Futile treatment - when is enough, enough?

Objective This paper examines two aspects of treatment decision making: withdrawal of treatment decisions made by a patient; and decisions to not proceed with treatment by a health professional. The paper aims to provide an overview of the law relating to the provision of treatment, then highlight the uncertainty as to the meaning of and costs associated with futile treatment. Methods The paper reviews the current legal and medical literature on futile treatment. Results Continuing treatment which is futile is not in the patient's best interests. Futility may be understood in both quantitative and qualitative terms. Recent legal cases have expanded the definition of futility to focus not on the nature of the treatment itself, but also on the health of the patient to whom treatment is provided. Conclusions As Australia's population ages, there is likely to be an increased focus on the allocation of scarce health resources. This will, inevitably, place constraints on the number and variety of treatments offered to patients. The level of constraint will be felt acutely where a proposed treatment offers little clinical efficacy. It is time to try to understand and agree on a workable definition of futility.

Road not taken: lessons to be learned from Queen v. Gillett.

Following the decision in the Gillet Case it may no longer be safe to rely on the Austroads guidelines when considering fitness to drive. This paper examines the case and its implications. Although the Guidelines claimed '... the identification and application of world best-practice...', they were disregarded by the court in Gillet. Both expert witnesses testified that on disclosure of epilepsy the accused would have been endorsed as fit for a licence application to the Roads & Traffic Authority, on the basis of 10 years of only nocturnal seizures, in accordance with the guidelines. The Court rejected this evidence and interpreted failure to disclose epilepsy as recognition of perceived risk and the previously undiagnosed sleep apnoea as the basis for that risk, despite being diagnosed after the accident. There needs to be greater certainty in the application of the guidelines, with legislative intervention and licenses should display a bold statement advising drivers of their responsibility to notify authorities of illnesses that could potentially affect driving.

Guardianship and consent.

It has been argued elsewhere that "consent is the hallmark of our health care system". If this is correct, then what is the position of those who are not capable of deciding whether (or not) to give consent to health care? This paper briefly examines the law and ethics of substitute decision-making. Its principal arguments are three. Firstly, that because exercising a choice (or exercising one's autonomy) presupposes the capacity to do so, there are an increasing number of people who are not capable of exercising their autonomy in health care settings. Second, that as they are not capable of making an autonomous choice, the law permits another fundamental bioethical principle, that of beneficence, to operate so as to ensure that such people are not denied treatment which they may need. This principle is reflected in the use of Guardianship tribunals. Finally, very brief comment is made on the leading difficulty in this field, which is ascribing a clear meaning to the term competency--the standard which separates the people who are permitted to exercise an autonomous choice, and those not permitted to do so.

Can children withhold consent to treatment?

A dilemma exists when a doctor is faced with a child or young person who refuses medically indicated treatment. The Gillick case has been interpreted by many to mean that a child of sufficient age and intelligence could validly consent or refuse consent to treatment. Recent decisions of the Court of Appeal on a child's refusal of medical treatment have clouded the issue and undermined the spirit of the Gillick decision and the Children Act 1989. It is now the case that a child patient whose competence is in doubt will be found rational if he or she accepts the proposal to treat but may be found incompetent if he or she disagrees. Practitioners are alerted to the anomalies now exhibited by the law on the issue of children's consent and refusal. The impact of the decisions from the perspectives of medicine, ethics, and the law are examined. Practitioners should review each case of child care carefully and in cases of doubt seek legal advice.