The scene opens as the healthcare ethics committee (HEC) and cardiologist (Dr. C) are discussing Mr. H.

Dr. C: A LVAD as destination therapy—with all due respect to Mr. H and his family—has not a chance in hell of prolonging or improving his life. Meth and noncompliance will cause more complications. How could his wife provide sufficient home care? At best with a LVAD, Mr. H might live a few extra weeks with more pain and suffering.

HEC member A: Could the LVAD provide a two to five percent chance of survival for six months or more?

Dr. C: Many LVAD patients are helped in this way, but Mr. H’s meth use and noncompliance give him a terrible prognosis.^{Footnote 1,Footnote 2,Footnote 3,Footnote 4,Footnote 5} However, I guess a two to five percent chance of such improvement is possible.

HEC member B: Suppose a near-terminal cancer patient has one more nonexperimental treatment available that has a two to five percent chance of improving survival and quality. The other ninety-five to ninety-eight percent that receive it die soon and with more pain and suffering. Palliative care helps some. Assuming a sound informed consent process and autonomous choices, wouldn’t providers honor the patient/family request for the potential two to five percent chance of benefit? Wouldn’t doing so serve the aim of respecting autonomy and beneficence? And wouldn’t the patient/family be best poised to make the judgments?

Dr. C: I’m trying very hard not be defensive here and to avoid thinking that you are questioning my medical judgment.

HEC chair: Dr. C, your professional integrity is not in question. Rather, we are trying to introduce different ways of thinking about options. Members A and B are exploring whether the outlook is truly hopeless or just very bad and what that would mean. Our committee’s diverse membership promotes varying takes on projected outcomes. Apparently, the odds are very against Mr. H, but they aren’t hopeless.

HEC member D: I know LVADs require in-home professional caregivers, and patients, family, and others need special training. I don’t see how the patient’s wife could provide sufficient assistance. But in Mr. H’s community, extended families, community members, and faith groups can, and commonly do, help.

Dr. C: But surely he will continue meth use.

HEC member D: How certain is it that repeated meth use will cause a quick death?

Dr. C: There’s a high probability, but medical prognoses just aren’t that precise.

HEC member D: Many in our community are meth users, and it wrecks havoc that we are trying to stop. But some of these users still have lives with some quality and families who love them. And those families decide to struggle through and do what they can. Sometimes we can help.

Dr. C: I’m still very pessimistic, but you’ve given me other ways to think about his care, and I appreciate your input. I’ll arrange urgent assessment of how to arrange background support for Mr. H and proceed soon with the LVAD.

HEC chair: Thank you Dr. C. We can help promote the community side of support. Let’s discuss next steps.

Comment: This scenario highlights some obligations that HECs have regarding medical judgments that drive clinical decisions. I need not rehearse the arguments that judgments about care options coupled to morbidity and mortality projections have values at the core. The 2–5 percent example illustrates background value judgments about cancer or meth addiction. We might ourselves choose not to select a method of treatment that has 95–98 percent death odds coupled with more suffering. We might also believe that approving drugs with such poor efficacy is an unjust distribution of resources. But there will generally be more sympathy toward a cancer patient’s choice of the 2–5 percent option than that of a meth addict. Judgments about the latter will often include background biases and stereotypes about addiction and personal responsibility. Racial, ethnic, class, and/or cultural bias could also be present. A major challenge for HECs is to find diplomatic ways to unpack such value judgments and give them a fair hearing. Ensuring diverse perspectives is one key strategy.

If decisions to withhold treatment in pressing life-threatening and life-quality-threatening cases involve value judgments, respect for persons and fairness require not only that all relevant stakeholders and their advocates have a voice but that their participation is empowered. Given the vulnerability and powerlessness of patients and families comparable to Mr. H and his wife, it is crucial that community advocates have a strong voice. Otherwise the dominant voices in the healthcare institution—and here the cardiologist would very likely be one—have unjust advantage. The upshot is that the institution, reasonably through the HEC, has the obligation in contentious cases to ensure an equitable decision process and fair stakeholder representation. The HEC needs to work against the forces of marginalization, disempowerment, and—frankly—oppression.^{Footnote 6} Of course, promoting equity is not an easy goal, because HECs themselves are embedded in institutions and may be dominated by physicians such that other health professionals and community representatives lack fair input. And community representation may well be a token arrangement.

The issues discussed here are central to medical futility or nonbeneficial care debates.^{Footnote 7,Footnote 8} The case of Mr. H could be addressed as a representative scenario.

Some may object that Dr. C’s response and the case resolution are ideal and unrealistic. They may be unrealistic in the sense that such constructive encounters with clinicians may be uncommon. Power dynamics will be one reason for such an observation. But to the extent that the realism charge is true, it is a system problem that HEC committees and institutions should address. The background question is whether there are fair decision processes such that all stakeholders are respected and empowered. If not, there is justice work to do.