Regulating medical futility: neither excessive patient's autonomy nor physician's paternalism

In the era of an aging population and escalating healthcare costs, the futility debate has become the object of extended critical attention. The issue has divided experts in relevant fields into two camps. The proponents of medical futility defend the physician's exclusive right to determine the futility of treatment and decide whether treatment should be withheld or withdrawn. On the other hand, opponents believe that a discourse of power lies at the heart of the futility debate. They believe that medical futility was constructed, in part, as a means of enhancing the physician's domination in a context wherein medical authority was threatened. This paper presents some current approaches to the futility debate and highlights positions taken by physicians and bioethicists. It concludes that establishing an operational guideline, either at hospital or national level, is a critical requirement for resolving problems posed by futility. It suggests that policies should not be based on either excessive patient's autonomy or physician's paternalism.     

Pitfalls in diagnosis of occupational lung disease for purposes of compensation--one physician's perspective

Occupational caused lung disease (OLD) is almost always compensable, either by application to workers' compensation agencies or by a civil lawsuit. For this reason the diagnosis usually comes under close scrutiny. Several pitfalls can occur when a physician diagnoses a patient as having lung disease of occupational origin, especially when compensation is at issue. These pitfalls can trap both the attorney advocate and his client, and lead to a result opposite of that intended (e.g., the claim one supports can be denied). For purposes of discussion I have categorized the pitfalls as follows: A. Making an unsupported medical diagnosis (looking for a "quick fix"). B. Echoing an unsupported diagnosis made by someone else. C. Inadequate clarification of 'impairment' and 'disability.' D. Ignoring or minimizing relevant medical history. E. Arguing against yourself. F. Ignoring the possibility of a rare or unusual diagnosis. G. Not obtaining or reviewing independent chest x-rays and reports. H. Attributing causation with certainty when it is unwarranted by the facts. I. Relying on a claimant's own smoking history. J. Misinterpreting pulmonary function and arterial blood gas tests. K. Missing the real cause of a patient's complaint. L. Diagnosing occupational lung disease without attempting to remove the patient from the cause. M. Confusion over basic terminology and pathophysiology in OLD. N. Using sloppy or incorrect language, including misspelling. O. Not saying "I don't know," when you don't know. Pitfalls in diagnosis generally arise from either physician bias or inadequate evaluation. Although most pitfalls seem to be made by physicians on the plaintiff's side, they are also made by physicians on the defendant's side, as when bias interferes with recognizing a condition that is occupational in origin. Ideally, the fact that diagnosis of OLD involves the legal profession should not affect a physician's objectivity or clinical approach. Physicians have an obligation to help assure that deserving patients receive compensation, and that claimants without a compensable occupational illness are not unjustly rewarded. However, the attorney's need to prove a diagnosis "with medical certainty," and the defendant's need to refute that diagnosis with equal certainty, often skew what would otherwise be a straightforward diagnostic process. Resulting pitfalls in diagnosis can, in the end, trap the physician advocate and the side he is trying to help.