to the editor: In the “Curbside Consultation”1 that appeared in the May 1, 2003 issue of American Family Physician, Dr. Putnam gives a careful analysis of a difficult case involving the decision to resuscitate a patient against her wishes. He discusses the data that were available at the time of the decision and points out what additional information might be useful. Although I generally agree with his position, I would like to raise two important additional points.
First, the initial case presentation states that the “hospital’s ethics committee was consulted, and the determination was made that it would be prudent to follow the niece’s wishes about decision-making for her aunt.”1 Dr. Putnam does not provide any further information about the committee’s debate or conclusion, but what is important is that this conclusion is not an ethical claim. The committee concluded that it would be “prudent” to treat this patient against her will, not that it would be “right”; and while this was likely a safer course legally, that bears little impact on whether it was right. Dr. Putnam states that “an ethics committee should address ethical standards and legal precedents,”1 but this is far too weak a criticism of what seems (in the absence of any contrary information) to be no more than a defense against a possible lawsuit masked as a statement of ethics. An ethics committee must give ethical advice, not mere legal or prudential advice, and the members of that committee cannot forget that their conclusions are meant to assist people struggling with a serious moral decision. A decision from the ethics committee lends credence, just by its existence, to the moral correctness of that decision. This is a responsibility that an ethics committee cannot take lightly, as it seems the committee in this article may have done.
Secondly, Dr. Putnam correctly notes that cardiopulmonary resuscitation (CPR) can be futile care when the burdens of it outweigh the benefits; however, he also suggests that the decision to administer CPR should be made by physicians without family involvement in order to “protect a family from the possibility of tremendous guilt associated with making [such] a choice.”1 Not only is such a policy potentially dangerous, both legally and morally (What happens when a family member chats with a friend who is a physician, and innocently asks whether CPR was attempted?), but it is unnecessary in this case. The patient had clearly indicated in the preceding two years that, to her, the benefits of CPR in her current condition would not outweigh the burdens. Based on the understanding that this patient had arrived at in consultation with her family physician, CPR can properly be labeled as futile in this case. No physician should take the responsibility of weighing those benefits and burdens in cases such as this, because the responsibility had already been taken by the patient.
editor’s note: This letter was sent to the author of “Do I Have to Resuscitate This Patient Against Her Wishes?,” who declined to reply.