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Futile treatment, junior doctors and role virtues
  1. Rosalind McDougall
  1. Correspondence to Rosalind McDougall, Centre for Health and Society, University of Melbourne VIC 3010, Australia; rosjmcdougall{at}gmail.com

Abstract

Futile treatment is one ethically challenging situation commonly encountered by junior doctors. By analysing an intern's story using a role virtues framework, I propose a set of three steps for junior doctors facing this problem. I claim that junior doctors ought always to investigate the rationale underlying decisions to proceed with apparently futile treatment and discuss their concerns with their seniors, even if such discussion will be difficult. I also suggest that junior doctors facing this ethical challenge ought always to be willing to initiate and engage in ethical dialogue, and that in some situations further action (such as taking concerns outside the team or refusing to participate in treatment) may be morally appropriate.

  • Futility
  • junior doctors
  • internship
  • roles
  • virtue ethics
  • applied and professional ethics
  • education for healthcare professionals
  • care of the dying patient

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This story was told by Nicole (a pseudonym), during an interview for an Australian study of junior doctors' ethical challenges.1 Several details have been altered to protect patient confidentiality.As the night team, all you're trying to do is to maintain status quo and pretty much follow the treating team's plans, and get your patients safely through to morning at which time the treating team can make some more decisions during the day.I had this old guy, Eastern European, he was very elderly. And he spoke some English but not a great deal. And he'd come with an old person infection. I think he'd had a UTI [urinary tract infection] or a pneumonia or something, that really potentially might have been treatable and then maybe he might have needed some nursing home care or something. But during, I think on about the fourth day of his admission while he was getting some antibiotics and fluids, he got confused in the middle of the night, you know, as really elderly people with an infection do. Especially when they're in hospital and it's the middle of the night. And he'd got up and wandered into a utility room, a pan room, thinking it was the bathroom and peed. And then slipped in it and broken his hip. So it was just a big disaster…It was another intern who was taking care of the unit at that time, so I was aware of this guy, that he'd fallen over and broken his hip and he'd got a hip replacement.By the time I was on nights he was post-op[erative]. And he was about a week post-op and still doing very badly - really not eating anything, still constantly delirious. The impression that I got was that the treating team had pretty much given up on him. I'd be called to him every night because he hadn't had enough fluid that day. I'd try and put a drip in and he'd rip it out. After I think the first or second time I just didn't want to put drips in him anymore because he'd really hurt himself. His skin was so thin that he'd ripped off a whole big flap on his hand when he'd got confused and pulled the drip out. And he was still confused so it was a fair bet that exactly the same thing would happen again. And he wasn't eating anything so he was severely malnourished. Someone had also put a urinary catheter in him, which he'd also pulled out and tore his urethra and so then every night I would get calls about him because he hadn't had enough fluid or he was bleeding from his penis again because some bright spark had put a catheter in which he'd ripped out. And I just was getting so frustrated because we were just harming this man as far as I was concerned. He needed palliative care. He didn't need to be lying around on a medical ward and for me to go and try and think of some slipshod solution in the middle of the night…Then I got called to him on a Saturday night [at] like 3 or 4 a.m. because he'd had the staples of his hip surgery removed that day. The wound had broken down, had not healed at all. It was just like two edges with a big hole in between. The nurses were like ‘what are we going to do?’ and so we sort of just patched it up for the night and I'd speak to the surgeons in the morning because I knew that they were not going to do anything about this really elderly really unwell guy. He'd already had one operation overnight.And so I spoke to them the next morning and it was the orthopaedic registrar on…He was like ‘oh ok, well we'll need to take him to theatre and replace his hip joint’. I was like ‘this man is really old! He hasn't eaten anything for two weeks. He's chronically confused and’ and he [the registrar] was like ‘no no no, it's never going to heal if we don't put another hip in’. I was like ‘it's never going to heal if we do put another hip in!’.I went back that night and they'd taken him to theatre and put another hip in. The thing was that they hadn't even written in the notes, it really looked like they'd just, I don't think he'd even gone and looked at the guy. It was like ‘oh I just need to put a new hip in’. That was a Sunday he would have got his hip joint. And then he died on the Tuesday or the Wednesday.And I really thought that he should have got to palliative care about ten days before he died. And maybe his last ten days would have been a lot nicer. And he didn't need all these painful interventions that were futile. But, I mean, that's another position, because when you're on the night team it's really difficult to get stuff done and to have influence on what the actual treatment plan is. And the patients often seem, are often worse overnight. Especially because they're more confused and things like that.I just thought that was a really bad outcome…I don't know what the orthopaedic registrar was thinking. But I mean it's easy to say that but then equally, maybe someone else, maybe me or maybe the medical team should have said a week earlier ‘we need to stop all interventions for this person’.

A role virtue conflict: good team member or good doctor?

Elsewhere I have put forward a framework for analysing doctors' ethical challenges based on the notion that doctors are required to be good qua multiple roles and thus that their ethical challenges are usefully understood as role virtue conflicts.2 In this paper, my aim is to apply this framework to the subject of junior doctors' involvement in futile treatment. Nicole's description of the situation suggests that she is experiencing a conflict between being a good team member and being a good doctor. The pull of her obligations as a team member who cooperates with her seniors and is sensitive to the boundaries of her particular role is clear in her statement that ‘(a)s the night team, all you're trying to do is to maintain status quo’. She is clear that it is the treating team who do the medical decision-making in these situations. But her perception of her role as this patient's doctor is also evident. She is ‘frustrated’ by the way his hospital stay is progressing and wants palliative care for him, seeing the current situation as just a series of ‘slipshod solution(s)’.

As well as her roles as team member and doctor, Nicole's situation is further complicated by her role as a learner. Towards the end of her story, she seems to express some doubt about her perception of the situation. Having described how difficult it is to influence a patient's treatment when working nights, she then comments that ‘the patients often seem, are often worse overnight (e)specially because they're more confused and things like that’, seemingly justifying the registrar's dismissal of her concerns. An alternative possible interpretation of her comment is that Nicole felt that the registrar was failing to fully comprehend the extent of the patient's problems because the registrar was not seeing the patient at night. However, a comment earlier in her interview suggests that it was Nicole's own assessment of the patient that she doubts to some degree. Earlier in her interview, Nicole stated that ‘you never really trust yourself because you're always aware of your own inexperience’. In the context of this comment, it seems that her status as a learner is salient to her and she is thus hesitant about her assessment of this patient's condition.

Nicole's situation can thus be understood as a role virtue conflict. As a junior doctor working in a hospital, she needs to be simultaneously a good doctor, a good team member and a good learner. The demands of these different roles are conflicting, creating a serious ethical difficulty for her.

Using role virtues to generate guidance

The various virtues associated with each of the three roles can provide insights into what junior doctors ought to do when their seniors are advocating treatment that seems to be futile. I have argued elsewhere for possible sets of role virtues for the roles of doctor, team member and medical learner and these are summarised in table 1.2

Table 1

Role virtues for doctors, team members and medical learners

Doctor's virtues

Compassion and benevolence are two of the doctor role virtues particularly relevant to situations like Nicole's. The good doctor acts for the benefit of the patient, recognising and addressing his or her individual suffering. A third relevant virtue is humility. The good doctor uses medical technology and his or her power only in ways that benefit patients. As Oakley and Cocking highlight, the good doctor is willing to concede that treatment has failed.3 It seems clear that the doctor acting with compassion, benevolence and humility would not choose the second hip replacement undergone by Nicole's patient nor the other continued interventions. In a situation where the patient or family members were requesting treatment that the doctor believed would not benefit the patient, compassion might perhaps direct the doctor to act differently. But in Nicole's story, because no relatives were asking for the treatment and the patient was resisting the interventions, the doctor's role virtues point away from proceeding with treatment.

These virtues of the good doctor require the doctor to advocate against a treatment plan that is not beneficial to the patient. However, it is crucial that a doctor faced with an apparently futile intervention investigates the decision-maker's reasons for choosing such a treatment. The questioning doctor could be wrong in his or her assessment of the potential benefit offered by the treatment, owing to inexperience or lack of information (either about the clinical nature of the intervention or about the patient's wishes and values). This is particularly the case for junior doctors, with their limited experience. The questioning doctor needs to understand the rationale behind the decision-making doctor's (or doctors') choice, in order to judge that the proposed treatment is not beneficial for the patient and is therefore genuinely incompatible with the role virtues of benevolence and compassion. This would most probably involve discussion with the senior doctor to identify his or her reasons for choosing the intervention. Additional research may also be useful, drawing on the expertise of other senior doctors or publications. However, as discussed further in the next section, the junior doctor needs to ensure that information is sought in a way that is sensitive to, and respectful of, their senior colleagues.

If the questioning doctor continues to believe that the treatment is futile having sought this additional information, the characteristics of the good doctor require him or her to argue against the treatment. For the junior doctor in this position, he or she must speak to the registrars and consultants. In order to have any chance of altering the course of the patient's treatment, the junior doctor needs to express his or her concerns to the senior doctors, particularly those with decision-making power. In Nicole's case, the doctor role virtues point to speaking up, with the aim of preventing the operation and stopping the other burdensome interventions.

Team member's virtues

Superficially, the role virtues of the team member seem to point to simply complying with the seniors' decision as the appropriate action in a situation like Nicole's. Being cooperative, role-sensitive and trusting of fellow team members, it appears initially that the good team member would acquiesce in the seniors' decision and implement the treatment plan without delay or question. However, on closer analysis, two aspects of the team member role virtues indicate that they in fact support junior doctors speaking up in this type of situation.

First, the good team member is communicative. Junior doctors often spend more time with patients than their senior colleagues do and thus can have additional information and insights to contribute to decision-making about patients' care. Communicating his or her concerns on this type of value-based question could further be seen as an attribute of the good team member, be they junior or senior. Such questioning serves as a warning light function for the team, prompting reflection on the appropriateness of the team's direction. If the good team member is communicative, then he or she does not remain silent when faced with apparently futile treatment.

Second, the team member role virtues are in fact compatible with the action-option suggested by the doctor role virtues—namely, investigating the decision-maker's rationale and discussing concerns with senior doctors. Questioning the treatment plan can be done in a way that is compatible with being a good team member, thus satisfying the virtue sets of both the doctor and team member roles. With appropriately timed and respectful questioning, it is possible to seek seniors' reasons and discuss concerns without causing offence or disrupting team functioning.

Medical learner's virtues

The role virtue set of the medical learner also points to investigating the rationale and discussing concerns as the appropriate action-option in a situation like Nicole's. Being curious, reflective about his or her own learning and motivated to improve his or her clinical skills, the good medical learner would want to understand the reasons behind the senior doctor's decision in order to improve his or her own decision-making. The virtue of being vocal similarly points to asking questions about that decision and discussing one's concerns. Junior doctors, with their limited clinical experience, may have an unwarranted level of conviction about a patient's imminent death. They are yet to have the sobering experience, reported by more senior doctors, of patients recovering after a hasty death appeared inevitable. Seeking further information about why a more experienced colleague sees pursuing treatment as appropriate would therefore be the choice of the good medical learner.

Three steps

Thus, a role-based analysis suggests a series of three steps for Nicole and other junior doctors faced with involvement in treatment that they perceive to be futile. This overlap between the courses of action suggested by the different sets of role virtues does not undermine the value of distinguishing between the various roles and analysing Nicole's situation in this way. The distinctions between the roles are useful to the process of analysis and understanding, even if the results may ultimately overlap as they do in this case.

1. Always investigate rationale

Junior doctors ought always to pursue their concerns rather than implement without question the treatment decisions made by their senior colleagues. It is crucial that they first find out more about the rationale behind a decision to proceed with treatment that appears to be futile, in a way that is respectful to the decision-making doctor.

2. If concern remains, engage seniors in discussion sensitively and with an open mind

Having sought this additional information, if the junior doctor still believes that the treatment chosen by colleagues is of no benefit to the patient then he or she ought to discuss these concerns with senior team members in a sensitive and respectful way. Junior doctors ought to initiate and engage in this type of discussion open-mindedly. The aim of the discussion, at least initially, ought to be increasing their understanding rather than necessarily persuading the consultant. This openness ought to apply to ethical values as well as medical knowledge. Junior doctors ought to enter such a discussion willing, for example, to alter their own view of what constitutes futile treatment. It is well-accepted that, alongside their medical knowledge, junior doctors' and medical students' ethical views are shaped by their colleagues.4 Making these discussions explicit and reflective means that the views are more likely to be well-justified and ethically sound.

It is worth noting that Nicole did express her view about the futility of the second hip replacement. She spoke to the registrar, clearly expressing her opinion that the operation was futile. However, this did not change the trajectory of the patient's treatment nor resolve her feeling of discomfort. Her experience suggests that consultants need to be involved when junior doctors are expressing concerns about futile treatment. Shreves and Moss' findings about junior doctors' ethical disagreements with consultants indicate that consultants are ‘largely unaware’ of junior doctors' concerns despite believing that it is important to involve junior doctors in treatment decision-making.5 These researchers suggest that ‘residency directors need to encourage house staff (ie, junior doctors) to discuss their ethical conflicts with attending doctors (ie, consultants)’.5 Considering the consultants' position as the key medical decision-makers, junior doctors will, in many cases, need to discuss their concerns about futility with colleagues at this level.

These first two steps may seem a radically minimal obligatory action for junior doctors faced with involvement in futile treatment. However, evidence about junior doctors' behaviour in relation to speaking up about issues in their workplace suggests that it is in fact quite a demanding position from their perspective, asking significantly more than many feel comfortable doing. This reticence about speaking up aligns with Shreves and Moss' finding that most junior doctors do not express their ethical concerns to their senior colleagues.5 Further evidence for junior doctors' unwillingness to discuss concerns with seniors comes from several studies suggesting that medical students are strongly disinclined to speak up, even when they believe that they should.6–8 Discussion of concerns with seniors is thus a substantial and, for many junior doctors, quite demanding action to posit as morally obligatory.

3. Decide whether further action is required

A junior doctor may be morally required to go beyond these first two steps. Depending on the particular circumstances, further action such as approaching senior hospital staff outside the team or refusing to participate in a futile intervention may be appropriate. In some cases, the junior doctor may legitimately decide not to take further action despite his or her concerns. Motivated by the effective functioning of the team (rather than by, for example, self-preservation), the junior doctor may judge that ethically he or she ought to concede. Such yielding is an appropriate part of membership of most kinds of teams; if all team members pursued all of their own views doggedly, a team could not function. While it is always appropriate for team members to express their views and thus contribute their perspective to the team's deliberations, refusal to consider any form of compromise would quickly cripple most teams. The difficulty is, of course, judging which views are appropriate targets of compromise and which are sufficiently important to justify steadfast insistence.

Compassion for patients is not a value that should readily be compromised by junior doctors. Doing more will be morally required, particularly when the burden of the treatment for the patient is substantial and where further action could be taken without causing massive disruption to the team's work. If a junior doctor, having spoken open-mindedly with his or her seniors, still considers a proposed treatment futile then further action is likely to be morally appropriate in a high proportion of cases. Further action by the junior doctor will generally be morally required, particularly when his or her opposition to the treatment is grounded in compassion.

One form that further action could take is refusal to participate in the futile treatment. Refusal to participate differs from avoidance, which could be criticised as cowardly. Where a junior doctor decides to refuse to participate in a procedure for ethical reasons, his or her behaviour should be guided by the role virtues. Refusal to participate should be overt and public within the treating team (in contrast, for example, to avoiding involvement through deception), and limited to the problematic treatment. When attempts to advocate for the patient through discussion have failed, making other team members aware of his or her belief that the treatment compromises patient well-being is a way that the junior doctor can continue to advocate for the patient's interests. Merely avoiding involvement does not achieve this. Making other team members aware of one's views also aligns with the team member role virtue of being communicative. A junior doctor refusing to be involved in a procedure will, in many cases, burden other staff. In line with the team member role virtues, the objecting junior doctor should act so as to minimise this burden—for example, by swapping tasks with other junior doctors on the ward rather than simply avoiding the problematic procedure. Again, openness about objection is important in facilitating this. The junior doctor who decides to refuse to participate also needs to consider carefully which aspects of the proposed treatment are in conflict with the core ethical value at stake, and limit refusal to these aspects. Nicole, for example, could refuse to book the operating theatre for the second hip replacement or to assist in the operation, but ought not to refuse to care for the patient postoperatively. It is the operation itself that is contrary to the patient's well-being. Too wide a scope of refusal runs the risk of compromising the value that the junior doctor is trying to promote.

This analysis points to a need for junior doctors to be trained in effective communication with colleagues, including appropriate questioning of seniors. Many medical schools currently emphasise the importance of doctors' communication with patients and spend considerable time and resources equipping students with this skill. Although less widespread in medical curricula, communication with colleagues is a similarly essential element of medical education. It too is necessary for effective patient care and facilitates doctors' ongoing clinical learning. Just as communicating with patients can be challenging and requires the development of a particular set of attitudes and strategies, communication with colleagues can be similarly demanding and thus requires a specific learnable set of skills. Senior doctors involved in training juniors may also need encouragement to see as appropriate juniors' questioning and skills in responding in ways that address juniors' needs.

Acknowledgments

The author is grateful to Nicole for sharing her story, to Lynn Gillam and Andrew Alexandra for their feedback, and also to the audience at the Melbourne Bioethics Research Network seminar series where an earlier version of this work was presented.

References

Footnotes

  • Funding This research was funded by an Australian Postgraduate Award.

  • Competing interests None.

  • Ethics approval This study was conducted with the approval of the hospital involved, which cannot be named for reasons of participant confidentiality.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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