Arbitrary? Unilateral?

Take a look at this conversation, at "The Cheerful Oncologist".

I have often wished that my patients' bodies had read the books and articles that I have. In anthropomorphic fits, I am certain that if their bodies knew better, I wouldn't even have a job.

At the very least, I wish that decision-makers - both families and patients - could know all that I know about medical care and its consequences.

Unfortunately that's not how bodies, patients or families work. I'll admit that some of the confusion may be due to the fact that so many doctors can't or don't learn to explain medical terms and care to patients and families. Interpretation between the two languages is difficult to learn and teach.

Just one of the reasons we still call medicine an "art." At least occasionally.

Besides, we keep changing the "rules" about what we expect bodies to do.

Once upon a time, people who could not breathe for themselves were considered to have a "natural death." The redefinition of renal failure is even more recent. As a matter of fact, in my memory, the dilemmas of resources and medical decision-making at the end of life have been pressured as much by the advent of dialysis as by the ventilator.

Early ethical and practical discussions about dialysis treated it as a semi-chronic treatment to be used with the expectation of a kidney transplant or to give the patient a chance to heal. The reality of life and bodies led to restrictions on who qualified for dialysis during the early years, and doctors still make referral determinations based on age and other health factors. (See this article for more on treatment of ESRD and this one on the symptoms and side-effects of dialysis. Remember that these numbers concern outpatient and ambulatory patients, not patients in the ICU with so many other complications.)

Wesley Smith, the author of The Culture of Death, is discussing the ethics of the care of Andrea Clark on his blog, Secondhand Smoke. He and the lawyer for Mrs. Clark's family are complaining of the lack of "due process" in medicine.

However, they reject the process in place. Perhaps there are not enough lawyer-guided steps? Should judges practice medicine? Are all doctors potential slaves who must suspend their own judgment and consciences? How far will we take this - remember, some (lawyers, doctors, activists) believe that I am abandoning patients when I refuse to refer for abortion.

Doctors don't practice medicine by "due process." We use evidence and experience. While some of us love our algorhythms, "cookbook medicine" doesn't always serve at the extremes of disease and life. We must, however, plan and anticipate for the consequences of each decision. And our experience will influence each step and choice.

There is no conspiracy, here. There is common education, experiences and evidence.

Whether Mrs. Clark has been in the hospital since November or January (the accounts I've read vary), there has been a long trial of intensive technological intervention in order to give her heart a chance to heal, her brain a chance to resume its drive to spontaneous breathing, her kidneys a chance to begin filtering the blood and again make urine.

I hope the family is prepared for the coming decisions when Mrs. Clark's heart fails, when her hepatic congestion makes her liver fail, when a stress ulcer begins bleeding, etc.

Perhaps one change needed is a process for the doctor to determine that no new treatments will be added, while continuing the current intensity of treatments. While it's true that there is no ethical difference between one life saving treatment and another, the burdens of treatment add up, with the numbers and the length of time the treatments are used. From what I've seen and heard, though, the law isn't very clear on this option, and the lawyers and family would be - and perhaps have been - just as hostile to the idea of limits as they are to stopping the dialysis.

Wasn't St. Luke's the hospital that led the way in heart transplants . . . that led to kidney transplants, etc.? What are the limits?

Edited for spelling "algorhythms" - 11-03-06