When are medical treatments worthwhile and when are they futile? This is a complex and often divisive question. Even experienced doctors sometimes disagree about whether to treat, or not to treat.
Take, for example, the controversy surrounding the former director of The Alfred hospital’s trauma centre, Thomas Kossmann. In 2007, colleagues accused Dr Kossmann of providing “excessive treatment” to critically ill patients. In 2008, the Victorian Ombudsman accused him of “harvesting patients” to maximise income, and inappropriate billing.
After extensive investigations by the Australian Tax Office, the Transport Accident Commission, WorkSafe and the Medical Practitioners Board, Dr Kossmann was cleared of wrongdoing. Although many issues about Dr Kossmann’s work practices have been put to rest, the question about when to treat a critically ill patient remains ongoing and controversial.
In a busy, modern trauma centre, state-of-the-art technologies and cutting edge surgical interventions are standard fare. In this environment, doctors must not only decide what is technically possible but also what is ethically permissible and economically viable.
Today, trauma specialists must decide when to use life-saving technologies. They must make quick decisions about providing, or withholding, treatment that may, or may not, save a person’s life. Trauma specialists also make decisions about the costs of saving an individual’s life. These are difficult decisions, often made more difficult by the noise, chaos and urgency of a trauma centre.
Some doctors choose to withhold treatment when they consider a patient’s prognosis to be poor. They might justify these decisions with calculations about a patient’s quality of life. Other doctors believe that all life is valuable, and that every attempt should be made to prolong it.
It is common for doctors working in a trauma centre to adopt a “let’s try it and see what happens” approach. It is during the first 24 hours of care that many of the crucial decisions need to be made. Some trauma specialists describe keeping patients alive, even in the short term, as a win.
This principle of “doing everything” to save lives is developed during medical training, fuelled by the fear of legal action and reinforced by financial considerations. However, many doctors recognise that “doing everything” is not always in a patient’s best interest.
There are diverse views among health care professionals, consumers and the public about whether an invasive treatment is justified or excessive, whether treatment is futile or worthwhile. There is rarely a right or wrong answer. In many instances, conflicts can be resolved collaboratively at a patient’s bed-side. However, in the high pressure world of a busy trauma centre, life and death decisions are left almost entirely to the discretion of the doctor in charge.
Why do we allow these difficult ethical decisions to be made by an individual doctor? We could instead insist on regular and routine reviews that encourage reflection and give voice to a diversity of views. Few trauma surgeons have the time, resources or training to sort through complex ethical problems on their own. Is it simply assumed that medical expertise is enough to ensure that doctors will make the “right decisions”?
Life-saving technologies are accompanied by the responsibility to use these technologies wisely. Perhaps this responsibility could be shared among health care professionals from a range of disciplines, and consumers. Some doctors might argue that you need expert medical knowledge to be competent to judge the issues. But contemporary health care decisions are as much social, economic, ethical and political as they are medical and scientific.
Rather than finger-pointing after crises like that at The Alfred’s trauma centre, responsibility for life and death decisions should be shared. Decisions about providing, withholding or withdrawing treatment are contested and would benefit from ongoing scrutiny by a team of health care professionals. These multidisciplinary reviews should be routine and shared openly with the public. In this way, we can all take some responsibility to ensure that lifesaving technologies are used justly.
This article was first published in The Age on 9 February 2011