Hostname: page-component-78c5997874-94fs2 Total loading time: 0 Render date: 2024-11-09T09:21:04.019Z Has data issue: false hasContentIssue false
  • English
  • Français

How Physicians Talk about Futility: Making Words Mean Too Many Things

Published online by Cambridge University Press:  01 January 2021

Mildred Z. Solomon
Get access Rights & Permissions [Opens in a new window]

Extract

“There's glory for you!”

“I don't know what you mean by ‘glory,’ ” Alice said.

Humpty Dumpty smiled contemptuously. “Of course, you dont—till I tell you. I meant ‘there's a nice knock-down argument.’”

“But ‘glory’ doesn't mean a ‘nice knock-down argument,” Alice objected.

“When I use a word,” Humpty Dumpty said, in rather a scornful tone, “it means just what I choose it to mean—neither more nor less.”

“The question is,” said Alice, “whether you can make words mean so many different things.”

“The question is,” said Humpty Dumpty, “which is to be master, that's all.”

When applied bioethics confronts the topic of futility, the question of who is to be master turns out to be central. Indeed, much of the literature on futility has focused on exactly this question: who gets to define the terms of the debate? Who gets to decide that treatment is “futile” and therefore allowably withheld or withdrawn?

Type
Article
Information
Journal of Law, Medicine & Ethics , Volume 21 , Issue 2 , Summer 1993 , pp. 231 - 237
Copyright
Copyright © American Society of Law, Medicine and Ethics 1993

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Rebecca Jackson, Associate Director of Decisions Near the End of Life, and Andrea Carlos, Research Associate, ably assisted with the interviews. I am grateful to the Director of Continuing Medical Education at the hospital for his help and to the physicians who spoke so sincerely about the dilemmas they confront in their practice. This work was supported, in part, by a grant from the W.K. Kellogg Foundation. Earlier versions were presented at the 1991 Annual Meeting of the American Public Health Association’s Bioethics Forum in Atlanta, Georgia and at the 1992 Decisions Near the End of Life national training conference in Albuquerque, New Mexico.Google Scholar
Carroll, L., The Annotated Alice. Gardner, M. (ed.) New York: Clarkson N. Potter (Carroll's book published originally in 1865), as reprinted in Kirk, J. & Miller, M. Reliability and Validity in Qualitative Research, Sage Publications, 1986; Qualitative Research Methods, Volume 1.Google Scholar
See, e.g., Alpers, A. & Lo, B., “Futility: Not Just a Medical Issue,” Law, Medicine and Health Care, Winter 1992; 20 (4): 327–329; Veatch, R. & Spicer, C., “Medically Futile Care: The Role of the Physician in Setting Limits,” American Journal of Law and Medicine 18 (1 & 2): 15-36;; S. Youngner, “Who Defines Futility?” JAMA 1988; 260 (14): 2094-5.Google Scholar
See, e.g., Koch, K., Meyers, B., Sandroni, S., “Analysis of Power in Medical Decision-Making: An Argument for Physician Autonomy,” Law, Medicine and Health Care, Winter 1992; 20 (4): 320–326; Murphy, D., “Do-Not-Resuscitate Orders: Time for Reappraisal in Long-Term-Care Institutions,” JAMA 1988; 260: 2098 – 2101; Paris, J., Crone, R., Reardon, F., “Physician Refusal of Requested Treatment: The Case of Baby L,” NEJM 1990; 322 (14): 1012 - 1014 Schneiderman, L., Jecker, N., Jonsen, A., “Medical Futility: Its Meaning and Ethical Implications,” Annals of Internal Medicine, June 15, 1990: 112 (12): 949 - 954; Tomlinson, T. & Brody, H., “Futility and the Ethics of Resuscitation,” JAMA Sept. 12, 1990; 264 (10): 1276 - 1280.Google Scholar
Callahan, D., “Medical Futility, Medical Necessity: The Problem Without a Name,” Hastings Center Report July–August 1991: 30–35; Miles, S., “Medical Futility,” Law, Medicine and Health Care, Winter 1992; 20 (4): 310 - 315.Google Scholar
Brennan, T., “Physicians and Futile Care: Using Ethics Committees to Slow the Momentum,” Law, Medicine and Health Care, Winter 1992; 20 (4): 336–339; see also Alpers & Lo and Veatch & Spicer, supra note 2.CrossRefGoogle Scholar
Truog, R., Brett, A., Frader, J., “The Problem with Futility,” NEJM, June 4, 1992; 326 (23): 1560–1564.Google Scholar
Youngner, , supra note 2.Google Scholar
Schneiderman, , Jecker, and Jonsen, , supra note 3.Google Scholar
Tomlinson, & Brody, , supra note 3; Truog, Brett & Frader, supra note 6.Google Scholar
Cranford, R. & Gostin, L., “Futility. A Concept in Search of a Definition,” Law, Medicine and Health Care Winter 1992; 20 (4): 307–309. Also Truog, Brett & Frader, supra note 6.Google Scholar
For example, Youngner, (supra note 2) points out that Murphy's (supra note 3) own actions—namely, “talking turkey” with patients about the disadvantages of attempting CPR in their frail condition, belie his conclusion that physicians need not discuss CPR with their patients.Google Scholar
Alpers, , Lo, and Youngner, , supra note 2; Cranford, & Gostin, , supra note 10; Tomlinson, & Brody, , supra note 3; Truog, , Brett, & Frader, , supra note 6.Google Scholar
Solomon, M.Z., O'Donnell, L., Jennings, B., Guilfoy, V., Wolf, S.M., Nolan, R., Jackson, R., Koch-Weser, D., Donnelley, S., “Decisions Near the End of Life: Professional Views on Life-Sustaining Treatments, American Journal of Public Health. January 1993, 83 (1): 14–22; Solomon, M.Z., “Life and Death Decisions: Physicians' Perspectives and Their Implications for Professional Education,” Cambridge, Massachusetts: Harvard University; 1991. Dissertation. Ann Arbor, Michigan: University Microfilms International Dissertation Information Service, Order No. 9132384.Google Scholar
Solomon, M.Z., Jennnings, B., Guilfoy, V., Jackson, R., O'Donnell, L., Wolf, S.M., Nolan, K., Koch-Weser, D., Donnelley, S., “Toward an Expanded Vision of Clinical Ethics Education: From the Individual to the Institution, Kennedy Institute of Ethics Journal, September 1991; 1: 225–245.CrossRefGoogle Scholar
At her suggestion, I adapted this question from one that Carol Gilligan has found to be extremely useful in studies of moral orientation. See, e.g., Gilligan, C. In a Different Voice, Cambridge, MA: Harvard University Press, 1982.Google Scholar
Brown, L., Argyris, D., Attanucci, J., Bardige, B., Gilligan, C., Johnston, K., Miller, B., Osborne, D., Tappan, M., Ward, J., Wiggins, G., Wilcox, D., A Guide to Reading Narratives of Conflict and Choice for Self and Moral Voice, (Monograph No. 1), 1988; Cambridge, MA: Harvard Graduate School of Education, Center for the Study of Gender, Education and Human Development. See also: Maxwell, J. & Miller, B., “Two Aspects of Thought and Two Components of Qualitative Data Analysis,” presented at the Conference on Computers and Qualitative Research, Breckenridge, Colorado, October 1990; Mishler, E., Research Interviewing: Context and Narrative, Cambridge, MA: Harvard University Press, 1986.Google Scholar
Mishler, E., The Discourse of Medicine, 1984; Norwood, NJ: Ablex Publishing Company.Google Scholar
Belenky, M., Clenchy, B., Goldberger, N. & Tarule, J., Women's Ways of Knowing: The Development of Self, Voice and Mind. 1986; New York: Basic Books; Gilligan, supra note 15; Ward, J., Taylor, J., Gilligan, C., Bardige, B., Mapping the Moral Domain, 1989; Cambridge, MA: Harvard University Press.Google Scholar
This summary finding appeared in Solomon, M.Z., “Futility as a Criterion in Limiting Treatment,” (letter) N. Eng. J. Med. 1992; 327 (17): 1239.Google Scholar
Solomon, , O'Donnell, , Jennings, , Guilfoy, et al. supra note 13 and Solomon, supra note 13.Google Scholar
McCrary, S.V., Swanson, J., Perkins, H., Winslade, W., “Treatment Decisions for Terminally Ill Patients: Physicians' Legal Defensiveness and Knowledge of Medical Law,” Law, Medicine and Health Care, Winter 1992; 20 (4): 364–376.CrossRefGoogle Scholar
Schön, D., Educating the Reflective Practitioner. 1987; San Francisco: Joseey Bass, page 33.Google Scholar
Schön, , supra note 22, page 33.Google Scholar
Pellegrino, E. as quoted in Education Development Center, “Working with the Law,” Decisions Near the End of Life, 4, 1989, Newton, MA: Education Development Center, Inc.Google Scholar
Alpers, & Lo, , supra note 2.Google Scholar