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March 16, 2007
Determining survival
Sometimes intervention is folly, says doctor.
RON FRIEDMAN
Technological and medical advances have enabled doctors to save
lives at increasingly earlier stages of childbirth. Whether or not
they should do so was the topic for debate during When Doctors Say
No, a Philosopher's Café at the Vancouver Jewish Community
Centre last weekend.
The discussion was moderated by Rabbi Laura Duhan Kaplan. Dr. Susan
Albersheim, who has been working at the neonatal intensive care
nursery at British Columbia Children's and Women's Hospital for
more than 20 years, was the guest speaker.
Albersheim noted that the normal gestation period for humans is
between 37 and 40 weeks. But the chances for successful intervention
at an earlier stage has increased dramatically.
"Years ago, we said 28 weeks was the limit [at which to intervene]
and now, we're going down to 23, 24, 25 weeks," said Albersheim.
"One of the major issues I deal with is the threshold of viability.
When I say, 'When doctors say no,' I'm talking about doctors saying:
'We will not provide this kind of a treatment.' "
Currently, the accepted threshold stands at roughly 22 weeks. "We
will not start treatment at 20 or 21 weeks," said Albersheim.
"There is a general agreement, around the world, that [that]
would not be something we can do, so that's a definite no."
Albersheim introduced the concept of futility. "It's very sad,"
she conceded, "and it's very heart-wrenching to sit there and
say, 'No, we cannot do anything at that gestational age,' but there
are some absolute limits."
She distinguished between two types of futility: physiological futility,
which means that a certain treatment cannot cure this particular
problem, and evaluative futility, which means that if you start
a certain treatment, the outcome will be a bad one, resulting in
a severe handicap that will limit the quality of life of the child.
"We feel that it is our responsibility as medical professionals
to set limits and to say that we have responsibility for outcome
and if there is no chance of having a normal outcome, it is not
reasonable to start, because the harms are great," said Albersheim.
"At very young ages, it's not just a matter of, you treat.
There are major consequences to starting treatment.
"In our institution, we have no babies at 22 weeks that are
considered in the normal range. All of them that have survived,
which are very few, have handicaps and, therefore, we looked at
this carefully and decided that we will not start treatment at 22
weeks."
The discussion of thresholds is not limited solely to neonatal decisions.
"Though I'm speaking about the beginning of life, a lot of
the issues are similar throughout the life-span," said Albersheim.
"Though it's the not-yet competent that I'm dealing with, later
on in life, it is often the no longer competent, and though you
have certain nuances that are slightly different at the other extreme
of life, you do have a lot of the same major issues that come up."
Deciding who gets to weigh in on the decision is an important issue.
One obvious factor is the parents' wishes. Albersheim noted that
parents have a tendency to say, "Do everything," but often
it is a question of whether to do everything possible or simply
everything reasonable.
"Doing everything possible may well be an attitude that results
in something that is both inhumane and wasteful," said Albersheim.
In Canada, another factor that plays a part is the issue of finite
resources and their distribution. "We have a different health-care
system and we don't necessarily have the obligation just for one
patient, and they [parents] don't necessarily have a right to demand
everything, because we only have a finite amount of money in our
health-care budget," said Albersheim. "So far, it's been
the system of 'the squeaky wheel': whoever complains the loudest
gets the money, but things will change, probably, and we have to
consider it, up front, and not wait for it to be a crisis in order
to really think about it very carefully."
Another aspect that arose in the discussion was the issue of religious
beliefs affecting both doctors and patients.
"The bottom line in Jewish medical ethics is, of course, preserve
life and promote life and that no one can judge quality of life
for another person," said Kaplan. "If it is within your
means to provide treatment, then you have a duty to do it. However,
based on current halachic thinking, the way that you judge whether
you are able to provide something or not is not based on outcome
– it's based on your time and your resources."
Albersheim said that when dealing with medical issues, "I park
my Judaism outside."
Ron Friedman is a student in the journalism master's program
at the University of British Columbia.
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