THE PROBLEM OF OVERTREATMENT
Giving patients more treatment than is medically appropriate is bad for everyone. It is first and foremost bad for the patient. For example, futile attempts at CPR can result in cracked ribs, hasty intubation can damage the trachea, and iatrogenic effects are associated with many other medical procedures. When patients are heavily sedated or unconscious, overtreatment can be dehumanizing. It treats the patient not as a person we are trying to help, but as a body, or body part, where we are trying to produce an effect:
get the heart beating, make the lungs breath, hydrate and nourish the body. When the justification for treating the patient is to meet the demands of family members who insist on “doing everything,” this exploits the patient. In the broadest sense, to exploit someone means to take unfair advantage of them (Wertheimer, 1996). On a Kantian analysis, the problem with exploitation is that it violates the dignity of the patient. Kant held that persons have an inherent worth and dignity, and therefore must always be treated as ends, and never as means only. If the patient is treated solely as a means to realize others' (e.g., a loved one's) ends, this violates the requirement to respect persons.
For family members, overtreating the patient does a different kind of damage. As long as a loved one is aggressively treated, it becomes psychologically more difficult to face and accept the reality of the patient's impending death or deterioration. As Martin (2008) notes, hope plays a framing role in relation to our uptake, interpretation, and deliberative use of information. In this manner, hope can lead families to ignore or downplay the fact that treatment is not producing a desired state of affairs. Health professionals unwittingly encourage such an approach when they continue treatment against all odds based on vague and unsubstantiated ideas, such as the idea that optimism or a “fighting spirit” benefits the patient's health, or is life-prolonging (Schneiderman, 2005). Overtreatment can also create an ethical force all its own, leading those who surround the patient to conclude that the right thing to do is “everything,” or that fighting the disease is always the best, most honorable ideal. In the grips of such ideas, holding back and doing less can become exceedingly difficult. For family members, doing less may seem like a failure to love the patient enough, or to meet one's family obligation. Such an ethic ignores the fact that there are other, better ways to care for patients. Health professionals can model more appropriate caring by emphasizing palliative and comfort measures, and by assuring family members that their loved one will not be abandoned.
Finally, overtreatment is bad for providers because it undermines their integrity as health professionals, representing a breach of the duty to advocate on behalf of the patient's best interests. It is not surprising that overtreatment creates “moral distress” for providers, understood as the suffering that occurs when the right course of action is known but cannot be carried out because of institutional or other constraints (Jameton, 1984; Wilkinson, 1987). Moral distress in this situation arises because providers fail to uphold professional standards of care, which require doing what is in the patient's best interest and avoiding harm to the patient.
Moral distress is not just a “bad feeling.” It has been demonstrated to be seriously detrimental to the provider's family relationships and professional performance, culminating in a loss of focus, reduced patience, and burnout (McClendon & Buckner, 2007; Meltzer & Huckabay, 2004). It affects physical well-being, self-image, spirituality, personal relationships, and job
satisfaction (Elpern, Covert, & Kleinpell, 2005; Silen, Tang, Wadensten, & Ahlstrom, 2008; Wilkinson, 1987). Physical symptoms include heart palpitations, diarrhea, headaches, fatigue, and insomnia (Elpern et al., 2005; Silen et al., 2008; Wilkinson, 1987). A hallmark of moral distress is often an external and uncontrollable circumstance preventing an individual from doing the right thing (Russell, 2012; Webster & Baylis, 2000). One example of an external circumstance frustrating a provider's attempt to withhold or withdraw treatment might be a family member's demands to “do everything.” Another might be fear of a legal challenge by family members if treatment is withdrawn or withheld. Situations involving the provision of heroic interventions to attempt to save terminal and dying patients are associated with some of the highest levels of moral distress (Elpern et al., 2005; McClendon & Buckner, 2007). Although nurses are particularly vulnerable, any provider can experience moral distress when overtreating a patient (Russell, 2012).
Understanding overtreatment requires not only specifying why it is a problem, but also how it relates to other problems that arise in the care of critically ill and dying patients. There is a close connection between the problem of overtreatment and the provision of futile interventions. The American Medical Association (1999) describes futile treatment as involving aggressive treatment to sustain life in individuals that are not likely to survive or achieve a successful outcome. So defined, using a futile intervention is a sufficient condition for overtreatment. Futility itself is closely linked to the psychological phenomenon of moral distress discussed above. While moral distress can arise in a variety of contexts, evidence suggests that it is most often preceded by incidents of futile treatment (Mobley, Rady, Verheijde, Patel, & Larson, 2007).
However, medical futility and overtreatment do not mean exactly the same thing. There are instances where overtreatment occurs without the use of futile interventions. For instance, an aggressive but beneficial surgery may qualify as overtreating the patient because a less aggressive and equally beneficial method of treatment, such as medical management, is available. Here, the surgery helps the patient and so it does not meet the definition of medical futility; however, the surgery does count as an instance of overtreatment.
There is a close connection between overtreatment and threats to the professional integrity of health care providers. This arises because physicians and other health care providers have a beneficence-based obligation to do what is best for their patient. When providers feel compelled to act in violation of this professional value, it undermines their professional integrity. “Integrity” in this sense refers to acting in accordance with one's most fundamental moral values and commitments. Williams (1981) describes a person of integrity as someone whose moral dispositions are so deeply ingrained and whose moral principles are so firmly held that the person
nearly always acts in accordance with them. Not only is integrity undermined by continuing with inappropriate or futile medical interventions, such interventions can also distract the medical team from focusing on palliative care options that would truly benefit the patient. The failure to do the right thing is compounded when the provider not only uses treatments that are not helping the patient, but also refrains from the aggressive use of beneficial, palliative care options.
Of course, a provider may also overtreat a patient without any loss of integrity or feeling of moral distress. A self-assured provider, for example, may confidently pursue futile interventions because the provider sees the use of high-technology instruments is an end in itself, perhaps enhancing professional self-image and increasing self-esteem. Or, economic incentives may create a climate where it becomes normal for providers to perform procedures with the goal of gaining reimbursement, regardless of whether those procedures actually help the patient or are in the patient's best interests. When an economic model replaces traditional beneficence, providers come to regard fees as the goal of services and may be less likely to feel moral distress about overtreatment because it aligns with this goal. However, in both of these instances, providers are exploiting the patient. Exploitation in this instance builds on the Kantian idea noted above; it involves not only a purely instrumental utilization of a person for one's own advantage, or for the sake of one's own ends, but also a utilization that clearly harms the patient (Buchanan, 1985). In these instances, there is no ethical justification for overtreatment, and the goal of helping the sick should be reinstated.
History of the Problem
The interrelated problems of overtreatment, medical futility, and moral distress have become ubiquitous in health care. It is easy to forget that this was not always the case. For example, if we look back to the 1970s and 1980s, the legal and bioethical cases gaining attention were more likely to involve situations where patients or families asked to withdraw treatment, and the health care institution either felt it was improper to do so, or wanted legal immunity first. So, for example, in In Re Quinlan (1976), the family requested that treatment be stopped despite misgivings on the part of the institution. Likewise in Saikewicz (1977), Brophy (1986), Conroy (1985), Cruzan (1990), and other cases during this time, patients or family members requested that treatment be withheld or withdrawn.
During the decade of the 1990s we witnessed a reversal of this trend. Cases such as Wanglie (Angell, 1991; Miles, 1991), Baby K (1993), Baby Ryan (Kolata, 1994), Hamilton (Anonymous, 1994), and Gilgunn (1995) dealt with situations in which the patient, or more often the family, wished to do
everything possible for a loved one. Thus, in Wanglie, the family wished to persist with treatment of an 86-year-old woman in a persistent vegetative state over the objections of doctors at Hennepin County Medical Center who wanted the patient removed from the respirator. Wanglie believed that life should be maintained as long as possible, no matter what the circumstances, and asserted that his wife, Helga Wanglie, shared his belief.
As noted already at the beginning of this chapter, there is ample evidence, beginning with Solomon's study in 1993, that health care professionals are concerned that the treatments they provide to patients at the end of life (EOL) are overly burdensome and that they are practicing more aggressively than they should. This is bad for patients and families, and creates moral distress among providers.