Managed Care

Guide to Critical Care Ethics Not Ready for Prime Time

Michael S. Victoroff, MD

I have been invited to review a publication from the Society of Critical Care Medicine titled Critical Care Ethics: A Practice Guide from the ACCM Ethics Committee, edited by Dan R. Thompson, MD, MA, and Heidi B. Kummer, MD, MPH. I am strongly biased in favor of professional organizations studying and publishing their own ethical guidelines. Medicine, particularly managed care, has a large stake in ethics education, which cruises like a sidecar alongside the greater enterprise, indulged so long as it remains deferential. So, I picked up this skinny volume with positive expectations.

Dismayingly, I found it hard to come up with comments about the product that are as positive as its aspirations.

The authors of this 70-page pamphlet were members of the American College of Critical Care Medicine Ethics Committee, six MDs and one RN. It was edited by two other physicians. It comprises 21 chapters averaging three pages each.

The aim is to provide "Answers to common questions relevant to critical care ethics," but what the authors have served up is a list of ingredients without the recipes describing how to make the dishes.

Chapter 1 presents "The ethical principles I need to know" in 2.5 pages. The discussion is so cursory as to create more confusion than understanding. Grammatical errors abound, and some remarks introduce bias without context or elaboration. For example, out of four sentences explaining distributive justice, one of them is "This issue is extremely relevant to medical care in the U.S. and by definition does not exist in the U.S." What does not exist? "This issue?" or "distributive justice?" Either statement would be indefensible.

Chapter 2 sketchily outlines a system for approaching ethical decisions. Even its first sentence stumbles: "We all have issues that are not clear as to the ethical direction to take." While some chapters are better written, there is abundant awkwardness of this kind. This section catalogs ethical questions a clinician might encounter, but there is no advice about how to analyze the answers or balance conflicts among them. At the end of the list, the authors blithely announce, "At this juncture, one can make some assessment of the issues and hopefully come to a conclusion." It is unclear how.

Hard to follow

Chapter 3 is a choppy and somewhat hard-to-follow review of advance directives. There are predicates without subjects, pronouns with ambiguous antecedents, and other examples of the jarring style that pervades the work. I got the impression of an essay that started out maximally compressed and then was edited into incoherence. The summary message is skeptical about the value of all forms of advance directive in clinical settings. The authors remark, "Even the popular TV show Steinfeld devoted an episode to the 'fallacies' of the 'living will.'"

Chapter 4 brings more confusion than clarity to the difference between withholding and withdrawing therapy. Like other sections, it restates material available in better form elsewhere. It invokes the concept (today mostly discarded) of ordinary vs. extraordinary treatment. There are broad statements about legal cases and the court system without background or analysis. This chapter concludes with the limp argument that we are forced to accept that there is no difference between withholding and withdrawing because, otherwise, "there is a morally untenable situation that can lead to irrational nontreatment." Such reverse logic makes feeble ethics. Better arguments for the moral equivalence between withholding and withdrawing can be found in the literature.

Chapter 5 tries to define and discuss "euthanasia" (a label that has been applied to at least five distinct practices) in 2.5 pages. The authors condense the issues almost into bullet points, which do injustice to the material and serve readers badly.

Chapter 6 takes an overly categorical stance on the need for "formal judicial proceedings" in cases where patient wishes cannot be determined. Chapter 7 is a cursory swipe at consent for research. Chapter 8, "Dealing with an observant religious family," astonishingly equates "religious beliefs" with "the Judeo-Christian faith" (as if that were a valid, singular construct). In barely more than a page, the authors skim through a few doctrinal matters (like "vitalism") and totally ignore the oceanic breadth of the subject.

The remaining chapters flash past in the same stroboscopic style. Involuntary treatment (Jehovah's Witnesses, etc.) is handled with a set of categorical sound bites like: "Any disease that can be transmitted easily by nonsexual contact and poses a potential threat to the welfare of society as a whole would justify involuntary treatment." This generalization is simply bad advice. The section reads like cue cards for a 15-second TV interview.

There are two fairly good pages on complementary medicine. A discussion of withdrawing nutrition is short and bumpy. One chapter struggles to explain the functions of an ethics committee, ending with the paradoxical advice: "Be sure that the question that you want answered is really something that can be answered."

A chapter on interpersonal conflicts fails to mention the best option in some cases, namely to withdraw the physician. A chapter on pain control provides more categorical generalizations and dogmatic conclusions. Of course, categorical advice can be valid: "There is no maximum allowable dose of pain medications in the suffering patient." But this section, covering clinical and moral issues about narcotics management for adults and children in less than three pages does not mention physiologic tolerance.

Much left out

A single page on the "rule of double effect" omits the origins of this doctrine and the subtle — some might say sophistical — reasoning that supports it. The authors offer this "rule" (like other ethical principles cited throughout the book) as a formula to solve the uncomfortable physician dilemma of weighing actions that have unavoidably bad consequences. At times the authors seemed to treat ethical problems as disorders to be cured with prescriptions. (Incidentally, one of the books' references, Jonson, Siegler and Winslade's Clinical Ethics, handles this philosophical material much better — in two pages.)

What might have been a helpful chapter on brain death and the persistent vegetative state (PVS) is hobbled by apparent confusion over its goals. The disjointed introduction mentions, without clarifying, several legal definitions of death. Short paragraphs seem to be extracts from guidelines for distinguishing and diagnosing PVS and brain death in adults and children. Transplants and life support are mentioned, but there is no thread to follow that would lead to advice about an ethical decision.

The second longest chapter (3.5 pages) is a discussion of "futility," where the authors find that "the least value-laden and most objective" way to resolve the problem is simply to displace it into a problem of defining medical benefit. They rifle through important topics like flash cards, without discernable order (scientific standards, expectations, costs, probability, law, litigation, communication, etc.), in the rush misplacing the distinction between therapeutic utility and quality of life. They swipe at the problem of financial limits, but it's like a cat batting a ball of string. There is no real discussion of resource limitations, or ironically for a book on critical care, of triage in any of its senses.

The booklet finishes with 14 legal cases that should be familiar to any critical care specialist (e.g., Quinlan, Bouvia, Brophy, Doe), but the summaries are so brief and incoherent that people acquainted with the actual cases might not recognize them.

I am having a hard time visualizing the audience for whom this volume was intended. If I were standing at the bedside of a critically ill patient with an ethical problem, I can't see it being much use, whether I were a specialist physician, a nurse, a student, or a family member. The book is far too simplistic for specialists, and doesn't provide enough background to be useful to students. It doesn't offer the detailed prompting needed in a guideline. Its categorical generalities, sometimes insensitive tone and paternalistic use of the royal "we" (providers) would annoy many patients. Ultimately, it isn't that the authors have said much wrong (in fact, everything is more or less right in my view), but that they failed at the primary task of ethics, which is to explain moral judgments.

Well-written and reasoned ethics guidelines can provide critical input when expert advice is needed. I would argue that an hour of ethics education might enhance quality of care in many ICUs more than another hour of pharmacology. In a constructive spirit, I would consider this little booklet to be a rough draft for something about twice its length.

I hope the SCCM will hire a professional writer (style counts!) and take another shot.

Michael S. Victoroff, MD, is a family practitioner and ethicist in Denver who has also been an HMO medical director. He reports no conflicts of interest in relation to his column in Managed Care.

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