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Commentary
Too much of a good thing Zohar Lederman Primi Ranola and James Kirkpatrick call for a change in the way we manage cardiopulmonary resuscitation (CPR). They recommend an approach that is specifically tailored to each individual, where persons will be asked to include in their advance directive precise and detailed information in case they would undergo CPR in the future. Such information will include their wishes regarding whether to be coded, which methods to be employed during the code, the maximal duration of the code, etc. The authors conclude, “…a tailored approach to resuscitation, with a clear recommendation from the provider, based on both the clinical picture and what can be gleaned from the patient’s values, would likely both support autonomous decision-making and avoid at least some unnecessary irrational resuscitative measures…”.1 Consider the following scenario. You go to see your primary care physician, and together you decide to draft some sort of advance directive. The physician first asks if you would want to be resuscitated, to which you reply “yes, of course.” Next, she asks if you would want your relatives to be present during CPR, to which you reply, “yes, of course.”2 She types in your responses, and continues: “would you want to receive electrical shocks and if so what is the maximal number of shocks you would like to receive?” You think to yourself what an odd question and respond hesitantly, “yes I guess I would want to receive shocks. How many? I don’t know; how many do you usually give?” The barge of questions continues: how long do you want your resuscitation to last? how many healthcare professionals do you want treating you? what do you want to be the colour of the beddings? Eventually, you can only respond with an incredulous stare—how do you know which drugs you want to be administered? Clearly, healthcare should be governed first and foremost by patients’ autonomy. Their wishes and decisions should be respected as much as possible, even if Correspondence to Dr Zohar Lederman, Centre for Biomedical Ethics, National University of Singapore, Singapore 129790, Singapore; [email protected]
healthcare professionals do not approve. Some patients will want more control over their healthcare than others and healthcare professionals should modify their involvement in a specific case based on their interpretation of the specific context.3 4 However, Primi and Kirkpatrick overlook an important distinction between the goals held by patients and what patients perceive as means to achieve these goals.5 When patients go to the doctor, they do so for a reason. Hopefully, they have a goal in mind and they want their doctor to help them achieve that goal. Some patients are actually not clear about their goals, and in this case the doctor should help them and/ or their families to ascertain these goals. Staying alive, being pain-free, treating a wound, etc. are some possible goals. These goals depend on patients’ individual values; one wants to stay alive because one values life as important, the same way one values life without pain as important.6 7 Since patients’ goals hinge upon their values, healthcare professionals as such have no special expertise;5 they may provide some good advice as how to best live life, but it would not be something they learnt during medical school or from medical textbooks. When it comes to the means to best achieve patients’ goals, physicians do possess a special expertise, which they acquired through their studies and professional experience. Potentially, they know best how to prolong your life, how to treat your illness and how to reduce your pain. Physicians may be wrong about the best medical approach, of course, but overall they are more likely than lay people to get it right—particularly if they follow guidelines.8 To apply the distinction to the paper, the authors seem to equate a decision on the number of shocks given to a decision whether to use emergency cardiopulmonary bypass (ECPB). They claim that, “[o] ther patients might gladly welcome ECPB to allow them to become organ donors.” 1 But the comparison is inaccurate. The number of shocks is nothing but a means to an end: staying alive and/or maintaining cognitive abilities. Conversely, according to the authors, ECPB is a means for a different end altogether: donating one’s organs. Patients should be asked and inform
Lederman Z. J Med Ethics August 2015 Vol 41 No 8
healthcare professionals about their ends (and their values for which they seek these ends) but not about the means to achieve these ends; “would you want to be resuscitated” is a question about ends, while “how many shocks” and “how long” are questions about means. Oddly, Primi and Kirkpatrick do seem to be aware of the means–end distinction. Despite their overall argument, they sensibly acknowledge that, “[s]uch plans should not include measures that make no physiological sense…or are otherwise highly unlikely to achieve desired outcomes…resuscitative measures which may have temporary physiological effect but little chance of long term benefit may be discussed and discarded without being formally offered.” This acknowledgement leaves the reader wondering—how would the authors respond to a patient who wants to extend the duration of CPR to 1 h or 2 h? And what about a patient who wants to receive 50 mg of epinephrine (much more than common practice) or no less than 80 electrical shocks? I agree with the authors that patients should be able to make decisions based on what they deem to be valuable and that healthcare professionals should respect these decisions regardless of their own attitudes. I also agree that patients should receive all the relevant information to allow them to make informed decisions. But too much information and too much autonomy are too much of a good thing.9–11 Correction notice This article has been corrected since it was published Online First. The first name in the opening sentence was corrected. Competing interests None. Provenance and peer review Commissioned; internally peer reviewed.
To cite Lederman Z. J Med Ethics 2015;41:667–668. Received 19 September 2014 Accepted 29 September 2014 Published Online First 23 October 2014
▸ http://dx.doi.org/10.1136/medethics-2013-101949 J Med Ethics 2015;41:667–668. doi:10.1136/medethics-2014-102442
667
Downloaded from http://jme.bmj.com/ on October 23, 2017 - Published by group.bmj.com
Commentary REFERENCES 1
2
3
668
Ranola PA, Merchant RM, Perman SM, et al. How long is long enough, and have we done everything we should?Ethics of calling codes. J Med Ethics 2015;41:663–6. Lederman Z, Garasic M, Piperberg M. Family presence during cardiopulmonary resuscitation: who should decide? J Med Ethics 2014;40:315–19. Emanuel EJ, Emanuel LL. Four models of the physician-patient relationship. JAMA 1992;267(16): 2221–6.
4
5
6
7
Sulmasy DP, Snyder L. Substituted interests and best judgments. An integrated model of surrogate decision making. JAMA 2010;304(17):1946–7. Groll D. What healthcare providers know: a taxonomy of clinical disagreements. Hastings Cent Rep 2011;41(5):27–36. Khan SA, Gomes B, Higginson IJ. End-of-life care— what do cancer patients want? Nat Rev Clin Oncol 2014;11:100–8. Sulmasy DP. Speaking of the value of life. Kennedy Inst Ethics J 2011;21(2):183.
8
9
10 11
Cabana MD, Rand CS, Powe NR, et al. Why don’t physicians follow clinical practice guidelines. JAMA 1999;282(15):1458–65. Callahan D. Autonomy: a moral good, not a moral obsession. Hastings Cent Rep 1984;14: 40–2. Schwartz PA. Questioning the quantitative imperative. Hastings Cent Rep 2011;41:230–9. Lederman Z, Piperberg M. The struggle for autonomy: too much, too little or not at all? Cuad Bioét 2012;XXIII(1):233–5.
Lederman Z. J Med Ethics August 2015 Vol 41 No 8
Downloaded from http://jme.bmj.com/ on October 23, 2017 - Published by group.bmj.com
Too much of a good thing Zohar Lederman J Med Ethics 2015 41: 667-668 originally published online October 23, 2014
doi: 10.1136/medethics-2014-102442 Updated information and services can be found at: http://jme.bmj.com/content/41/8/667
These include:
References Email alerting service
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This article cites 11 articles, 2 of which you can access for free at: http://jme.bmj.com/content/41/8/667#BIBL Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article.
Articles on similar topics can be found in the following collections Research and publication ethics (490) General practice / family medicine (94) Hospice (121)
Notes
To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/
Commentary
Too much of a good thing Zohar Lederman Primi Ranola and James Kirkpatrick call for a change in the way we manage cardiopulmonary resuscitation (CPR). They recommend an approach that is specifically tailored to each individual, where persons will be asked to include in their advance directive precise and detailed information in case they would undergo CPR in the future. Such information will include their wishes regarding whether to be coded, which methods to be employed during the code, the maximal duration of the code, etc. The authors conclude, “…a tailored approach to resuscitation, with a clear recommendation from the provider, based on both the clinical picture and what can be gleaned from the patient’s values, would likely both support autonomous decision-making and avoid at least some unnecessary irrational resuscitative measures…”.1 Consider the following scenario. You go to see your primary care physician, and together you decide to draft some sort of advance directive. The physician first asks if you would want to be resuscitated, to which you reply “yes, of course.” Next, she asks if you would want your relatives to be present during CPR, to which you reply, “yes, of course.”2 She types in your responses, and continues: “would you want to receive electrical shocks and if so what is the maximal number of shocks you would like to receive?” You think to yourself what an odd question and respond hesitantly, “yes I guess I would want to receive shocks. How many? I don’t know; how many do you usually give?” The barge of questions continues: how long do you want your resuscitation to last? how many healthcare professionals do you want treating you? what do you want to be the colour of the beddings? Eventually, you can only respond with an incredulous stare—how do you know which drugs you want to be administered? Clearly, healthcare should be governed first and foremost by patients’ autonomy. Their wishes and decisions should be respected as much as possible, even if Correspondence to Dr Zohar Lederman, Centre for Biomedical Ethics, National University of Singapore, Singapore 129790, Singapore; [email protected]
healthcare professionals do not approve. Some patients will want more control over their healthcare than others and healthcare professionals should modify their involvement in a specific case based on their interpretation of the specific context.3 4 However, Primi and Kirkpatrick overlook an important distinction between the goals held by patients and what patients perceive as means to achieve these goals.5 When patients go to the doctor, they do so for a reason. Hopefully, they have a goal in mind and they want their doctor to help them achieve that goal. Some patients are actually not clear about their goals, and in this case the doctor should help them and/ or their families to ascertain these goals. Staying alive, being pain-free, treating a wound, etc. are some possible goals. These goals depend on patients’ individual values; one wants to stay alive because one values life as important, the same way one values life without pain as important.6 7 Since patients’ goals hinge upon their values, healthcare professionals as such have no special expertise;5 they may provide some good advice as how to best live life, but it would not be something they learnt during medical school or from medical textbooks. When it comes to the means to best achieve patients’ goals, physicians do possess a special expertise, which they acquired through their studies and professional experience. Potentially, they know best how to prolong your life, how to treat your illness and how to reduce your pain. Physicians may be wrong about the best medical approach, of course, but overall they are more likely than lay people to get it right—particularly if they follow guidelines.8 To apply the distinction to the paper, the authors seem to equate a decision on the number of shocks given to a decision whether to use emergency cardiopulmonary bypass (ECPB). They claim that, “[o] ther patients might gladly welcome ECPB to allow them to become organ donors.” 1 But the comparison is inaccurate. The number of shocks is nothing but a means to an end: staying alive and/or maintaining cognitive abilities. Conversely, according to the authors, ECPB is a means for a different end altogether: donating one’s organs. Patients should be asked and inform
Lederman Z. J Med Ethics August 2015 Vol 41 No 8
healthcare professionals about their ends (and their values for which they seek these ends) but not about the means to achieve these ends; “would you want to be resuscitated” is a question about ends, while “how many shocks” and “how long” are questions about means. Oddly, Primi and Kirkpatrick do seem to be aware of the means–end distinction. Despite their overall argument, they sensibly acknowledge that, “[s]uch plans should not include measures that make no physiological sense…or are otherwise highly unlikely to achieve desired outcomes…resuscitative measures which may have temporary physiological effect but little chance of long term benefit may be discussed and discarded without being formally offered.” This acknowledgement leaves the reader wondering—how would the authors respond to a patient who wants to extend the duration of CPR to 1 h or 2 h? And what about a patient who wants to receive 50 mg of epinephrine (much more than common practice) or no less than 80 electrical shocks? I agree with the authors that patients should be able to make decisions based on what they deem to be valuable and that healthcare professionals should respect these decisions regardless of their own attitudes. I also agree that patients should receive all the relevant information to allow them to make informed decisions. But too much information and too much autonomy are too much of a good thing.9–11 Correction notice This article has been corrected since it was published Online First. The first name in the opening sentence was corrected. Competing interests None. Provenance and peer review Commissioned; internally peer reviewed.
To cite Lederman Z. J Med Ethics 2015;41:667–668. Received 19 September 2014 Accepted 29 September 2014 Published Online First 23 October 2014
▸ http://dx.doi.org/10.1136/medethics-2013-101949 J Med Ethics 2015;41:667–668. doi:10.1136/medethics-2014-102442
667
Downloaded from http://jme.bmj.com/ on October 23, 2017 - Published by group.bmj.com
Commentary REFERENCES 1
2
3
668
Ranola PA, Merchant RM, Perman SM, et al. How long is long enough, and have we done everything we should?Ethics of calling codes. J Med Ethics 2015;41:663–6. Lederman Z, Garasic M, Piperberg M. Family presence during cardiopulmonary resuscitation: who should decide? J Med Ethics 2014;40:315–19. Emanuel EJ, Emanuel LL. Four models of the physician-patient relationship. JAMA 1992;267(16): 2221–6.
4
5
6
7
Sulmasy DP, Snyder L. Substituted interests and best judgments. An integrated model of surrogate decision making. JAMA 2010;304(17):1946–7. Groll D. What healthcare providers know: a taxonomy of clinical disagreements. Hastings Cent Rep 2011;41(5):27–36. Khan SA, Gomes B, Higginson IJ. End-of-life care— what do cancer patients want? Nat Rev Clin Oncol 2014;11:100–8. Sulmasy DP. Speaking of the value of life. Kennedy Inst Ethics J 2011;21(2):183.
8
9
10 11
Cabana MD, Rand CS, Powe NR, et al. Why don’t physicians follow clinical practice guidelines. JAMA 1999;282(15):1458–65. Callahan D. Autonomy: a moral good, not a moral obsession. Hastings Cent Rep 1984;14: 40–2. Schwartz PA. Questioning the quantitative imperative. Hastings Cent Rep 2011;41:230–9. Lederman Z, Piperberg M. The struggle for autonomy: too much, too little or not at all? Cuad Bioét 2012;XXIII(1):233–5.
Lederman Z. J Med Ethics August 2015 Vol 41 No 8
Downloaded from http://jme.bmj.com/ on October 23, 2017 - Published by group.bmj.com
Too much of a good thing Zohar Lederman J Med Ethics 2015 41: 667-668 originally published online October 23, 2014
doi: 10.1136/medethics-2014-102442 Updated information and services can be found at: http://jme.bmj.com/content/41/8/667
These include:
References Email alerting service
Topic Collections
This article cites 11 articles, 2 of which you can access for free at: http://jme.bmj.com/content/41/8/667#BIBL Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article.
Articles on similar topics can be found in the following collections Research and publication ethics (490) General practice / family medicine (94) Hospice (121)
Notes
To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/
