He made his wholly nonsectarian presentation in a Bioethics Grand Rounds that was organized by the Loma Linda University Center for Christian Bioethics. Roy Branson is its Director and Alice Kong is its Coordinator.
Chooljian’s two-fold thesis was that the term "medical futility" has no widely accepted meaning and that, therefore, in the absence of such a consensus, establishing fair procedures for dealing with cases in which there appears to be "nothing left to do" is essential.
He began with the recent Jacki McMath case in the San Francisco Bay Area as well as the much earlier Nancy Beth Cruzan case in Missouri. He then provided a detailed analysis of some of the various ways the term "medical futility" is now being used in medicine, law and institutional policies. He gave special attention to the guidelines of the United States Veterans Administration where he now serves. He also reported on his retrospective analysis of the recommendations made by an Institutional Ethics Committee at the Stanford University Medical Center.
Along the way Chooljian explored the differences between the Quantitative and Qualitative methods of establishing "medical futility” in clinical cases. The first of these estimates the possibility or probability of achieving desired outcomes. The second relies upon what a "reasonable person," or upon what professionals and their societies, would find appropriate. The challenge is that it is not always obvious what this would be.
Chooljian demonstrated something that physician and philosopher Tristram Engelhardt and others have long emphasized. This is that many of us live in societies that are so pluralistic that we often encounter each other as moral strangers. In this cultural mix, it is so difficult to achieve consensus about many important issues that the best we can do is to establish fair procedures that protect all people despite their differing views and values.
I would emphasize that those whom these procedures protect are obligated to protect them in return. Using democratic procedures to destroy them must not be allowed.
Donna Carson Reeves, a pediatrician who is also a lawyer, emphasized to me before Chooljian began his presentation how important it is that such procedures make latent conflicts of interests manifest. Hospice organizations that make more money the sooner their patients die are illustrative.
There is another reason why "medical futility" has no widely accepted definition. It is that those who use this term do not always specify whether they are using it descriptively (“What is.”) or prescriptively (“What ought to be.”). What's more, the possibility of committing what David Hume and others have called the naturalistic fallacy by trying to derive the second from nothing but the first is always at hand.
For the most part, clinicians should do the descriptive work and patients, and their loved ones, should do the prescriptive. To be sure, in everyday life it is not possible to divide these cleanly and evenly and it shouldn't be. What’s more, some patients appropriately seek more guidance about what ought to be done than others.
Yet it is difficult to imagine a case in which it would be helpful for a clinician to reduce a patient’s number of genuine choices by disguising an ethical decision as a purely medical one.