly with people about the inevitability of death and what matters to them as they live towards it. There are a few elements to this. First, we must acknowledge that all of us will die, and medicine cannot indefinitely delay it. Clinicians need to help patients come to terms with that as a concrete reality, not just a vague idea. We need to talk with patients about what matters to them in life, and so in their dying. When it becomes apparent that they are facing an illness that may end in their death, we must talk about the kinds of treatments that are available, and what these entail, for them and their life projects. This might enable them to put together a meaningful set of advanced care directives or patient care plans that identify the kinds of treatment they would want and which they would not – and allow clinicians to identify the kinds of treatment they would and would not be willing to provide for them. Of course, there are significant legal and ethical questions about the status of advanced care directives, given the ways that people see things very differently prospectively and in reality, as well as complications about their implementation in the exigencies of medical emergencies.7 I would suggest that they best operate as guides for conversations with patients and their families including, when necessary, shaping (but not determining) proxy decision-making in emergencies. We need to foster a conversation in the wider community about these matters.8
“Clinicians need to help patients come to terms with that as a concrete reality, not just a vague idea. We need to talk with patients about what matters to them in life, and so in their dying.”
Christian doctors have a lot to offer to this conversation. We have a vision of life in community that can sustain this kind of humane medicine. We have a clear recognition of the limits of the human condition, and that only God can free us from our bondage to death – and gloriously has done so. We know that we don’t ‘get out of life alive’, but that we are delivered through death to immortality. We have a long tradition of caring for dying people in ways that honour them and their inherent dignity, even as they face the indignities of dying. And we know that, while some medical treatments may be futile, our care for people in need never is.
Rev Dr Andrew Sloane Rev Dr Andrew Sloane practiced briefly as a doctor before training for Baptist ministry. He is Senior Lecturer in Old Testament and Christian Thought, and Director of Postgraduate Studies at Morling College in Sydney. His current research is focused on philosophy and theology of medicine and related questions.
Back to issue: Hot Topics #1
- Gerald P. McKenny, To Relieve the Human Condition: Bioethics,
Technology, and the Body. Albany: University of New York Press, 1997.
- McKenny, 22.
- Stanley Hauerwas, The End of American Protestantism,
- See Jeffrey P. Bishop, The Anticipatory Corpse: Medicine, Power and the Care of the Dying. Notre Dame, IN: UNDP, 2011, for an insightful analysis of this phenomenon.
- See Atul Gawande, Being Mortal: Medicine and What Matters in the End. New York: Metropolitan Books, 2014.
- I address these matters at length in Andrew Sloane, Vulnerability and Care: Christian Reflections on the Philosophy of Medicine. London: Bloomsbury T&T Clark, 2016.
- See William Davis, Departing in Peace: Biblical Decision-Making at the End of Life. Phillipsburg: P&R Publishing, 2017, for a conservative Reformed argument in support of such a view.
- As is now happening in the ‘secular’ media. See See http://www.abc. net.au/news/2018-07-28/rethinking-our-approach-to-death-and-having-a-plan-for-dying/10014582.