J M Trau | PubMed Health

PubMed1994

Futility, autonomy, and informed consent.

If clinicians deem a treatment medically futile, is it appropriate to mention such a treatment to patients? Do healthcare professionals violate informed consent if they do not offer patients an opportunity to decline futile treatments? The notion of futility involves an assessment of patient best interest--both short-term and long-term therapeutic benefit for a patient and the community in which he or she intends to survive and flourish. Although survival interests may be construed as long term, a treatment that offers survival without any promise of flourishing is not the goal of medicine and is futile. Flourishing requires some cognitive and affective function. The goal of informed consent practices is to ensure that patients accept the benefits of treatment with cognizance of the burdens and risks. Given the impact of illness on the emotional and psychological states of patients and their families and their resultant vulnerability, the omission of futile options from treatment plans is logical and exemplifies the best of paternalistic behavior. The claim that requests for futile treatment must be honored is based on a perverse understanding of patient autonomy. Rational medicine demands that patients' requests be reasonable from a clinical perspective, as well as from a subjective one. The practice of informed consent can be implemented as a balance between these two interests.

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PubMed1993

In the best interest of the patient. Applying this standard to healthcare decision making must be done in a community context.

Acting in the "best interest" of another implies taking certain steps or following certain rules so that the person and his or her concrete human community will survive and potentially flourish. The long-term understanding of best interest refers to the balance of benefits and burdens with respect to the ultimate goals or purposes of a community within which an individual is situated; short-term best interest refers to that balance with respect to a specific healthcare decision, without reference to the overall situation. However, considering only short-term best interest is unsatisfactory in the final analysis. Any decision to sacrifice individual preference for communal best interest should include three crucial aspects: (1) The individual must be a willing (or potentially willing, in the case of a child) member of the community, (2) individuals never lose their moral standing in the community, and (3) society can justify failure to accept the autonomous decisions of some individuals only (a) if it is impossible, (b) that failure is necessitated by attempts to meet the needs of other individuals, and (c) that decision is not based on unfair or unjust practices. Applying the concept of best interest to nontherapeutic research on children, one can conclude that the indirect benefit to the child is in his or her best interest only when the long-term benefit to the community, in terms of both survival and flourishing, is adequately considered. In addition, healthcare surrogate decision makers, acting in the best interest of a person who cannot make decisions and has not previously expressed his or her wishes, must take into account the long-term interests of the community.

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