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Ordinary Means

Fundamentals


Always ordinary, seldom extraordinary.

Without a doubt, the most challenging and difficult decision that a patient or their caregiver has to make is when to stop taking steps to preserve life. It’s a complex maze of choices that is made based on the known factors at the time. At best, it’s an educated guess. After all, there are very few absolutes in the practice of medicine.

When confronted with these challenging moments, the most important thing to do is to go through the decision making process with one’s intellect in charge. These situations are invariably emotional. It’s possible to be empathic while still making rational decisions. Emotions are illogical by nature, and to be held captive by them will leave you in the lurch. Inaction of any kind in these critical junctures may indeed cause prolonged suffering.

Medicine evolves and improves on a daily basis. New and different treatment options are constantly making it to the floors of hospitals, nursing homes, and medical arts buildings. An excellent way to determine the right course of action is to hold each treatment up to a standard of “ordinary means” versus “extraordinary means.”

We are required to pursue all ordinary means in order to preserve life. We can, but are not obligated to, pursue extraordinary means.

Ordinary Means
To put it simply, ordinary means are those treatments that are reasonable, practicable, and responsible. They are backed by extensive medical research and present no outsized financial burden. Their function is not strictly to prolong life, but to correct deficiencies.

Even complex interventions can fall under the standard of ordinary means. Placing a motor vehicle accident patient on life support immediately upon arrival in the ER in order to allow the trauma team to diagnose and treat the major injuries is an ordinary means of sustaining life. The intent, whether cognitively acknowledged at the time or not, is to buy the surgeon much needed time to act in order to save a life.

We are always required to attempt to utilize ordinary means when treating patients.

Extraordinary Means
Extraordinary means can relate to those treatments that are experimental, or those ordinary means that are applied in an extraordinary way.

Consider first experimental treatments. There’s a difference between attempting a course of treatment that has been tested, but not proven, and using a terminally ill patient as a test subject unto themselves. In order for an experimental treatment to be considered, there must be at least some clinical data to support the conclusion that it may provide some benefit to the patient. Seldom is it ethical to attempt a treatment on a patient without previous clinical testing using consenting human subjects.

Ordinary means can also be used in an extraordinary way. Think back on our motor vehicle accident patient. Placing them on a ventilator in an emergent situation was an ordinary way to preserve life. Imagine that the patient’s injuries were substantial. Leaving them in a indefinite comatose state, on the ventilator, without hope for improvement or recovery moves this use into the extraordinary means category. What is begun as ordinary means can end as extraordinary means.

A treatment could also be considered extraordinary if it causes undue suffering for a patient. Consider a patient at an advanced age with stage four pancreatic cancer. The lethality of this cancer is well documented. While the patient has a negative prognosis, and there may be palliative surgical options to ease the pain of the tumors, the difficulty of enduring those surgeries may make them extraordinary means.

We are never required to employ extraordinary means, although they may not be inherently unethical. A through ethical and medical review of the particulars of a patient’s cause should be conducted in order to determine ethical treatment.

Very, Very Grey
Without a doubt, it’s difficult to objectively evaluate whether any particular course is ordinary or extraordinary. Real life cases tend to come in all shades of grey, with far too few coming in black or white. The ethical choice can only be evaluated individually, in each particular case, in light of the facts known at the time.

About the Author

CHET COLLINS is a full-time sidekick to three small humans. He gets his best creative work done during their nap time. He’s had a keen interest in bioethics since 2003.

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