The American Journal of Bioethics

ISSN: 1526-5161 (Print) 1536-0075 (Online) Journal homepage: http://www.tandfonline.com/loi/uajb20

Anorexia Nervosa, “Futility,” and Category Errors Ronald W. Pies To cite this article: Ronald W. Pies (2015) Anorexia Nervosa, “Futility,” and Category Errors, The American Journal of Bioethics, 15:7, 44-46, DOI: 10.1080/15265161.2015.1039734 To link to this article: http://dx.doi.org/10.1080/15265161.2015.1039734

Published online: 06 Jul 2015.

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Date: 05 November 2015, At: 18:59

The American Journal of Bioethics, 15(7): 44–60, 2015 Copyright © Taylor & Francis Group, LLC ISSN: 1526-5161 print / 1536-0075 online DOI: 10.1080/15265161.2015.1039734

Open Peer Commentaries

Anorexia Nervosa, “Futility,” and Category Errors Ronald W. Pies, Tufts University and SUNY Upstate Medical University

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“Philosophical problems arise when language goes on holiday.” (Ludwig Wittgenstein, Philosophical Investigations) futile (adj.) “incapable of producing result,” 1550s, from Middle French futile or directly from Latin futilis, futtilis “vain, worthless, futile,” a figurative use, literally “pouring out easily, easily emptied” (the Latin adjective used as a noun meant “a water vessel broad above and pointed below”), hence “leaky, unreliable.” (http://www.etymonline.com/index.php?termDfutile) futile: Of no importance; answering no useful end; useless; vain; worthless. (Webster’s Revised Unabridged Dictionary)

PREFATORY COMMENTS Before commenting directly on Dr. Geppert’s thoughtful article (Geppert 2015), I offer some preliminary remarks of a more philosophical nature. These prefatory comments reflect my belief that, prior to evaluating the medical–ethical issues raised in Dr. Geppert’s article, we need to examine some of the linguistic and semantic problems associated with the terms “futility” and “end stage disease.” In this regard, I am prompted by the famous aphorism of the philosopher Ludwig Wittgenstein, just quoted—that is, that many apparent problems in philosophy arise when we abandon our ordinary ways of using language (Stern 1995, 87). More specifically—and in the context of Dr. Geppert’s paper—I see philosophical and ethical problems as arising from what the philosopher Gilbert Ryle termed category errors (Tanney 2015). Put simply, a category error occurs “when things or facts of one kind are presented as if they belonged to another” (Oxford Dictionary of Philosophy 1994). I believe that much of the controversy in the matters discussed by Dr. Geppert stems from just such a confusion of categories; specifically, the misapplication of the terms “futility” and “end stage disease” to the condition or treatment of anorexia nervosa. Furthermore, I believe that once these linguistic confusions are cleared away, many of the medicolegal and ethical problems related to AN are more readily resolved. I now try to unpack this argument and show how it supports Dr. Geppert’s main conclusions.

CONFLATION OF CATEGORIES Consider the following statement: 1. Treatment of end-stage renal disease (ESRD) is wasteful of time, resources, and energy; therefore, physicians have no ethical obligation beyond providing palliative care to the patient with ESRD. What sort of claim is this? Is it a “scientific/medical” claim; a value judgment; or a claim regarding “ethical” behavior? Or is it a sort of “portmanteau” statement that conflates all three types of claims? If we examine the italicized terms, we find that they belong to quite different ontological categories and “discourses.” The first term— end-stage renal disease—belongs to the category of histopathology. ESRD, in particular, is an objectively verifiable condition, using well-accepted histological criteria (Chatziantoniou et al. 2004). In contrast, the second term— “wasteful” —is an evaluative term: It expresses a subjective value judgment regarding the use of time, energy, or money. Now, to be sure, all of medical ethics involves “values.” But it is important that clinicians distinguish between facts and values, and recognize that what may first appear to be an “objective” and “scientific” claim actually amounts to a covert value judgment. Finally, the third term is drawn from the discourse of medical ethics, which in turn draws from underlying ethical principles, such as “autonomy” and “beneficence.” There is nothing formally fallacious in the statement just shown. But I believe that serious philosophical problems may arise when terms from such widely different categories and discourses are conflated. By analogy, consider the italicized terms in this statement: 1. “Treatment of end-stage anorexia nervosa (AN) is futile; therefore, physicians have no ethical obligation beyond providing palliative care to end-stage AN patient.”

Address correspondence to Ronald W. Pies, SUNY Upstate Medical University, 750 E. Adams St., Syracuse, NY 13210, USA. E-mail: [email protected]

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This claim has essentially the same syntactic structure as the first statement, but the two claims diverge in important ways. Syntactically, the term “end-stage anorexia” appears to be the same kind of designation as “end-stage renal disease”; but when analyzed closely, this proves to be a category error of the sort described by Ryle. Why is this so? According to Medicine.net, “end stage” refers to “the last phase in the course of a progressive disease. As in, end-stage liver disease, end-stage lung disease, end-stage renal disease, end-stage cancer, etc.” (Medicine.net 2012, italics added)

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Also, Mosby’s Medical Dictionary (2009) defines “end stage” as entailing “irreversible damage to vital tissues or organs”.

If we combine these two senses, we would posit that an “end stage” process entails (1) a characteristic temporal gradient, in which pathological changes reliably and predictably reach a terminus or maximum; and (2) actual and irreversible damage to vital tissues and organs. Yet when writers refer to “end stage” AN, they cannot point to a wellestablished temporal gradient of psychopathology that would allow one to say confidently, “This is the end of the process.” Unlike the well-documented and microscopically observable temporal changes that one can find in ESRD (Chatziantoniou et al. 2004), there is no comparably established time scale for AN’s “progression.” Patients with AN show a wide range of psychopathology, and a multitude of temporal changes and fluctuations—and arguably, each patient is unique in these respects. Thus, while many AN patients will indeed demonstrate a “neuropsychological inability to accept that their depleted weight is life-threatening,” as Dr. Geppert correctly notes, this is not the case with all AN patients. More to the point, we have no “lab test,” psychometric measure, or biomarker that allows us to say definitively that a particular AN patient’s impaired reality-testing (or denial of illness) is irreversible. Indeed, the potential for “reversibility” can almost never be ruled out in AN, since we can never eliminate the possibility that the patient will gain insight into her condition and the need for treatment—even in advanced and refractory cases. Accordingly, from the standpoint of medical ethics and the principle of beneficence, Dr. Geppert rightly observes that “the intrinsic value of life trumps the presumption that further treatment efforts will fail or ‘that treatment would inevitably be futile.’” Furthermore, even highly refractory and chronic AN does not necessarily result in “actual and irreversible damage to vital tissues and organs.” Of course, if starvation and inanition proceed past a certain point, the AN patient may indeed incur such organ and tissue damage as a complication of AN—but this is only a possible, not an inevitable, outcome of the patient’s psychopathology. It cannot be analogized to the inexorable histopathological deterioration in, say, ESRD, pancreatic cancer, or end-stage cirrhosis. Thus, in my view—and in this, I concur with Dr. Geppert—the term “end stage” is misapplied to AN. It is a

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Rylean category error, akin to applying the term “viviparous” to birds or reptiles. As Dr. Geppert argues, “Cases of chronic AN discussed in the literature represent examples of treatment-refractory illness, and not, as their authors posit them, models of end-stage psychiatric disorders for which futility judgments would be ethically warranted on medical grounds.”

FUTILTY AND VALUES Now, with respect to statement 2, consider the second italicized term, “futile.” Although potentially a value-neutral term—denoting some action that is simply “unproductive of success”—the term “futile” is freighted with negative connotations, for example, indicating an action “of no importance . . . useless; vain; worthless.” The term “futility” implicitly expresses a negative value judgment about the expenditure of time, effort, and perhaps money as well. Even if we define “futility” in operational terms— such as “the patient has failed to respond to all known effective treatments”—we cannot ignore the way the word “futility” is used and understood in ordinary language, as a term of derogation or depreciation.1 And ordinary language, in turn, can have powerful effects on the attitudes and behaviors of caregivers, leading, for example, to demoralization. (Imagine a team meeting of doctors and nurses at which the attending physician announces, “Ms. X, who has severe anorexia nervosa, has failed every treatment approach to date and denies that she has a life-threatening condition. Nevertheless, I am proposing that we try something futile.”) In my view, invoking the term “futile” may reflect not an objective medical determination, but rather the clinician’s frustration and feeling of impotence when treating the patient with refractory AN. In this sense, the label “futile” could be considered an indicator of negative countertransference, involving the reification of the clinician’s sense of despair.

CONSEQUENTIALIST VERSUS DEONTOLOGICAL ETHICS There is a further point to be made with regard to withholding putatively “futile” treatments. Any claim that treatment of highly refractory AN would be “futile”—and therefore, should be avoided—amounts to a consequentialist or utilitarian ethos. It justifies itself on the basis of certain outcome-related criteria: for exaxmple, whether the 1. There are of course instances in which the term “futility” or “futile” is grounded in secure and objective scientific knowledge, if not in “common sense.” Thus, if we say, “It is futile to administer cardiopulmonary resuscitation to a patient whose heart stopped beating two weeks ago and who shows no electrical activity in the brain,” we are arguably using “futile” in a straightforward, scientific sense. But the further we veer away from such objective and empirical data, the less scientific and more evaluative the term “futile” becomes.

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The American Journal of Bioethics

effort would be worth the time, energy, expenditure of resources, and so on. In contrast, a deontological (dutybased) ethos would stress the physician’s inherent duty and moral obligation to care for even the sickest and most treatment-resistant patient, regardless of the chances of success (Fieser n.d.). Indeed, absent medical follow-up, a strictly deontological ethos might view placing the socalled “end-stage” AN patient in a hospice as a form of abandonment on the part of the patient’s physicians—notwithstanding the argument of Lopez, Yager, and Feinstein (2010) that “Futility is not the withdrawal of all care, only the withdrawal of aggressive treatments; a shift of care from active treatment to palliative or comfort care.” That said, medical ethics generally embodies both consequentialist and deontological ethics, depending on the particular patient’s circumstances; accordingly, I do not wish to characterize conscientious hospice treatment (with medical follow-up and consultation) as “abandonment.” FUTILITY, SUBJECTIVITY, AND TEMPORALITY While various writers have proposed clinical/operational criteria for “medical futility” in AN (e.g., Lopez et al. 2010), there are no widely agreed upon standards for reaching such a determination. For example, Lopez and colleagues (2010) include among their criteria for palliative care a situation in which the patient “appear[s] to face an inexorably terminal course.” But how, exactly, is this “appearance” to be determined—by whom, and by means of what objective criteria? What appears “inexorable” to one clinician may appear merely probable to another. Moreover, the Lopez and colleagues criteria for palliative care in AN seem to view poor response to “competent treatment” thus far as justifying the prospective assumption that subsequent treatments will also be of no avail; this, in my view, is fallacious. Indeed, citing Kasman (2004), Lopez and colleagues (2010) define “medical futility” as “a clinical action serving no useful purpose in attaining a specified goal for a given patient.” But this definition applies only to a particular action at a particular time; logically and clinically, one cannot extrapolate from this to future actions—which, in theory, might well attain the desired therapeutic goal. Many of us working with chronically ill, treatment-refractory populations have witnessed multiple treatment failures in a given patient— often with three or more therapists or therapies—only to find that with the next treatment trial, the patient shows significant improvement. (I have personally witnessed this in patients with severe, chronic schizophrenia who responded almost miraculously to the atypical antipsychotic agent clozapine.)

premature.” And once we dispose of the misleading terms “futile” and “end stage” with respect to AN, contentious medical–ethical issues (e.g., guardianship, forced feeding, right to refuse treatment, hospice care, etc.) become amenable to the same considerations physicians weigh when treating any refractory psychiatric illness in which judgment is often impaired. To be sure, the assessment of mental competence in AN may be exceedingly difficult—but no more so than, for example, in patients with schizophrenia whose delusions are very subtle or hard to discern. In short, there is nothing unique about AN or its neuropsychological impairments, with regard to medical–ethical determinations. In conclusion, I believe Dr. Geppert is correct that “futility” in psychiatry is a concept whose time has not yet come—and perhaps never should. &

REFERENCES Chatziantoniou, C, J. J. Boffa, P. L. Tharaux, M. Flamant, P. Ronco, and J. C. Dussaule. 2004. Progression and regression in renal vascular and glomerular fibrosis. International Journal of Experimental Pathology 85(1): 1–11. http://dx.doi.org/10.1111/j.0959-9673. 2004.00376.x. Fieser, J. n.d. Ethics. In Internet encyclopedia of philosophy. Available at: http://www.iep.utm.edu/ethics/#SH2b. Geppert, C. M. A. 2015. Futility in chronic anorexia nervosa: A concept whose time has not yet come. American Journal of Bioethics 15(7): 34–43. Kasman D. 2004. When is medical treatment futile? Journal of General Internal Medicine 19: 1053–1056. http://dx.doi.org/10.1111/ j.1525-1497.2004.40134.x. Lopez, A., J. Yager, and R. E. Feinstein. 2010. Medical futility and psychiatry: Palliative care and hospice care as a last resort in the treatment of refractory anorexia nervosa. International Journal of Eating Disorders 43(4): 372–377 Medicine.net. 2012. Definition of end-stage. Accessed at: http:// www.medicinenet.com/script/main/art.asp?articlekeyD30946. Mosby’s Medical Dictionary. 2009. Definition of end-stage. 8th edi. Elsevier, Available at: http://medical-dictionary.thefreediction ary.com/end-stageCdisease. Oxford Dictionary of Philosophy. 1994. ed. S. Blackburn, 58. New York, NY: Oxford University Press. Stern D. G. 1995. Wittgenstein on mind and language. New York, NY: Oxford University Press. Tanney, J. 2015. Gilbert Ryle. In The Stanford encyclopedia of philosophy, ed. E. N. Zalta. Available at: http://plato.stanford.edu/ archives/spr2015/entries/ryle.

CONCLUSION

Webster’s Revised Unabridged Dictionary. Accessed at http://www. encyclo.co.uk/webster/F/90

I agree with Dr. Geppert that “futility judgments in chronic AN are empirically precarious and ethically

Wittgenstein L. 2001. Philosophical investigations. Malden, MA: Blackwell.

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July, Volume 15, Number 7, 2015

Anorexia Nervosa, "Futility," and Category Errors.

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