The functional status questionnaire: Reliability and ...

JOURNALOF GENERALINTERNALMEDICINE,Volume 1

Ethics and Critical Care Medicine. EDITED BY JOHN C. MOSKOP AND LORETTA KOPELMAN. Boston, Kluwer Pub-

lishers, 1985. $34.50. CHANGES in h e a l t h c a r e t e c h n o l o g y , o r g a n i z a t i o n , a n d r e i m b u r s e m e n t a r e a l s o c h a n g i n g critical c a r e ethics. To a d d r e s s this e v o l v i n g field, E a s t C a r o l i n a University School of M e d i c i n e s p o n s o r e d a s y m p o s i u m in w h i c h s o m e of A m e r i c a ' s most d i s t i n g u i s h e d m e d i c a l e t h i c i s t s p a r t i c i p a t e d . This b o o k c o n t a i n s e i g h t e e n e s s a y s pres e n t e d a t t h e M a r c h 1983 s y m p o s i u m , e n t i t l e d "Moral Choice and Medical Crisis." Two s p e a k e r s e x a m i n e critical c a r e ethics in the context of c o n t e m p o r a r y A m e r i c a n society. Veatch a t t r i b u t e s the u n u s u a l p r e d o m i n a n c e of critical c a r e i s s u e s in A m e r i c a n m e d i c a l e t h i c s to four factors: c o m m i t m e n t of c o n s i d e r a b l e r e s o u r c e s to critical care, a m b i v a l e n c e about m e d i c a l technology, s t a u n c h i n d i v i d u a l i s m a m o n g p a t i e n t s , a n d a t r a d i t i o n of p a t e r n a l i s m a m o n g p h y s i cians. Reich w a r n s that, a s c o r p o r a t i o n s a c q u i r e i n c r e a s ing control over A m e r i c a n h e a l t h c a r e ( i n c l u d i n g critical care), m e d i c i n e m u s t r e a s s e r t its t r a d i t i o n a l v a l u e s of p r o f e s s i o n a l integrity, p a t i e n t a u t o n o m y , a n d b a l a n c e d c o n s i d e r a t i o n of c o s t s a n d equity. A l t h o u g h t h e y c a n r e c o m m e n d no solutions, s e v e r a l s p e a k e r s a d d r e s s the p r o b l e m of s c a r c e critical c a r e resources. Perrin, for e x a m p l e , c o n s i d e r s a l l of the m e t h o d s currently u s e d to limit e x p e n d i t u r e s from a s t a t e c r i p p l e d c h i l d r e n ' s fund to b e e t h i c a l l y u n a c c e p t a b l e . A r g u m e n t s f a v o r i n g e i t h e r p r e v e n t i v e c a r e or critical c a r e i m p r e s s Moskop a s e q u a l l y r e f u t a b l e . E n g l e h a r d t c h a l l e n g e s society to r e c o g n i z e t h e limits of critical c a r e r e s o u r c e s a n d to m a k e e n t i t l e m e n t d e c i s i o n s a c c o r d i n g l y ; Margolis, however, c o n t e n d s s u c h d e c i s i o n s c a n n o t b e m o r a l l y justified. A few a u t h o r s c o n s i d e r i s s u e s r e g a r d i n g the c a r e of i n d i v i d u a l p a t i e n t s . K o p e l m a n a r g u e s that H i p p o c r a t i c b e n e f i c e n c e - - t h e p h y s i c i a n ' s p l e d g e to benefit t h e sick - - p r o m o t e s c o m p a s s i o n for the c r i t i c a l l y ill p a t i e n t . Hon-

(Nov~Dec), 1986

oring p a t i e n t s ' c h o i c e s is the s u p r e m e v a l u e in t h e r a p y , a c c o r d i n g to P e l l e g r i n o a n d Katz. Katz, h o w e v e r , imp o s e s on p a t i e n t s the d u t y to reflect a b o u t their choices, a n d on p h y s i c i a n s t h e d u t y to c o m m u n i c a t e w i t h p a t i e n t s a b o u t t h o s e choices. Heiser s u g g e s t s t h a t our a c k n o w l e d g i n g N a t u r e ' s p o w e r to h e a l a n d m a n ' s r e l a t i v e powe r l e s s n e s s s h o u l d l e a d to p r o p e r r e s t r a i n t in c r i t i c a l care. What, then, d o e s this b o o k t e a c h a b o u t c r i t i c a l c a r e ethics? F u t u r e r e s o u r c e s will a l m o s t c e r t a i n l y b e l i m i t e d . W e A m e r i c a n s s h o u l d no l o n g e r d e c e i v e o u r s e l v e s t h a t medical resources are limitless, and that everyone who n e e d s critical c a r e will g e t it; w e m u s t a s s e s s our res o u r c e s r e a l i s t i c a l l y . In a d d i t i o n , t h e e t h i c a l p r i n c i p l e s a l r e a d y a r t i c u l a t e d for critical c a r e a r e e x t r e m e l y b r o a d at best. C l i n i c a l a p p l i c a t i o n of t h e p r i n c i p l e s of beneficence, r e s p e c t for p a t i e n t s ' a u t o n o m y , a n d p r o p e r res t r a i n t in c h o o s i n g t h e r a p y r e q u i r e c o n s i d e r a b l y m o r e definition t h a n t h e s p e a k e r s give. W h a t d o e s b e n e f i c e n c e r e q u i r e t h e p h y s i c i a n to d o for c h r o n i c a l l y v e g e t a t i v e , v e n t i l a t o r - d e p e n d e n t p a t i e n t s ? W h a t justification s h o u l d the p h y s i c i a n r e q u i r e from t h e a c u t e m y o c a r d i a l infarction p a t i e n t to a c c e d e to the p a t i e n t ' s w i s h e s for prem a t u r e d i s c h a r g e ? W h a t is p r o p e r t h e r a p e u t i c r e s t r a i n t for c a n c e r p a t i e n t s w h o w a n t c a r d i o p u l m o n a r y r e s u s c i tation? More u s e of c a s e s to i l l u s t r a t e t h e a p p l i c a t i o n of t h e s e p r i n c i p l e s in a c t u a l p a t i e n t c a r e w o u l d h e l p in approaching these and similar questions. This book l a y s t h e c o n c e p t u a l g r o u n d w o r k for p o s i n g i m p o r t a n t q u e s t i o n s in critical c a r e ethics: How s h o u l d limited resources be used? and What specifically does e t h i c s r e q u i r e in t r e a t i n g c r i t i c a l l y ill p a t i e n t s ? M e d i c i n e a n d e t h i c s m u s t a d d r e s s t h e s e q u e s t i o n s o p e n l y a n d prop o s e a n s w e r s . U n f o r t u n a t e l y a n y a n s w e r s will p r o b a b l y e n t a i l s o m e t r a g i c c o n s e q u e n c e s . Yet w e m u s t m a k e the b e s t c h o i c e s p o s s i b l e a n d a c c e p t r e s p o n s i b i l i t y for them. " T r a g e d y is a p a r t of h u m a n life," o n e e t h i c i s t s a y s in the book, " a n d m o r a l i t y g o e s h a n d in h a n d w i t h t r a g e d y . " - - H e n r y S. Perkins, MD, U n i v e r s i t y of Texas, S a n Antonio, TX

ERRATUM An error appeared in the article, The Functional Status Questionnaire: Reliability and Validity When Used in Primary Care (J G ~ INTERNMED 1986;1:143-149). The formula for calculation of FSQ scale scores, on page 145, should read: n

S S = (~ yi) i = 1 n

-

427

n

• 100 k

where SS = transformed FSQ scale score yi = individual questionnaire response score n = n u m b e r of q u e s t i o n s i n t h e s c a l e for w h i c h v a l i d i n f o r mation is available k = maximum minus minimum valid response score