The Existence of Pragmatism in Futility of Care
In a meeting today I was reminded of how pragmatism and futility of care collide. A colleague pulled me aside and asked for my opinion on a case. I agreed to listen and as I listened I began to understand how experiences, the truth, and hope collide with the concept of futility of care.
The case, an older patient, diagnosed with an aggressive form of cancer, refuses to follow medical recommendations. The patient is at a point where radiation and chemotherapy will not help. There is no cure. After much discussion, the patient agreed to palliative care and receiving intravenous feeding. The patient, despite the prognosis, believes this treatment will help strengthen them so they may receive chemotherapy. The family and the medical team understand the intravenous feeding will not bring about a recovery. There is no reprieve, no beating this form of cancer but the patient believes otherwise. My colleague’s query was: Is there an ethical obligation to intervene and stop any care which is futile? My answer was: there is an ethical obligation to understand the patient’s truth and respect their decision for treatment. To do this, we must examine the concepts of pragmatism and futility of care.
What we perceive, form judgments on, and then mold into our belief system comes from external experiences. William James, a Pragmatist, describes how, in the normal case, we have an established body of views and opinions, and issues about what to believe arise when a new experience puts them under strain. We will accept a new opinion when “[I]t preserves the older stock of truths with a minimum of modification, stretching them just enough to make them admit the novelty, but conceiving that in ways as familiar as the case leaves possible.”1 It is the patient’s experience and therefore their truth that treatment of any kind will strengthen the body allowing for further treatments which address the cause of the patient illness. In this case, the patient believes intravenous feedings will help them in their goal to fight cancer. They don’t have any reason not to think this because previous experiences with medical care have made them better. For the patient, medical care represents hope, and this is a form of truth which makes the patient comfortable. While the family and the medical team understand intravenous feeding is futile because the cancer is aggressive and will not let the patient heal enough to fight, the patient, despite the prognosis, remains faithful to an older form of truth. Forming truth out of experience creates a problem because, while, the patient has experienced better health through medical intervention facts gathered by the family and medical team has shown all care is futile.
Richard Rorty, a philosopher, may have the answer to the dilemma the family, patient and medical team are facing. Rorty said: “What pragmatists teach us about the truth is that there is nothing very systematic or constructive to say about truth at all. In particular, this concept does not capture any systematic or metaphysical relation between our beliefs and utterances, on the one hand, and reality on the other….sometimes we might find it useful to express our fallibility by saying that some of our beliefs may not be true”1 We are fallible.
We want our beliefs to be true because the truth we believe in gives us hope. In this case, the patient’s belief in intravenous feeding gives hope despite the growing realization there is none. Is the care futile? No. The intravenous feedings provide comfort to the patient who is coming to terms with their prognosis of death. Futility of care exists if there is harm done to the patient. There is no harm, and one could argue there is a benefit to the intravenous feedings because they’re providing hope to the patient, however, false it may be in the family and medical team’s opinion. There are times when if there is no harm to the patient and care is benefitting the patient, in this case allowing the patient to hold onto hope, care must continue. To remove treatment is to remove hope, and once removed, care becomes futile.
1. Pragmatism (Stanford Encyclopedia of Philosophy), http://plato.stanford.edu/entries/pragmatism/ (accessed October 03, 2016).