The fallacy of futility-care theory

There are many things I could talk about in the raging debate over what is euphemistically called “health care reform,” but for now I wish to focus on one issue. And that is “end-of-life” care. This, in turn, is bound up with “futility-care theory.”

The argument, in a nutshell, is that, at best, there’s no point pouring medical resources into a lost cause. Moreover, since medical resources are finite, we’re depriving others who’d benefit from such care.

In application to end-of-life care, so the argument goes, we devote inordinate medical resources to patients in the final year of life. It would be more responsible to divert those resources to other patients with a better chance of survival, improvement, or cure.

There’s a certain moral and logical appeal to this argument, is there not? If you have one donated liver, and two patients with liver disease, they can’t both have the same liver. So shouldn’t you give the liver to the patient with better prospects for recovery?

Now, I don’t deny that it’s sometimes necessary to make those life-and-death decisions. However, I would like to point out that there’s a fallacy running through a lot of this debate.

How do you know that medical care is futile or not? Is that a prospective judgment or a retrospective judgment? If despite your best efforts, the patient dies, then your efforts were futile. But, of course, that’s something you only find out after the fact.

Same thing with “end-of-life” care. How do you know that a patient is in the final year of life? Well, if he dies, then, by definition, he died in the final year of his life. But do you know in advance of the fact that this year will be the final year of his life?

Consider all of the patients who are wheeled into the ER with life-threatening injuries. The staff pours all their medical resources into saving their lives. In some cases they succeed, and in other cases they fail. In hindsight, they wasted finite medical resources on some patients who turned out to be a lost cause. But that’s with the benefit of hindsight.

To examine this from the opposite end of the spectrum, consider the patients whose lives they saved by throwing all their medical resources at the patient. Patients who would have died absent their heroic efforts to save them.

So the whole question of futile-care theory or end-of-life care is coasting on a tautology. The only patients who are counted are the patients who die. The patients who recover are never counted.

Yet, were it not for the same resources devoted to both sets of patients, the rate of mortality would be far higher. Those not presently counted–because they were cured (as a result of medical treatment)–would suddenly become an actuarial statistic.

So the underlying tautology cannot justify the rationing of care, for the rationing of care involves a prospective judgment (on whether or not the patient is not a lost cause), whereas the futility of care which is used to justify the rationing of care involves a retrospective judgment.