Medical Futility - Conflict and Illusory Consensus

Wesley Smith, a well-known opponent to medical futility policies and laws, clarified his position in commenting on a new study in the Archives of Pediatrics and Adolescent Medicine.  He writes: "My opposition to what I call Futile Care Theory has never been about withdrawing treatment that sustains life but does not provide cure or improvement, but about medical personnel and/or ethics committees forcing an end to treatment over the objections of those who want non elective treatment continued."  

It strikes me that depending on how the term "coercion" is used, I could almost agree with Wesley here.  It seems rare that providers literally coerce surrogates into stopping what the provider thinks is non-beneficial treatment.  Providers typically lack the power to take any such a position.  Far more relevant than coercion in this context is the ethical justifiability of persuasion and manipulation.  For example, the option to continue the ventilator is simply not presented or is not presented as a "real" option.  

In other words, medical personnel and ethics committees rarely "force" treatment over surrogate objections, because there often are no surrogate objections in the first place.  There is no conflict.  There appears to be consensus.  

However, that the consensus is arguably "manufactured" in the sense that the surrogates do not get full "Canterbury" style informed consent.  Providers have been rightly focusing their energies into avoiding futility disputes rather than into resolving them once they arise.   Some of this conflict avoidance comes through better ACP and through better EOL communication.  But some of this avoidance comes through preempting the surrogate's choice(s) at the front end rather than at the back end.