Vol. 70 July 1, 2012 There’s a New “F” Word in Town

Care is never futile, but medical interventions sometimes are. (1)

Ten years ago our community hospital’s Ethics Committee spent a lot of time trying to reach a consensus on the meaning and implications of the “F” word. Our context almost always was the ethical dilemmas of end-of-life decisions, renal dialysis, continued ICU care, and mechanical ventilation support. Was it ethical to continue renal dialysis on the Jamaican woman when we considered dialysis to be a medically futile treatment or should we send her back to her country as she requested where it ws not avialable?  Should the young man comatose after being struck by lightening be continued on ventilation support when any further treatment appeared to be futile?

At that time our futility discussions focused primarily on patient or family “demands” to continue expensive therapy with little hope of real benefit to the patient. Our discussions closely mirrored articles in the medical and popular literature at the time, and, likewise, did not result in a consensus of the definition of futility. At a 2003 meeting our Ethics Committee reviewed four different kinds of failed attempts to define futility, 1) by reaching a medical consensus, 2) by using empirical data, 3) accepting patient-defined futility, and 4) accepting physician-defined futility. We could only conclude that sometimes all we could say was, “We feel that further care is futile.” There are three “F” words in that simple sentence. Our attremptd emphasis on feelings never really helped in making the message any easier to deliver, understand, or accept. Trying to substitute one “F” word for another never really stuck to the wall.

With the passage of the Affordable Care Act the context of “futility” discussions has broadened considerably as legislators, insurance companies, and providers struggle with the central problem of how to pay for universal access to all kinds of medical care without using the “R” word.  The most recent example of that changing context is an essay by a MD lawyer advocating the new “F” word of “Frugality” (2).

The author argues that even if and when we reduce medical care costs by eliminating the estimated 30% spent on “wasted or ineffective measures” (3) we will still be facing the apparently inexorable annual rise of medical care costs “unless we start saying no to some beneficial care”. He does not think that the Independent Payment Advisory Board (IPAB) with the authority to change Medicare payment policies, or the Medicare “luxury tax” on Cadillac employment-based health insurance, or the current incentives for new Accountable Care Organizations and insurance companies will be enough to slow the rise of medical care costs. The new “Frugality” will only be achieved by more selective adoption of new technology. This means that after we say “no” to non-beneficial technology “we will need to say ‘no’ to some potentially beneficial new technologies because of imperfect data about clinical effectiveness”.

Daniel Callahan, President Emeritus of the Hasting Centers and one of our most respected Medical Ethics gurus, made the same argument in his 2009 book, Taming the Beloved Beast: How Medical Technology Costs are Destroying Our Health Care System (4) His opinion is that multiple studies in the 1980s-1900s comparing the cost reduction effects of regulation vs. competition are inconclusive, and that there is little evidence that the “business model” of competition works in health care. His solution to reducing medical care costs is to restrict the unbridled introduction of new technology. In his view new technology often raises the cost of medical care without improving health. The answer is rigorous assessment of new technology (both drugs and devices). “Technology assessment must COMMAND, not just COMMEND.”

“Futility” is such a negative, dead-end word. It is the end. “There is nothing more we can do.” It is colored by end-of-life issues, discussion of which are necessary and important, but which have become politicized.

“Frugality” implies a positive value, a process. “Thrifty” made it to the Boy Scout pledge, but it could have been “frugality” just as easily.
Lets hope that “frugality” sticks to the wall.
We shall see.

References:
1.Poncy M. Ethics and futile care. Program and abstracts of the National Conference of Gerontological Nurse Practitioners 25th Annual Meeting; September 27-October 1, 2006; Ponte Vedra Beach, Florida.
2. Beyond the “R Word”? Medicine’s New Frugality, NEJM 366;21, G. Bloche, pg. 1951
3. Implications of Regional Variations in Medicare Spending, Ann Int Med 2003;138, Winneberg, et al., pg. 288-298
4. Princeton University Press, 267 pages

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