From the Editor
This issue of the Report is bookended by two pieces that take contrasting—although perhaps compatible—positions on medical care for those in dire straits. At the end of the issue is an article that considers whether patients may be denied admission to intensive care units on grounds that they are too sick to benefit. We think of ICUs as reserved for the sickest of the sick, notes author Andrew Courtwright, but in fact, “too sick to benefit” is an increasingly common reason given for not putting a patient in the ICU. In fact, according to recent studies Courtwright cites, “too sick to benefit” is the rationale for between 19 and 37 percent of denials of admission.
The problem Courtwright addresses is that the description “too sick to benefit” is too vague to be used reliably. The rough idea is that some diseases are such that patients get steadily worse no matter what care is rendered, and for these patients, ICU care is burdensome and pointlessly costly. Yet because the idea is still quite rough, triage on that basis is done case by case, and nonclinical matters, such as the patient's quality of life before getting to the hospital, sometimes get factored in. Courtwright, a physician, proposes that the criteria for “too sick to benefit” can be clarified by drawing on a concept originally developed in neonatalogy—namely, “lethality.” The definition belies the name, to some degree, though: the idea of lethality is not just that a disease has a high mortality rate, but that its mortality rate is not significantly affected by the level of care the patient receives.
Meanwhile, the first essay in the book tells the story of a man whose physician more or less told him he was too sick to benefit (under some understanding of the idea) and should opt for death. There are several pieces of information that are critical in the story. Author William Peace, an anthropologist by training, is also the author of the blog Bad Cripple; he has been partially paralyzed since 1978 and was in the hospital for treatment of a large open wound. The physician was a man Peace had never met, but who immediately cleared the room and then, in the middle of-the-night solitude, encouraged Peace to contemplate his miserable fortunes and choose death.
Peace would surely be wary of any physician who began talking about patients who are too sick to benefit from intensive care. On the other hand, “too sick to benefit” as examined by Courtwright is not the same as the “too crippled to benefit” wielded by Peace's physician. Indeed, Courtwright's goal is precisely to eliminate the kinds of considerations that Peace's physician seems to have had in mind. Also, the conclusion Peace's physician was urging is eliminated: Courtwright does not suggest that “too sick to benefit” can be used to choose death. Although by clarifying “too sick to benefit” Courtwright is in some sense defending it, he points out that clarifying it along the lines he proposes might well end up limiting its use to a narrower range of cases. His goal is not to cut down on ICU admissions, though, but to avoid ICU admissions that do nobody any good.
One might also hope that no physician ever talked to a patient (or a surrogate) about lethality using the bedside manner of Peace's physician.
In the coming weeks, The Hastings Center's blog, Bioethics Forum, will feature a moderated discussion of Peace's essay, the experience he endured, and what it can tell us about decisions to forego treatment. —GEK