By Victoria Tabut LLB
Medical Ethics and the Law
Introduction
Clinical Ethics is the field of
activities that investigate what medical practitioners as professionals should
do or how they should behave concerning a certain case, especially in the
process of decision making[1].
The newborn period is defined as
beginning at birth and lasting through the 28th day following birth[2].
A child is defined as any person who
has not attained the age of eighteen (18)[3].
Background
The debate as to the meaning of medical futility and what physicians
should do in such cases; in the course of Medical Practice, dates back to the
time of the writings of Hippocrates and Plato where it was said, "To
attempt futile treatment is to display an ignorance that is allied to
madness".[4]
The claim that an intervention is
futile is used to justify a shift in the ethical obligations owed to a patient[5]. This is the shift from the recognition of a
patient’s negative rights (the right to refuse treatment) to the decision to
withhold or withdraw treatment by a physician. In the English case of Airedale
NHS Trust ν Bland[6],' Lord Goff of
Chieveley said: Medical
treatment is [not] appropriate or requisite simply to prolong a patient's life,
when such treatment has no therapeutic
purpose of any possible kind,
as where it is futile because the patient is unconscious and there is no prospect of any improvement in his condition[7].
Definition
There has
been difficulty in construing the exact definition of medical futility. The earliest known attempt to define futility
comes from the Hippocratic Corpus in
what is currently recognized as the quantitative definition[8]. It is further explained as a situation when
physicians conclude (either through personal experience, experiences shared
with colleagues, or considerations of published empirical data) that in the
last 100 cases a medical treatment has been useless, then that treatment is
regarded as futile. This argument is a
purely quantitative account based on a probability established by the empirical
methods of medicine as a science[9].
On the other hand, Plato had a qualitative perspective of futility
which emphasized the inappropriateness of persisting with treatment which
leaves the surviving patient with a "useless" life[10]. The qualitative
approach to futility is based on an argument that physicians should not
be required to provide treatments to achieve objectives that are inconsistent
with legitimate medical goals[11]. Futility occurs when there is a goal, there is an action aimed at
achieving the goal, and there is virtual certainty the action will
fail.[12]
Controversial Agenda
The problems associated with defining
futility have encompassed: Patient rights and speculations about the limits of
patient autonomy, economic capacity, professional integrity and the role of the
physician in the physician-patient relationship, as well as the lack of shared
values as to what may be regarded as medically necessary in a particular case[13].
Drafting a concrete medical or legal
definition of futility as well as setting parameters in regard to such would be
instrumental in deciding when treatment should be withdrawn or withheld[14]. However, fashioning such terminology and
scope would be in direct contravention of a patient’s constitutional rights,
patient’s autonomy in respect of decision making, as well as inconsistency with
cultural and religious aspects.
In what is regarded as the developing
world, certain socio-cultural backgrounds as well as religious beliefs have adverse
effects in the recognition of medical futility. As a result, there are limited
legal provisions; that is statute and case law, in this field.
Despite this fact, the evolution of
medicine to reliance on technological advancements to sustain life, together
with a steady erosion of doctor decision-making authority, and societal
pressure to contain health care costs[15] demand for a reform of laws to address these
emerging issues[16].
Legal Provisions
The Constitution of Kenya, 2010, (“The Constitution”) recognizes
the right to life, and that life begins at conception[17]. The
Constitution guarantees every person the highest attainable standard of health
inclusive of health care services, maternal and reproductive health care and
the right to emergency medical treatment[18]. The Constitution ensures that the
vulnerable groups, marginalized groups and minorities (including but not
limited to the illiterate, the medically incapacitated, the uneducated and
uninformed) should have reasonable access to health care services[19].
Article 2
(5) of the Constitution of Kenya, 2010, recognizes that the general rules of
international law shall form part of the law of Kenya. The right to life is an
inherent universal right that is protected by Law. As a qualified right,
Article 2 of the European Convention on Human Rights only recognizes the
limitation of execution upon a conviction or with use of reasonable force where
necessary only[20]. Article 5 of the African Charter on
the Rights and Welfare of the Child states that every child has a right to
life. States are encouraged to ensure that all individuals enjoy the best
attainable standard of health care[21] and this is also specified to
children[22], this is because children are
regarded as in need of special medical care and assistance[23].
Medical practitioners, and especially physicians, are held to high
standards under International laws as evidenced in the Declaration of
Geneva. Physicians are required to
maintain utmost respect for human life and that their patients’ health and
welfare be their principal concern[24].
Many
international instruments focus on defining human rights and fundamental
freedoms. Usually, most of these rights are qualified (not absolute) and are
therefore subject to certain exceptions. It is the mandate of each member
states to define the scope of these rights and their limitations so as to
prevent either violation or infringement of these rights. Article 4 of the Convention on the
Rights of the Child encourages member states to adopt or enact all appropriate
legislative, administrative, and other measures for the implementation of such
rights.
Statutes
in respect of medical practice are very procedural and mostly make provisions
in relation to registration and licensing of medical practitioners. Therefore,
there is little if no statutory authority in regard to medical futility.
The Kenya
National Patient’s Rights Charter of 2013[25] (“The Charter”) makes various
provisions in regard to the rights of patients, and is legally binding. The
Charter emphasizes on the right to informed consent to treatment[26] and the right to seek a second
medical opinion[27].
The draft of the Charter had explicitly recognized the Right to
special treatment in a clause that stated that: In addition to the right of
health care services, a provision of persons with special needs who require
special treatment shall be provided and the special needs are in the cases of
new born babies, children, maternal and reproductive health care, pregnant
women, the mentally incapacitated and mentally handicapped, the vulnerable
groups (e.g. the uneducated and ignorant), disabled, HIV and AIDS patients and
terminally ill patients[28].
This clause was subsequently omitted
from the final draft of the Charter.
Another clause that was
omitted stated that patient’s have the responsibility to observe and comply
with the prescribed treatment, rehabilitation and counseling process[29].
This is clear indication of the
reluctance of medico-legal service providers to engage in the controversial
matter of medical futility, whilst expressly admitting that this is an emerging
grey area.
Case Law
There is no Kenyan case law in respect
of medical futility. As a result, inference will be drawn from an American case
and contextualized to this particular jurisdiction.
In re Baby K. (1994)
Facts
In October of 1992, a baby girl was
born in Fairfax Hospital, Virginia, who unknowingly became a symbol of medical
futility[30]. Baby K was anencephalic[31], and as a result should have died a few days
after birth[32]. However, when she began having trouble
breathing, physicians provided her with assistance through the use of a machine
called a ventilator[33]. At the insistence of her mother, ventilator
treatment was administered in subsequent episodes of difficult breathing and,
remarkably, this cycle of medical care kept her from dying for over two years[34]. Her physicians believed the continued
provision of this kind of treatment was futile because she had no chance for a
conscious life[35]. Thus, they recommended that the hospital
seek a court order allowing them to refuse ventilator treatment during a future
episode of difficult breathing[36].
A federal judge ruled in July 1993
that the hospital has a duty to provide full medical care, including ventilator
support to Baby K under the Federal Law[37]. No weight was given to the claim that
further prolongation of Baby K’s dying process was futile and inhumane[38].
Issues for Determination
The question of whether Congress, in
passing EMTALA[39], had provided an exception for anencephalic
infants in respiratory distress[40].
Ruling
The court explicitly stated that
federal law overrode any state legislation[41]. The Court found
the language clear, and it was the discretion and mandate of Congress to
construct Federal legislation to clarify congressional intent that EMTALA’s
requirement for stabilization be “consistent with reasonable medical standards”[42]
Call for Legal Reform
Baby K died at the hospital due to
cardiac arrest in April 1995 after being vigorously resuscitated[43]. She was two and a half (2 1/2) years old,
and it was her sixth admission to the hospital[44].
It can be inferred from the term
‘medical futility’ that the treatment of such a patient will not confer any
benefits to the patient physiologically or otherwise. Essentially, this leads
to prolong suffering and especially so for newborns. More so, in a country of
limited resources like Kenya, this would directly deprive another patient of
the opportunity to be provided with treatment and any chances of cure or even
worse survival. It is also an infliction of psychological and emotional
suffering to the family of said patient.
Conclusion
It is clear that life-sustaining
measures and techniques are in a progressive state. As a result, there should
be a forum of interactive discussion about medical futility in a world of
constant and consistent technological advancement. The objective of such is to
ensure that certain standards of medical ethics are upheld, communication to
patient’s guardians about medical futility and subsequent effects are well
delivered, and most importantly legal reforms to reflect this position are
enacted.
[1] http://www.l.u-tokyo.ac.jp/dls/cleth/e/introduction/intro_1.html
<accessed 03/30/2016>
[2] http://www.eicd.com/guidelines/Newborn.htm<accessed
03/30/2016>
[3] The
Age of Majority Act, 1974, Cap 33; Laws of Kenya.
[4]
I. Kerridge, K, Mitchell, J. McPhee; Defining
Medical Futility in Ethics, Law and Clinical Practice: An Exercise in Futility?
(1997) 235, 4, Journal of Law and Medicine.
[5] Ibid.
[6] [1993] AC 789.
[7] Ibid at 869
[8]
LJ Schneiderman, N S Jecker and A R
Jonsen, "Medical Futility: Its Meaning and Ethical Implications"
(1990) 112, Annals of Internal
Medicine 949.
[9]
Ibid.
[10] Plato, The Republic (G. M Grube, trans, Hackett Publishing, Indianapolis,
1981), p 76
[11] I. Kerridge, K, Mitchell, J. McPhee; Defining Medical Futility in Ethics,
Law and Clinical Practice: An Exercise in Futility? (1997) 235, 4, Journal of
Law and Medicine.
[12] Trotter, G. (1999). Mediating disputes about medical
futility. Cambridge Quarterly of
Healthcare Ethics, 8(4): 527-537.
[13] I. Kerridge, K, Mitchell, J. McPhee; Defining Medical Futility in Ethics,
Law and Clinical Practice: An Exercise in Futility? (1997) 235, 4, Journal of
Law and Medicine.
[14]
M. A. Bonanno, the Case of Baby K: Exploring the Concept of Medical
Futility, Annals of Health Law, Vol. 4 [1995],
Iss. 1, Art. 9
[15] Soobramoney v Minister of Health,
KwaZulu-Natal, 1998 (1) SA 765 (CC), 1997 (12) BCLR 1696 (CC).
[16] M. A.
Bonanno, the Case of Baby K: Exploring the Concept of Medical Futility, Annals
of Health Law, Vol. 4 [1995], Iss. 1, Art. 9
[17]
Article 26, the Constitution of Kenya, 2010.
[18]
Article 43 (1) (a) and (2) of the Constitution of Kenya, 2010.
[19]
Article 21 as read together with Article 56 (e) of The Constitution of Kenya,
2010.
[20]
Amended by Protocols Nos. 1 and supplemented by Protocols Nos. 1, 4, 6, 7, 12
and 13
[21]
Article 16, African (Banjul) Charter on Human and Peoples' Rights.
[22]
Article 14, the African Charter on the Rights and Welfare of the Child.
[23]
Article 25, Universal Declaration of Human Rights.
[24]
World Medical Association, Declaration of Geneva (1948), International Code of Medical Ethics (1949),
[25] 1st
Edition, October 2013.
[26]
1.8 Of the Kenya National Patient’s Rights Charter of 2013.
[27]
1.11 Of the Kenya National Patient’s Rights Charter of 2013.
[28]Medico-Legal Practice Committee of the
Law Society of Kenya, Draft Of The National Patients’ Right Charter, 2012.
[29]
Ibid.
[30] M.
A. Bonanno, the Case of Baby K: Exploring the Concept of Medical Futility,
Annals of Health Law, Vol. 4 [1995], Iss. 1, Art. 9.
[31]
Anencephaly is a medical condition characterized by an incomplete brain; that
is, the brain is "entirely or substantially absent."
[32] M.
A. Bonanno, the Case of Baby K: Exploring the Concept of Medical Futility,
Annals of Health Law, Vol. 4 [1995], Iss. 1, Art. 9
[33]
Ibid.
[34]
See Marylou Tousignant & Bill Miller, Baby K's Mother Gives Her the Prayer
That Many Deny She Has, WASH. POST, Oct. 7, 1994, at A01.
[35] M.
A. Bonanno, the Case of Baby K: Exploring the Concept of Medical Futility,
Annals of Health Law, Vol. 4 [1995], Iss. 1, Art. 9
[36] M.
A. Bonanno, the Case of Baby K: Exploring the Concept of Medical Futility,
Annals of Health Law, Vol. 4 [1995], Iss. 1, Art. 9
[37] Rehabilitation
Act of 1973, the Americans with Disabilities Act of 1990, and the Emergency
Medical Treatment and Active Labor Act.
[38] http://web.stanford.edu/~mvr2j/sfsu09/extra/court%20cases%20futile%20treatment.pdf
<accessed 03/30/2016>
[39]
“The use of a mechanical ventilator to assist breathing is not ‘futile’ or
‘inhumane’ in relieving the acute symptoms of respiratory difficulty which is
the emergency medical treatment that must be treated under EMTALA. To hold
otherwise would allow hospital to deny emergency treatment to numerous classes
of patients, such as accident victims who have terminal cancer or AIDS, on the
grounds that they eventually will die anyway from these diseases and that
emergency care for them would therefore be futile.”
[40] http://web.stanford.edu/~mvr2j/sfsu09/extra/court%20cases%20futile%20treatment.pdf
<accessed 03/30/2016>
[41]
Ibid.
[42]
Ibid.
[43] http://web.stanford.edu/~mvr2j/sfsu09/extra/court%20cases%20futile%20treatment.pdf
<accessed 03/30/2016>
[44]
Ibid.