Why Do We Treat Hopeless Diseases? --A Philosophical and Ethical Inquiry into Patient and Physician Perspectives

Why Do We Treat Hopeless Diseases? --A Philosophical and Ethical Inquiry into Patient and Physician Perspectives | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Why Do We Treat Hopeless Diseases? --A Philosophical and Ethical Inquiry into Patient and Physician Perspectives Ling-Lang Huang This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5853347/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Decision-making for futile medical care is a significant challenge in contemporary bioethics, requiring a balance between life extension, quality of life, and the value of life. This study explores the effectiveness of Shared Decision-Making (SDM) in the context of futile medical care. Methods: This study adopts Heidegger's concept of "being-in-the-world" and Gadamer's "fusion of horizons" as its philosophical foundation. Semi-structured interviews were conducted with one patient and three treating physicians (a cardiologist, a cardiac surgeon, and a gynecologic oncologist). The Interpretative Phenomenological Analysis (IPA) method was used to analyze the reasons behind their willingness to pursue aggressive treatment despite evidence-based medicine (EBM) indicating futile care. Results: The findings reveal that significant differences in values between physicians and patients profoundly influence decision-making for futile medical care. A "good decision" does not always equate to a "right decision." Furthermore, patients need to be "included in the horizon" of physicians, meaning they must be fully seen and understood as whole and independent individuals. This inclusion is a crucial prerequisite for achieving the "fusion of horizons," fostering deeper interaction and mutual understanding between physicians and patients. Conclusions: Comprehensive SDM should be grounded in the "fusion of horizons" to promote meaningful understanding between physicians and patients. This study underscores the importance of integrating philosophical perspectives into clinical interactions to address the complexities of futile medical care. Three practical steps are proposed to enhance the implementation of SDM, offering guidance for clinical decision-making. Figures Figure 1 Background With the advancement of medical technology, clinical choices have become increasingly diverse, posing significant challenges in achieving optimal medical decisions mutually recognized by both physicians and patients. Physicians' recommendations based on Evidence-Based Medicine (EBM) may sometimes conflict with patients' holistic healthcare perspectives, which are rooted in their overall life considerations. This discrepancy becomes particularly evident when evaluating futile medical care, further testing the practice of Shared Decision-Making (SDM). The case of Ms. Wan, a terminal cervical cancer patient, highlights this challenge: “Ms. Wan (49 years old) was diagnosed with stage I cervical cancer at Hospital A in March 2021 and subsequently underwent three rounds of chemotherapy. However, the 8 cm tumor did not shrink, and by October, metastasis to the heart and left clavicle was detected. Physicians at Hospital A assessed that continued aggressive treatment constituted futile medical care and recommended a transition to palliative care. Nevertheless, Ms. Wan, unwilling to abandon hope, sought aggressive treatment at Hospital B. Physicians at Hospital B, understanding her expectations, decided to proceed with surgery and subsequent chemotherapy.” This case illustrates the divergence between physicians and patients regarding decisions on "futile medical care." While "objective" medical evidence inevitably encounters the challenge of "subjective" value judgments when addressing end-of-life issues, the process from disease assessment to medical decision-making is unavoidably influenced by subjective values. To date, there is no consensus on who should determine futile medical care. Some scholars argue that such judgments should be physician-led based on professional knowledge and evidence( 1 ), while others emphasize respecting patients' values and autonomy ( 2 ) or achieving a consensus through physician-patient collaboration ( 3 ). Still, others advocate for decision-making guided by established treatment goals ( 4 ). In addressing the boundary issues of futile medical care, we must return to the fundamental question: "What are the goals of medicine?" ( 5 ). According to Heidegger's (1962) theory of "being-in-the-world" and "temporality," individual medical decisions are inevitably influenced by their lifeworld and inner temporality (their past experiences, current circumstances, and future expectations). Physicians' clinical recommendations are grounded in their professional expertise, practical experience, and underlying value system. When there are significant differences between the life worlds of physicians and patients, reaching a consensus becomes even more challenging. The judgment of futile medical care is not a simple dichotomy between physicians' "evidence-based medicine" and patients' "values." Instead, the focus in the SDM process should be on the "fusion of horizons" ( 6 ) between physicians and patients. This study employs Interpretative Phenomenological Analysis (IPA) to conduct semi-structured interviews with Ms. Wan and three attending physicians from Hospital B (specialists in cardiology, cardiac surgery, and gynecologic oncology). By exploring factors influencing the willingness of both physicians and patients to continue treatment for a disease deemed hopeless by evidence-based standards, this study aims to address the question: "What are the goals of medicine?" Simultaneously, it seeks to supplement the practical steps of SDM based on the philosophical perspectives of Heidegger and Gadamer, promoting the integration of evidence-based medicine and holistic healthcare. Methods This study adopts Interpretative Phenomenological Analysis (IPA) as the research methodology, which emphasizes individuals' subjective experiences. This approach allows us to identify how individuals understand and interpret the phenomena they encounter ( 7 ). Through semi-structured interviews, an intrinsic case study ( 8 ) was conducted involving the patient and three attending physicians at Hospital B (specialists in cardiology, cardiac surgery, and gynecologic oncology). The aim was to identify the patient's needs and decision-making considerations during the medical process, as well as the physicians' motivations and values behind their choice of pursuing aggressive treatment. Interview Design and Participants This study primarily interviewed three physicians from Hospital B and Ms. Wan. The selection of Ms. Wan and the physicians from Hospital B as participants was based on the following reasons: Ms. Wan experienced a rapid deterioration of her condition within seven months (from stage I to terminal cervical cancer) and demonstrated distinctly different physician-patient relationships in the SDM processes with physicians from Hospitals A and B. The decision by physicians at Hospital B to pursue aggressive treatment provided a contrasting perspective for exploring the determination of futile medical care. A limitation of this study is that, due to Ms. Wan’s unfortunate passing during the research period, we were unable to interview physicians from Hospital A to directly understand the considerations behind their treatment decisions. However, through Ms. Wan's accounts and her medical records, we partially reconstructed the treatment recommendations and the criteria for determining futile medical care used by the physicians at Hospital A. Although this data does not come from primary sources, it provides a foundational perspective for comparing the decision-making processes of physicians from Hospitals A and B. Interview Process and Framework The interview process was approved by the Institutional Review Board (IRB) and conducted only after all participants provided written informed consent. The interviews were conducted face-to-face, lasting approximately 25–40 minutes, using a semi-structured interview framework. IPA focuses on a detailed examination of an individual's specific experience, and if the questions posed are too broad or abstract, participants may find it challenging to provide relevant answers ( 7 ). Therefore, we designed a total of ten questions for the interviews (see Table 1). Patient Interview Questions (Total: 10) Doctor Interview Questions (Total: 8) 1. Please share the entire course of your illness. 1. Please describe how you got to know and treated this patient. 2. What were your greatest fears and anxieties throughout the process? 2. What was your initial impression when you first saw this patient? 3. How did you make medical decisions during this process? Did you decide by yourself or discuss it with others? 3. During your interactions, what needs and pressures did you perceive the patient had? 4. Did their opinions affect your decisions? Whose opinion had the most influence on your choices? 4. What factors did you consider when giving medical advice to the patient? Did their life concerns affect your medical advice? 5. What were your feelings when making the final medical decision? Were you scared or worried? 5. What were your feelings when advising the patient? Did you have any worries or fears? 6. Did you fully understand the doctor's explanations? How did you handle situations when you didn't understand? 6. Did the patient fully understand your explanations? How was the communication between you and the patient? 7. How did you feel about the doctor during this process? Can you describe your communication with the doctor? 7. What was your most significant source of stress throughout the medical process? 8. What factors did you consider when making medical decisions? For example, family, friends, finances, etc. 8. After the treatment, is there anything you regret? 9. What kind of help did you expect from the doctor throughout the medical process? 10. How did you want people around you to treat and interact with you during your illness? What kind of support did you expect from them? (Table 1: Interview Questions) Results and Discussion The analysis of the interview data identified three critical factors that must be considered when conducting SDM for futile medical care: the distinction between a good decision and a right decision, holistic care for the patient, and the fusion of horizons. Based on the philosophical perspectives of Heidegger and Gadamer, this study provides recommendations for refining the steps of SDM. Each of these themes and their core implications are discussed in detail below. From Right Decision to Good Decision: The Ethics of Futility The concept of "futile medical care" has become a topic of increasing discussion. Although it appears to have an objective consensus, this is not entirely the case ( 9 ). A "one-size-fits-all definition" does not exist ( 10 ) because the determination of futile medical care involves multiple moral principles and perspectives ( 11 ). Schneiderman proposed a widely cited definition of futile medical care, categorizing it into two types( 12 ): Quantitative medical futility is related to the success of a treatment in achieving its intended goals. Qualitative medical futility is related to the value of a treatment to a patient’s QOL. Some scholars have further divided futile medical care into physiologic futility, quantitative futility, and qualitative futility ( 13 ). However, these classifications often lead to conflicts in clinical practice, particularly in ethical considerations, suggesting that there is no "absolutely objective" standard for determining futile medical care. Furthermore, observations from this study's case reveal that the judgments of futile medical care made by physicians at Hospitals A and B were inevitably influenced by their own values, which shaped their emphasis on different aspects of "futility": Hospital A Physicians, considering physiologic futility, believed that surgery would only exacerbate the patient's suffering and therefore recommended palliative care. Furthermore, they refused to provide aggressive treatment for the patient. Hospital B While acknowledging the risks of surgery, physicians centered their decisions on the patient's values (qualitative futility) and opted for aggressive treatment. Through interviews with three physicians from Hospital B, we discovered that, despite their shared focus on qualitative futility, the underlying reasons for their decisions reflected significant differences in values: Cardiologist Emphasized the value of medical actions in terms of the patient's "experience and meaning." He noted, "Even if performing this surgery is only to help her better prepare for the end of her life, I think it is worthwhile." Cardiac Surgeon Focused on the physiological benefits of surgery and its ability to address specific problems. He stated, "I primarily considered the medical aspects... if I subjected her to the risks of surgery, what kind of benefits could this risk bring her?" Gynecologic Oncologist Highlighted the importance of extending life, particularly emphasizing the value of every moment for cancer patients. He remarked, "For cancer patients, living an additional three or six months is meaningful to us." These differences indicate that even within the same medical case, interpretations of futile medical care vary significantly among physicians from different professional backgrounds. While the physicians at Hospital B recognized the limited efficacy of aggressive treatment in terms of "prolonging life," they prioritized the profound impact of treatment on the "meaning of life." As a result, they leaned towards aligning evidence-based medicine (EBM) judgments with the patient's values. This prompts a reflection on the essence and purpose of medicine: Should physicians prioritize "goodness" at the core, or should they be guided by "rightness"? This discussion is extended in the study by Schneiderman and Jecker (2011). Some scholars argue that the purpose of medicine lies in doing good, and thus, physicians not only have the right to refuse futile medical interventions but also bear the obligation to prevent unnecessary suffering for patients. Others contend that the core of medicine is to improve patients' quality of life rather than merely maintaining physiological functions ( 14 ). These differing perspectives have sparked debates on the prioritization of medical decisions—should the focus be on evidence-based "right decisions," or should priority be given to "good decisions" that respect patients' life needs? When these two goals conflict, which should take precedence? In the era when medicine was regarded as an art, Plato once warned: " You ought not to attempt to cure the eyes without the head, or the head without the body... neither ought you to attempt to cure the body without the soul " ( 15 ). This concept of treating the "patient as a whole" is even more critical in modern medicine ( 16 ), as advancements in technology have allowed the separation of the physical, mental, and spiritual aspects of patients. While life-support systems can prolong a patient’s life, they may also lead to a loss of quality of living, a phenomenon Daniel Callahan referred to as the "terrible mercy" ( 17 ). Therefore, in the context of futile medical care, clear boundaries should be established, prioritizing the "good decision" of the patient over the "right decision." The "patient" should not be regarded as a collective noun. Heidegger used the term Dasein to refer to each individual being ( 18 ), emphasizing that every individual exists before us as an independent entity. Each being has its unique lifeworld, and we cannot understand them apart from their lifeworld. This is what Heidegger referred to as "Being-in-the-world." At the same time, Heidegger redefined our understanding of time, stressing that time exists within us, rather than us existing within time. The triadic structure of "past-present-future" is not fragmented; the decisions we make "in the moment" are inevitably influenced by the historicity of our "past" and the projection toward our "future." Similarly, Gadamer argued that the major problem with the objectivity emphasized by science is that it erases the inherent historicity of experience ( 6 ). For each unique patient, the objectivity of EBM may conflict with the individuality of the patient. Therefore, universal data should not be applied indiscriminately to every unique clinical context and patient. The determination of "futile" medical care should be flexible. While the objective assessment of physiologic futility may fluctuate based on the patient's value judgments and life circumstances, qualitative futility more closely aligns with the vision of holistic care. From the interviews, we observed that throughout the series of medical decision-making processes, Ms. Wan was no longer a mere collection of reported data under medical observation. Instead, she revealed her authentic existence through her understanding of and expectations for her own life. In the process of rejecting or accepting physicians' medical recommendations, the patient's subjectivity was fully unveiled. For instance, undergoing surgery to extend life by merely three months might seem unworthy to some patients, while others might desperately need those three months to complete their life journey. These are crucial aspects that must be considered when conducting SDM. Holistic Care for the Patient During the interviews, Ms. Wan displayed a positive and resilient attitude, a characteristic also reflected in the descriptions provided by the three physicians. However, her two episodes of tears revealed a deep reliance on physicians' attention and support in the context of physician-patient interactions. This prompts a reevaluation of the importance of addressing patients' emotional needs and providing holistic support in medical decision-making. At Hospital A, the physicians explicitly recommended palliative care and stated that surgery was not suitable. While this direct recommendation was based on professional judgment, it left Ms. Wan feeling abandoned, leading to emotional distress. She recalled, "I asked, 'Does this mean I don’t even have the chance for surgery?' The doctor said, 'You do, but even if we operate, it would be pointless. I won’t perform surgery for you unless you end up in the ER in an emergency, and then I would operate.' …I felt like you had given up on me! I… I’m not incurable. I’m just harder to treat… I’m already struggling, but now you’re telling me this." In contrast, at Hospital B, the physician reshaped the physician-patient relationship through emotional support. Ms. Wan mentioned that the cardiologist stayed with her after the clinic hours to wait for her test results, demonstrating great attention and patience. She recalled, "All the other patients had left! The clinic was over! Yet he stayed in the consultation room with me to wait for my results… I felt like I had truly found a good doctor! He cared about me… Do you know what touched me the most about this doctor? The night before the surgery… he came to the ward specifically to see me, and he said… ‘I want to pray for you.’ It was the first time someone said they wanted to pray for me. Then he prayed for me, and after he left, I cried so much. He gave me so much confidence. I was initially very scared because it was my first time undergoing heart surgery." The tears Ms. Wan shed during these two narratives were deeply connected to her sense of "acceptance." Her emotional expressions not only reflected her level of acceptance of medical recommendations but also revealed her deeper needs—her desire to be seen as a fully recognized individual in the physician-patient interaction. Patients are not merely carriers of diseases; they have inner emotions and a need for acknowledgment and acceptance. They require not just a cure but also healing. When physicians stand alongside patients and provide emotional support, patients gain an extraordinary sense of strength and confidence ( 19 ). The concept of holistic care addresses not only patients' physiological issues but also offers critical support for their psychological and emotional well-being. As Charon pointed out in narrative medicine, physicians' emotional care is a fundamental cornerstone of building trust in the physician-patient relationship ( 20 ). The complete "visibility" of the patient during the medical process is an essential reflection of medical value. While treatment and therapy can be concretely evaluated for their efficacy, the meaning of care varies significantly ( 5 ). The boundary of futile medical care should signify the cessation of physiologic futility but not the cessation of care. For patients, the act itself is not the most critical factor; what truly matters is whether the physician can genuinely "see" the patient. Take Ms. Wan as an example: she was deeply moved by a prayer offered by her physician. However, the focus was not on the prayer itself, as Ms. Wan is not a Christian. What truly brought her to tears was the heartfelt effort someone made "for her"—offering blessings and comfort. For individuals enduring illness, such care carries profoundly significant meaning. Enhancing Shared Decision-Making (SDM): Fusion of Horizons This study proposes a set of recommendations for improving the Shared Decision-Making (SDM) process. Although Evidence-Based Medicine (EBM) provides an essential scientific foundation for medical decision-making, its "averaging" model ( 21 ) struggles to meet individualized needs. Since the ultimate bearer of medical interventions is the patient rather than the physician ( 10 ), and given the ambiguity, subjectivity, and complexity inherent in the definition of "futile medical care" ( 13 ), judgments based solely on medical or scientific perspectives are insufficient. As previously discussed, "good decisions" and "right decisions" are not always aligned in medical contexts. Physicians have a core responsibility to clearly communicate the "right decisions" derived from EBM to patients, bringing them closer to what patients perceive as "good decisions." Existing research indicates that the challenges surrounding futile medical care often stem from inadequate communication and understanding between physicians and patients ( 22 ). Therefore, integrating physician-driven EBM with Value-Based Medicine (VBM), which prioritizes patient well-being and care ( 23 ), is essential for enhancing the SDM process. According to the five steps of EBM ( 24 ), the first three steps (Ask—Acquire—Appraise) focus on the physiological aspects of the patient. However, the fourth and fifth steps (Apply—Assess) should be expanded to encompass the psychological and holistic being of the patient. During the application (Apply) of treatment plans and the final evaluation (Assess), a comprehensive assessment that incorporates holistic dimensions is necessary to achieve genuine holistic health care. The core of holistic health care lies in whether the patient's overall state of "being-in-the-world" (Heidegger) is acknowledged and valued by the physician. Patients not only care about whether their physical symptoms are treated but also about whether their emotions are addressed and whether their life values are respected. Through VBM, we emphasize the importance of the patient's overall life structure and further integrate Heidegger's concept of "being-in-the-world" and Gadamer's "fusion of horizons" to enhance the practice of SDM. We propose the following three coordinated steps (see Fig. 1): (Fig. 1: Steps to Enhance SDM) Step 1: Awareness Horizon refers to the perspective or framework of understanding shaped by an individual's historical background, culture, experiences, values, and prejudices ( 6 ). It serves as the starting point for understanding the world, but it is not fixed; it can expand through experience and learning. In the SDM process, physicians must recognize that each patient exists within a unique lifeworld, and the patient needs to truly "enter the horizon" to be fully seen. Simultaneously, physicians should be aware of the differences between their own horizon and that of the patient, acknowledging that the same illness may require different treatment approaches. Step 2: Integration Gadamer's concept of "Fusion of Horizons" does not advocate abandoning one's own horizon but instead expanding it to integrate with that of the patient. The key to this process is participation and listening. Physicians need to understand the patient's "being-in-the-world" to comprehend why a patient may reject an EBM-recommended optimal treatment plan. The "right decision" in Evidence-Based Medicine (EBM) does not always align with the individual needs of every patient, thereby failing to become a "good decision." Step 3: Respect If a patient, based on their overall life values, ultimately rejects the physician's EBM-based recommendation, the physician should set aside their adherence to scientific objectivity and respect the patient's final choice. However, we emphasize that the physician's role in the SDM process does not diminish, even if they are not the final arbiter of futile medical care. Physicians remain critical information providers who assist patients in making the best possible judgment, thereby avoiding concerns about being instrumentalized ( 25 ). Additionally, adopting the "good decision" as the ultimate criterion relieves physicians from the ethical pressure of either implementing or rejecting a patient's request for futile medical care ( 4 ). Conclusion The core of SDM lies in balancing the complementary relationship between Evidence-Based Medicine (EBM) and Value-Based Medicine (VBM). Treatment must be grounded in the scientific rigor of EBM to ensure objectivity and professionalism in medical decision-making. However, understanding and practice should be built on the foundation of VBM, which respects the individual needs and life values of patients. In this study, the issue of futile medical care is highlighted as a challenge involving differences in values between physicians and patients. Particularly in individual cases, the ultimate arbiter of boundaries should rest with the patient. However, this does not imply that the physician's role can be diminished or overlooked. The core responsibility of physicians is to assist patients in understanding the essence of treatment, including its potential significance, limitations, and risks. Physicians must tailor their communication and expression to the patient's individual differences, enabling patients to make decisions aligned with their values based on a comprehensive understanding. This process is not merely a transfer of medical knowledge but also a dialogue and collaboration founded on trust. The integration of physicians' professional expertise and patients' life values is essential to achieving genuine SDM. This study further reveals that variations in physicians' values across different specialties significantly impact physician-patient dialogue and recommendations. Particularly in interdisciplinary collaborative settings, how physicians effectively communicate and negotiate within diverse value contexts to co-create optimal medical plans in the patient's best interest remains a critical issue requiring careful consideration in the future. Recognizing and respecting these value differences is the foundation for achieving patient-centered holistic care. Declarations Ethics approval and consent to participate: Trial Registration Details Registry : Not applicable (This study is not a clinical trial but a qualitative research project). Trial Registration Number : Not applicable. Date of Registration : Not applicable. This study adheres to the principles of the Declaration of Helsinki. Approval was granted by the Institutional Review Board, Mackay Memorial Hospital, Taipei, Taiwan (Approval No. MMH-21MMHIS154e) on August 3, 2021. Consent for publication ： Not applicable Availability of data and materials ： The interview data used in this study includes records from one patient and three physicians. Due to the sensitive nature of the information and concerns regarding personal privacy, the data is securely stored in our institution's database. Researchers interested in accessing this data must obtain approval from our institution's ethics committee and sign a confidentiality agreement. For access requests, please contact the data manager, Ling-Lang Huang, via email at [email protected] . Competing interests ： The author declare that there have no financial interests. Funding: This work was supported by the Ministry of Science and Technology, Taiwan (Grant numbers：MOST 110-2511-H-715-001 - ). Authors' contributions ： The author solely conceptualized, designed, conducted the study, analyzed the data, and wrote the manuscript. The author read and approved the final manuscript. Acknowledgements ： The author would like to express heartfelt gratitude to all participants who generously shared their time and experiences during the interviews. Special thanks go to Ms. Wan, a patient who, despite being in the terminal stage of her illness, courageously shared her invaluable insights, which greatly enriched this study. The author also extends sincere appreciation to three physicians from different specialties for their thoughtful perspectives, which provided crucial depth and balance to the findings. The author honors and respects the contributions of all participants, whose input has been essential to advancing understanding in this field. Authors' information ： The author has a background in philosophy and currently teaches Medical Humanities and Medical Ethics in a medical school. With a longstanding focus on related issues, the author aims to integrate philosophical perspectives into the medical field to enrich discussions on holistic care. 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Economic and philosophic manuscripts of 1844. Mineola, N.Y.: Dover Publications; 2007. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5853347","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":409504287,"identity":"4fc0e58a-6dbe-46de-b069-d9ac31e5bcff","order_by":0,"name":"Ling-Lang Huang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA2UlEQVRIiWNgGAWjYFACxgYGhgq2en4QO6GAOC2NDQxn+BIkG0BaDIi1hrFNLsHgAIhNjBb+aYfbH/O2meUZn1+d+OGBAYM8v9gB/Fokbic2NvOcSys2u/F2swTQYYYzZycQsAaspewY47YbZzeAtCQY3CagRR6she0/4+YZZzf/IEqLAVhLG1viBv7ebcTZYgjUMnPOGTZjiRu82ywSDCQI+0XudvqDD28q2OT4+89uvvmjwkaeX5qAFhBg4gGREmCVEoSVgwDjDxDJf4A41aNgFIyCUTDyAAAN7EoIxr05owAAAABJRU5ErkJggg==","orcid":"","institution":"Mackay Medical College","correspondingAuthor":true,"prefix":"","firstName":"Ling-Lang","middleName":"","lastName":"Huang","suffix":""}],"badges":[],"createdAt":"2025-01-18 06:53:02","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5853347/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5853347/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":75314987,"identity":"e2531af6-80ac-44ac-b5c7-543f7b56ddfc","added_by":"auto","created_at":"2025-02-03 09:34:32","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":77091,"visible":true,"origin":"","legend":"\u003cp\u003eSteps to Enhance SDM\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-5853347/v1/e22b4a60c68b812987061cf1.png"},{"id":77318771,"identity":"06c84813-e0ef-4ad2-be26-0d56146e7b4e","added_by":"auto","created_at":"2025-02-27 11:08:20","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1506870,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5853347/v1/be34c845-36fd-401f-9da6-c81c8b5f2f46.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Why Do We Treat Hopeless Diseases? --A Philosophical and Ethical Inquiry into Patient and Physician Perspectives","fulltext":[{"header":"Background","content":"\u003cp\u003eWith the advancement of medical technology, clinical choices have become increasingly diverse, posing significant challenges in achieving optimal medical decisions mutually recognized by both physicians and patients. Physicians' recommendations based on Evidence-Based Medicine (EBM) may sometimes conflict with patients' holistic healthcare perspectives, which are rooted in their overall life considerations. This discrepancy becomes particularly evident when evaluating futile medical care, further testing the practice of Shared Decision-Making (SDM).\u003c/p\u003e \u003cp\u003eThe case of Ms. Wan, a terminal cervical cancer patient, highlights this challenge: \u003cb\u003e\u0026ldquo;Ms. Wan (49 years old) was diagnosed with stage I cervical cancer at Hospital A in March 2021 and subsequently underwent three rounds of chemotherapy. However, the 8 cm tumor did not shrink, and by October, metastasis to the heart and left clavicle was detected. Physicians at Hospital A assessed that continued aggressive treatment constituted futile medical care and recommended a transition to palliative care. Nevertheless, Ms. Wan, unwilling to abandon hope, sought aggressive treatment at Hospital B. Physicians at Hospital B, understanding her expectations, decided to proceed with surgery and subsequent chemotherapy.\u0026rdquo;\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThis case illustrates the divergence between physicians and patients regarding decisions on \"futile medical care.\" While \"objective\" medical evidence inevitably encounters the challenge of \"subjective\" value judgments when addressing end-of-life issues, the process from disease assessment to medical decision-making is unavoidably influenced by subjective values. To date, there is no consensus on who should determine futile medical care. Some scholars argue that such judgments should be physician-led based on professional knowledge and evidence(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e), while others emphasize respecting patients' values and autonomy (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) or achieving a consensus through physician-patient collaboration (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Still, others advocate for decision-making guided by established treatment goals (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). In addressing the boundary issues of futile medical care, we must return to the fundamental question: \"What are the goals of medicine?\" (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAccording to Heidegger's (1962) theory of \"being-in-the-world\" and \"temporality,\" individual medical decisions are inevitably influenced by their lifeworld and inner temporality (their past experiences, current circumstances, and future expectations). Physicians' clinical recommendations are grounded in their professional expertise, practical experience, and underlying value system. When there are significant differences between the life worlds of physicians and patients, reaching a consensus becomes even more challenging. The judgment of futile medical care is not a simple dichotomy between physicians' \"evidence-based medicine\" and patients' \"values.\" Instead, the focus in the SDM process should be on the \"fusion of horizons\" (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e) between physicians and patients.\u003c/p\u003e \u003cp\u003eThis study employs Interpretative Phenomenological Analysis (IPA) to conduct semi-structured interviews with Ms. Wan and three attending physicians from Hospital B (specialists in cardiology, cardiac surgery, and gynecologic oncology). By exploring factors influencing the willingness of both physicians and patients to continue treatment for a disease deemed hopeless by evidence-based standards, this study aims to address the question: \"What are the goals of medicine?\" Simultaneously, it seeks to supplement the practical steps of SDM based on the philosophical perspectives of Heidegger and Gadamer, promoting the integration of evidence-based medicine and holistic healthcare.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis study adopts Interpretative Phenomenological Analysis (IPA) as the research methodology, which emphasizes individuals' subjective experiences. This approach allows us to identify how individuals understand and interpret the phenomena they encounter (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Through semi-structured interviews, an intrinsic case study (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e) was conducted involving the patient and three attending physicians at Hospital B (specialists in cardiology, cardiac surgery, and gynecologic oncology). The aim was to identify the patient's needs and decision-making considerations during the medical process, as well as the physicians' motivations and values behind their choice of pursuing aggressive treatment.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eInterview Design and Participants\u003c/h2\u003e \u003cp\u003eThis study primarily interviewed three physicians from Hospital B and Ms. Wan. The selection of Ms. Wan and the physicians from Hospital B as participants was based on the following reasons:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eMs. Wan experienced a rapid deterioration of her condition within seven months (from stage I to terminal cervical cancer) and demonstrated distinctly different physician-patient relationships in the SDM processes with physicians from Hospitals A and B.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eThe decision by physicians at Hospital B to pursue aggressive treatment provided a contrasting perspective for exploring the determination of futile medical care.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eA limitation of this study is that, due to Ms. Wan\u0026rsquo;s unfortunate passing during the research period, we were unable to interview physicians from Hospital A to directly understand the considerations behind their treatment decisions. However, through Ms. Wan's accounts and her medical records, we partially reconstructed the treatment recommendations and the criteria for determining futile medical care used by the physicians at Hospital A. Although this data does not come from primary sources, it provides a foundational perspective for comparing the decision-making processes of physicians from Hospitals A and B.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eInterview Process and Framework\u003c/h3\u003e\n\u003cp\u003eThe interview process was approved by the Institutional Review Board (IRB) and conducted only after all participants provided written informed consent. The interviews were conducted face-to-face, lasting approximately 25\u0026ndash;40 minutes, using a semi-structured interview framework. IPA focuses on a detailed examination of an individual's specific experience, and if the questions posed are too broad or abstract, participants may find it challenging to provide relevant answers (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Therefore, we designed a total of ten questions for the interviews (see Table\u0026nbsp;1).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Taba\" border=\"1\"\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatient Interview Questions (Total: 10)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDoctor Interview Questions (Total: 8)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1. Please share the entire course of your illness.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1. Please describe how you got to know and treated this patient.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2. What were your greatest fears and anxieties throughout the process?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2. What was your initial impression when you first saw this patient?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3. How did you make medical decisions during this process? Did you decide by yourself or discuss it with others?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3. During your interactions, what needs and pressures did you perceive the patient had?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4. Did their opinions affect your decisions? Whose opinion had the most influence on your choices?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4. What factors did you consider when giving medical advice to the patient? Did their life concerns affect your medical advice?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5. What were your feelings when making the final medical decision? Were you scared or worried?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5. What were your feelings when advising the patient? Did you have any worries or fears?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6. Did you fully understand the doctor's explanations? How did you handle situations when you didn't understand?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6. Did the patient fully understand your explanations? How was the communication between you and the patient?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7. How did you feel about the doctor during this process? Can you describe your communication with the doctor?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7. What was your most significant source of stress throughout the medical process?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8. What factors did you consider when making medical decisions? For example, family, friends, finances, etc.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8. After the treatment, is there anything you regret?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e9. What kind of help did you expect from the doctor throughout the medical process?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10. How did you want people around you to treat and interact with you during your illness? What kind of support did you expect from them?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003e(Table\u0026nbsp;1: Interview Questions)\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Results and Discussion","content":"\u003cp\u003eThe analysis of the interview data identified three critical factors that must be considered when conducting SDM for futile medical care: the distinction between a good decision and a right decision, holistic care for the patient, and the fusion of horizons. Based on the philosophical perspectives of Heidegger and Gadamer, this study provides recommendations for refining the steps of SDM. Each of these themes and their core implications are discussed in detail below.\u003c/p\u003e\n\u003ch3\u003eFrom Right Decision to Good Decision: The Ethics of Futility\u003c/h3\u003e\n\u003cp\u003eThe concept of \"futile medical care\" has become a topic of increasing discussion. Although it appears to have an objective consensus, this is not entirely the case (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). A \"one-size-fits-all definition\" does not exist (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e) because the determination of futile medical care involves multiple moral principles and perspectives (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Schneiderman proposed a widely cited definition of futile medical care, categorizing it into two types(\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e):\u003c/p\u003e \u003cp\u003e \u003cb\u003eQuantitative medical futility is related to the success of a treatment in achieving its intended goals.\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eQualitative medical futility is related to the value of a treatment to a patient\u0026rsquo;s QOL.\u003c/b\u003e \u003c/p\u003e \u003cp\u003eSome scholars have further divided futile medical care into physiologic futility, quantitative futility, and qualitative futility (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). However, these classifications often lead to conflicts in clinical practice, particularly in ethical considerations, suggesting that there is no \"absolutely objective\" standard for determining futile medical care.\u003c/p\u003e \u003cp\u003eFurthermore, observations from this study's case reveal that the judgments of futile medical care made by physicians at Hospitals A and B were inevitably influenced by their own values, which shaped their emphasis on different aspects of \"futility\":\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eHospital A\u003c/strong\u003e \u003cp\u003ePhysicians, considering physiologic futility, believed that surgery would only exacerbate the patient's suffering and therefore recommended palliative care. Furthermore, they refused to provide aggressive treatment for the patient.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eHospital B\u003c/strong\u003e \u003cp\u003eWhile acknowledging the risks of surgery, physicians centered their decisions on the patient's values (qualitative futility) and opted for aggressive treatment.\u003c/p\u003e \u003c/p\u003e \u003cp\u003eThrough interviews with three physicians from Hospital B, we discovered that, despite their shared focus on qualitative futility, the underlying reasons for their decisions reflected significant differences in values:\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eCardiologist\u003c/strong\u003e \u003cp\u003eEmphasized the value of medical actions in terms of the patient's \"experience and meaning.\" He noted, \u003cb\u003e\"Even if performing this surgery is only to help her better prepare for the end of her life, I think it is worthwhile.\"\u003c/b\u003e\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eCardiac Surgeon\u003c/strong\u003e \u003cp\u003eFocused on the physiological benefits of surgery and its ability to address specific problems. He stated, \u003cb\u003e\"I primarily considered the medical aspects... if I subjected her to the risks of surgery, what kind of benefits could this risk bring her?\"\u003c/b\u003e\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eGynecologic Oncologist\u003c/strong\u003e \u003cp\u003eHighlighted the importance of extending life, particularly emphasizing the value of every moment for cancer patients. He remarked, \u003cb\u003e\"For cancer patients, living an additional three or six months is meaningful to us.\"\u003c/b\u003e\u003c/p\u003e \u003c/p\u003e \u003cp\u003eThese differences indicate that even within the same medical case, interpretations of futile medical care vary significantly among physicians from different professional backgrounds. While the physicians at Hospital B recognized the limited efficacy of aggressive treatment in terms of \"prolonging life,\" they prioritized the profound impact of treatment on the \"meaning of life.\" As a result, they leaned towards aligning evidence-based medicine (EBM) judgments with the patient's values.\u003c/p\u003e \u003cp\u003eThis prompts a reflection on the essence and purpose of medicine: Should physicians prioritize \"goodness\" at the core, or should they be guided by \"rightness\"?\u003c/p\u003e \u003cp\u003eThis discussion is extended in the study by Schneiderman and Jecker (2011). Some scholars argue that the purpose of medicine lies in doing good, and thus, physicians not only have the right to refuse futile medical interventions but also bear the obligation to prevent unnecessary suffering for patients. Others contend that the core of medicine is to improve patients' quality of life rather than merely maintaining physiological functions (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). These differing perspectives have sparked debates on the prioritization of medical decisions\u0026mdash;should the focus be on evidence-based \"right decisions,\" or should priority be given to \"good decisions\" that respect patients' life needs? When these two goals conflict, which should take precedence?\u003c/p\u003e \u003cp\u003eIn the era when medicine was regarded as an art, Plato once warned: \"\u003cb\u003eYou ought not to attempt to cure the eyes without the head, or the head without the body... neither ought you to attempt to cure the body without the soul\u003c/b\u003e\" (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). This concept of treating the \"patient as a whole\" is even more critical in modern medicine (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e), as advancements in technology have allowed the separation of the physical, mental, and spiritual aspects of patients. While life-support systems can prolong a patient\u0026rsquo;s life, they may also lead to a loss of quality of living, a phenomenon Daniel Callahan referred to as the \"terrible mercy\" (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Therefore, in the context of futile medical care, clear boundaries should be established, prioritizing the \"good decision\" of the patient over the \"right decision.\"\u003c/p\u003e \u003cp\u003eThe \"patient\" should not be regarded as a collective noun. Heidegger used the term \u003cb\u003eDasein\u003c/b\u003e to refer to each individual being (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e), emphasizing that every individual exists before us as an independent entity. Each being has its unique lifeworld, and we cannot understand them apart from their lifeworld. This is what Heidegger referred to as \"Being-in-the-world.\" At the same time, Heidegger redefined our understanding of time, stressing that time exists within us, rather than us existing within time. The triadic structure of \"past-present-future\" is not fragmented; the decisions we make \"in the moment\" are inevitably influenced by the historicity of our \"past\" and the projection toward our \"future.\"\u003c/p\u003e \u003cp\u003eSimilarly, Gadamer argued that the major problem with the objectivity emphasized by science is that it erases the inherent historicity of experience (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). For each unique patient, the objectivity of EBM may conflict with the individuality of the patient. Therefore, universal data should not be applied indiscriminately to every unique clinical context and patient. The determination of \"futile\" medical care should be flexible. While the objective assessment of physiologic futility may fluctuate based on the patient's value judgments and life circumstances, qualitative futility more closely aligns with the vision of holistic care.\u003c/p\u003e \u003cp\u003eFrom the interviews, we observed that throughout the series of medical decision-making processes, Ms. Wan was no longer a mere collection of reported data under medical observation. Instead, she revealed her authentic existence through her understanding of and expectations for her own life. In the process of rejecting or accepting physicians' medical recommendations, the patient's subjectivity was fully unveiled. For instance, undergoing surgery to extend life by merely three months might seem unworthy to some patients, while others might desperately need those three months to complete their life journey. These are crucial aspects that must be considered when conducting SDM.\u003c/p\u003e\n\u003ch3\u003eHolistic Care for the Patient\u003c/h3\u003e\n\u003cp\u003eDuring the interviews, Ms. Wan displayed a positive and resilient attitude, a characteristic also reflected in the descriptions provided by the three physicians. However, her two episodes of tears revealed a deep reliance on physicians' attention and support in the context of physician-patient interactions. This prompts a reevaluation of the importance of addressing patients' emotional needs and providing holistic support in medical decision-making.\u003c/p\u003e \u003cp\u003eAt Hospital A, the physicians explicitly recommended palliative care and stated that surgery was not suitable. While this direct recommendation was based on professional judgment, it left Ms. Wan feeling abandoned, leading to emotional distress. She recalled, \u003cb\u003e\"I asked, 'Does this mean I don\u0026rsquo;t even have the chance for surgery?' The doctor said, 'You do, but even if we operate, it would be pointless. I won\u0026rsquo;t perform surgery for you unless you end up in the ER in an emergency, and then I would operate.' \u0026hellip;I felt like you had given up on me! I\u0026hellip; I\u0026rsquo;m not incurable. I\u0026rsquo;m just harder to treat\u0026hellip; I\u0026rsquo;m already struggling, but now you\u0026rsquo;re telling me this.\"\u003c/b\u003e\u003c/p\u003e \u003cp\u003eIn contrast, at Hospital B, the physician reshaped the physician-patient relationship through emotional support. Ms. Wan mentioned that the cardiologist stayed with her after the clinic hours to wait for her test results, demonstrating great attention and patience. She recalled, \u003cb\u003e\"All the other patients had left! The clinic was over! Yet he stayed in the consultation room with me to wait for my results\u0026hellip; I felt like I had truly found a good doctor! He cared about me\u0026hellip; Do you know what touched me the most about this doctor? The night before the surgery\u0026hellip; he came to the ward specifically to see me, and he said\u0026hellip; \u0026lsquo;I want to pray for you.\u0026rsquo; It was the first time someone said they wanted to pray for me. Then he prayed for me, and after he left, I cried so much. He gave me so much confidence. I was initially very scared because it was my first time undergoing heart surgery.\"\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThe tears Ms. Wan shed during these two narratives were deeply connected to her sense of \"acceptance.\" Her emotional expressions not only reflected her level of acceptance of medical recommendations but also revealed her deeper needs\u0026mdash;her desire to be seen as a fully recognized individual in the physician-patient interaction. Patients are not merely carriers of diseases; they have inner emotions and a need for acknowledgment and acceptance. They require not just a cure but also healing. When physicians stand alongside patients and provide emotional support, patients gain an extraordinary sense of strength and confidence (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe concept of holistic care addresses not only patients' physiological issues but also offers critical support for their psychological and emotional well-being. As Charon pointed out in narrative medicine, physicians' emotional care is a fundamental cornerstone of building trust in the physician-patient relationship (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). The complete \"visibility\" of the patient during the medical process is an essential reflection of medical value. While treatment and therapy can be concretely evaluated for their efficacy, the meaning of care varies significantly (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). The boundary of futile medical care should signify the cessation of physiologic futility but not the cessation of care.\u003c/p\u003e \u003cp\u003eFor patients, the act itself is not the most critical factor; what truly matters is whether the physician can genuinely \"see\" the patient. Take Ms. Wan as an example: she was deeply moved by a prayer offered by her physician. However, the focus was not on the prayer itself, as Ms. Wan is not a Christian. What truly brought her to tears was the heartfelt effort someone made \"for her\"\u0026mdash;offering blessings and comfort. For individuals enduring illness, such care carries profoundly significant meaning.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eEnhancing Shared Decision-Making (SDM): Fusion of Horizons\u003c/h2\u003e \u003cp\u003eThis study proposes a set of recommendations for improving the Shared Decision-Making (SDM) process. Although Evidence-Based Medicine (EBM) provides an essential scientific foundation for medical decision-making, its \"averaging\" model (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e) struggles to meet individualized needs. Since the ultimate bearer of medical interventions is the patient rather than the physician (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e), and given the ambiguity, subjectivity, and complexity inherent in the definition of \"futile medical care\" (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e), judgments based solely on medical or scientific perspectives are insufficient.\u003c/p\u003e \u003cp\u003eAs previously discussed, \"good decisions\" and \"right decisions\" are not always aligned in medical contexts. Physicians have a core responsibility to clearly communicate the \"right decisions\" derived from EBM to patients, bringing them closer to what patients perceive as \"good decisions.\" Existing research indicates that the challenges surrounding futile medical care often stem from inadequate communication and understanding between physicians and patients (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Therefore, integrating physician-driven EBM with Value-Based Medicine (VBM), which prioritizes patient well-being and care (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e), is essential for enhancing the SDM process.\u003c/p\u003e \u003cp\u003eAccording to the five steps of EBM (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e), the first three steps (Ask\u0026mdash;Acquire\u0026mdash;Appraise) focus on the physiological aspects of the patient. However, the fourth and fifth steps (Apply\u0026mdash;Assess) should be expanded to encompass the psychological and holistic being of the patient. During the application (Apply) of treatment plans and the final evaluation (Assess), a comprehensive assessment that incorporates holistic dimensions is necessary to achieve genuine holistic health care.\u003c/p\u003e \u003cp\u003eThe core of holistic health care lies in whether the patient's overall state of \"being-in-the-world\" (Heidegger) is acknowledged and valued by the physician. Patients not only care about whether their physical symptoms are treated but also about whether their emotions are addressed and whether their life values are respected. Through VBM, we emphasize the importance of the patient's overall life structure and further integrate Heidegger's concept of \"being-in-the-world\" and Gadamer's \"fusion of horizons\" to enhance the practice of SDM.\u003c/p\u003e \u003cp\u003eWe propose the following three coordinated steps (see Fig.\u0026nbsp;1):\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e(Fig.\u0026nbsp;1: Steps to Enhance SDM)\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStep 1: Awareness\u003c/h3\u003e\n\u003cp\u003eHorizon refers to the perspective or framework of understanding shaped by an individual's historical background, culture, experiences, values, and prejudices (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). It serves as the starting point for understanding the world, but it is not fixed; it can expand through experience and learning. In the SDM process, physicians must recognize that each patient exists within a unique lifeworld, and the patient needs to truly \"enter the horizon\" to be fully seen. Simultaneously, physicians should be aware of the differences between their own horizon and that of the patient, acknowledging that the same illness may require different treatment approaches.\u003c/p\u003e\n\u003ch3\u003eStep 2: Integration\u003c/h3\u003e\n\u003cp\u003eGadamer's concept of \"Fusion of Horizons\" does not advocate abandoning one's own horizon but instead expanding it to integrate with that of the patient. The key to this process is participation and listening. Physicians need to understand the patient's \"being-in-the-world\" to comprehend why a patient may reject an EBM-recommended optimal treatment plan. The \"right decision\" in Evidence-Based Medicine (EBM) does not always align with the individual needs of every patient, thereby failing to become a \"good decision.\"\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eStep 3: Respect\u003c/h2\u003e \u003cp\u003eIf a patient, based on their overall life values, ultimately rejects the physician's EBM-based recommendation, the physician should set aside their adherence to scientific objectivity and respect the patient's final choice. However, we emphasize that the physician's role in the SDM process does not diminish, even if they are not the final arbiter of futile medical care. Physicians remain critical information providers who assist patients in making the best possible judgment, thereby avoiding concerns about being instrumentalized (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). Additionally, adopting the \"good decision\" as the ultimate criterion relieves physicians from the ethical pressure of either implementing or rejecting a patient's request for futile medical care (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe core of SDM lies in balancing the complementary relationship between Evidence-Based Medicine (EBM) and Value-Based Medicine (VBM). Treatment must be grounded in the scientific rigor of EBM to ensure objectivity and professionalism in medical decision-making. However, understanding and practice should be built on the foundation of VBM, which respects the individual needs and life values of patients. In this study, the issue of futile medical care is highlighted as a challenge involving differences in values between physicians and patients. Particularly in individual cases, the ultimate arbiter of boundaries should rest with the patient. However, this does not imply that the physician's role can be diminished or overlooked.\u003c/p\u003e \u003cp\u003eThe core responsibility of physicians is to assist patients in understanding the essence of treatment, including its potential significance, limitations, and risks. Physicians must tailor their communication and expression to the patient's individual differences, enabling patients to make decisions aligned with their values based on a comprehensive understanding. This process is not merely a transfer of medical knowledge but also a dialogue and collaboration founded on trust. The integration of physicians' professional expertise and patients' life values is essential to achieving genuine SDM.\u003c/p\u003e \u003cp\u003eThis study further reveals that variations in physicians' values across different specialties significantly impact physician-patient dialogue and recommendations. Particularly in interdisciplinary collaborative settings, how physicians effectively communicate and negotiate within diverse value contexts to co-create optimal medical plans in the patient's best interest remains a critical issue requiring careful consideration in the future. Recognizing and respecting these value differences is the foundation for achieving patient-centered holistic care.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTrial Registration Details\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRegistry\u003c/strong\u003e: Not applicable (This study is not a clinical trial but a qualitative research project).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrial Registration Number\u003c/strong\u003e: Not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDate of Registration\u003c/strong\u003e: Not applicable.\u003c/p\u003e\n\u003cp\u003eThis study adheres to the principles of the Declaration of Helsinki. Approval was granted by the Institutional Review Board, Mackay Memorial Hospital, Taipei, Taiwan (Approval No. MMH-21MMHIS154e) on August 3, 2021.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003cstrong\u003e：\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003cstrong\u003e：\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe interview data used in this study includes records from one patient and three physicians. Due to the sensitive nature of the information and concerns regarding personal privacy, the data is securely stored in our institution\u0026apos;s database. Researchers interested in accessing this data must obtain approval from our institution\u0026apos;s ethics committee and sign a confidentiality agreement. For access requests, please contact the data manager, Ling-Lang Huang, via email at [email protected].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003cstrong\u003e：\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe author declare that there have no financial interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by\u0026nbsp;the\u0026nbsp;Ministry of Science and Technology, Taiwan\u003cbr\u003e\u0026nbsp; (Grant numbers：MOST 110-2511-H-715-001 - ).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003cstrong\u003e：\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe author solely conceptualized, designed, conducted the study, analyzed the data, and wrote the manuscript. The author read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003cstrong\u003e：\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe author would like to express heartfelt gratitude to all participants who generously shared their time and experiences during the interviews. Special thanks go to Ms. Wan, a patient who, despite being in the terminal stage of her illness, courageously shared her invaluable insights, which greatly enriched this study. The author also extends sincere appreciation to three physicians from different specialties for their thoughtful perspectives, which provided crucial depth and balance to the findings. The author honors and respects the contributions of all participants, whose input has been essential to advancing understanding in this field.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; information\u003c/strong\u003e\u003cstrong\u003e：\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe author has a background in philosophy and currently teaches Medical Humanities and Medical Ethics in a medical school. With a longstanding focus on related issues, the author aims to integrate philosophical perspectives into the medical field to enrich discussions on holistic care.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eTomlinson T, Michalski AJ, Pentz RD, Kuuppelomaki M. Futile care in oncology: when to stop trying. Lancet Oncol. 2001;2(12):759-64.\u003c/li\u003e\n\u003cli\u003eQuill TE. Caring for Patients at the End of Life: Facing an Uncertain Future Together: Oxford University Press; 2001.\u003c/li\u003e\n\u003cli\u003eSwetz KM, Burkle CM, Berge KH, Lanier WL. Ten Common Questions (and Their Answers) on Medical Futility. Mayo Clinic Proceedings. 2014;89(7):943-59.\u003c/li\u003e\n\u003cli\u003eKasman DL. When is medical treatment futile?: A guide for students, residents, and physicians. Journal of General Internal Medicine. 2004;19(10):1053-6.\u003c/li\u003e\n\u003cli\u003eSchneiderman LJ, Jecker NS. Wrong Medicine\u0026mdash;Doctors,Patients, and Futlle Treament. 2nd ed. Johns Hopkins University Press2011.\u003c/li\u003e\n\u003cli\u003eGadamer H-G. Truth and method New York: Continuum; 2004.\u003c/li\u003e\n\u003cli\u003eSmith JAF, Paul; Larkin, Michael. Interpretative phenomenological analysis: theory, method and research. Los Angeles: SAGE; 2009.\u003c/li\u003e\n\u003cli\u003eStake RE. The art of case study research: sage; 1995.\u003c/li\u003e\n\u003cli\u003eLemmens C. A New Style of End-of-life Cases: A Patient\u0026rsquo;s Right to Demand Treatment or a Physician\u0026rsquo;s Right to Refuse Treatment? The Futility Debate Revisited. European Journal of Health Law. 2013;20(2):167-83.\u003c/li\u003e\n\u003cli\u003eMuller R, Kaiser S. Perceptions of medical futility in clinical practice - A qualitative systematic review. J Crit Care. 2018;48:78-84.\u003c/li\u003e\n\u003cli\u003eMiller-Smith L. The True Abuse of Futility. Perspect Biol Med. 2018;60(3):403-7.\u003c/li\u003e\n\u003cli\u003eSchneiderman LJ, Jecker NS, Jonsen AR. Medical futility: response to critiques. Ann Intern Med. 1996;125(8):669-74.\u003c/li\u003e\n\u003cli\u003eMaryam A, Nahid Dehghan N. Medical futility and its challenges: a review study. Journal of Medical Ethics and History of Medicine. 2016;9(1).\u003c/li\u003e\n\u003cli\u003eHuynh TN, Kleerup EC, Wiley JF, Savitsky TD, Guse D, Garber BJ, et al. The frequency and cost of treatment perceived to be futile in critical care. JAMA Intern Med. 2013;173(20):1887-94.\u003c/li\u003e\n\u003cli\u003ePlato. Charmides in Plato: The Collected Dialogues. Princeton: Princeton University Press; 1964.\u003c/li\u003e\n\u003cli\u003eSaric L, Prkic I, Jukic M. Futile Treatment-A Review. J Bioeth Inq. 2017;14(3):329-37.\u003c/li\u003e\n\u003cli\u003eCallahan D. Setting Limits: Medical Goals in an Aging Society. New York: Simon and Schuster; 1987.\u003c/li\u003e\n\u003cli\u003eHeidegger M. Being and Time Harper \u0026amp; Row; 1962.\u003c/li\u003e\n\u003cli\u003eSampaio S, Motta LBD, Caldas CP. Value-based medicine and palliative care: how do they converge? Expert Rev Pharmacoecon Outcomes Res. 2019;19(5):509-15.\u003c/li\u003e\n\u003cli\u003eCharon R. Narrative Medicine. N.Y.: Oxford Univ. Press; 2006.\u003c/li\u003e\n\u003cli\u003eTomasi DL. Medical Philosophy: A Philosophical Analysis of Patient Self-Perception in Diagnostics and Therapy: Columbia University Press; 2016.\u003c/li\u003e\n\u003cli\u003eSibbald RW, Downar M, Hawryluck L. Perceptions of \u0026quot;Futile Care\u0026quot; Among Caregivers in Intensive Care Units. Canadian Medical Association Journal (CMAJ). 2007;177(10):1201-8.\u003c/li\u003e\n\u003cli\u003eAmmar A. Values-Based Medicine (VsBM) and Evidence-Based Medicine (EBM). 2019.\u003c/li\u003e\n\u003cli\u003eGordon Guyatt ea. Evidence-Based Medicine. A New Approach to Teaching the Practice of Medicine. JAMA. 1992;Volume 268, Issue 17:2420-5.\u003c/li\u003e\n\u003cli\u003eMarx K. Economic and philosophic manuscripts of 1844. Mineola, N.Y.: Dover Publications; 2007.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-5853347/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5853347/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBackground: Decision-making for futile medical care is a significant challenge in contemporary bioethics, requiring a balance between life extension, quality of life, and the value of life. This study explores the effectiveness of Shared Decision-Making (SDM) in the context of futile medical care.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMethods: This study adopts Heidegger's concept of \"being-in-the-world\" and Gadamer's \"fusion of horizons\" as its philosophical foundation. Semi-structured interviews were conducted with one patient and three treating physicians (a cardiologist, a cardiac surgeon, and a gynecologic oncologist). The Interpretative Phenomenological Analysis (IPA) method was used to analyze the reasons behind their willingness to pursue aggressive treatment despite evidence-based medicine (EBM) indicating futile care.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eResults: The findings reveal that significant differences in values between physicians and patients profoundly influence decision-making for futile medical care. A \"good decision\" does not always equate to a \"right decision.\" Furthermore, patients need to be \"included in the horizon\" of physicians, meaning they must be fully seen and understood as whole and independent individuals. This inclusion is a crucial prerequisite for achieving the \"fusion of horizons,\" fostering deeper interaction and mutual understanding between physicians and patients.\u003c/p\u003e\n\u003cp\u003eConclusions: Comprehensive SDM should be grounded in the \"fusion of horizons\" to promote meaningful understanding between physicians and patients. This study underscores the importance of integrating philosophical perspectives into clinical interactions to address the complexities of futile medical care. Three practical steps are proposed to enhance the implementation of SDM, offering guidance for clinical decision-making. \u0026nbsp;\u003c/p\u003e","manuscriptTitle":"Why Do We Treat Hopeless Diseases? --A Philosophical and Ethical Inquiry into Patient and Physician Perspectives","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-02-03 09:34:28","doi":"10.21203/rs.3.rs-5853347/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"8487972f-8a97-4f08-9ce2-8b9ce9bc0f25","owner":[],"postedDate":"February 3rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-02-27T11:08:10+00:00","versionOfRecord":[],"versionCreatedAt":"2025-02-03 09:34:28","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5853347","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5853347","identity":"rs-5853347","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}