Hostname: page-component-8448b6f56d-qsmjn Total loading time: 0 Render date: 2024-04-20T02:00:40.878Z Has data issue: false hasContentIssue false
  • English
  • Français

Medical Futility

Published online by Cambridge University Press:  29 April 2021

Steven H. Miles
Get access Rights & Permissions [Opens in a new window]

Extract

“Medical futility” may be provisionally defined as a medical conclusion that a therapy is of no value to a patient and should not be prescribed. The current debate about medical futility is one of the most important and contentious in medical ethics. Proponents believe that allowing physicians to determine and withhold futile therapies can he done without disturbing the current paradigm of medical ethics which respects patient autonomy with regard to informed consent and the right to refuse treatment. Others conclude that medical futility is simply an unacceptable form of medical paternalism. Some adopt a middle position that doctors can predict medical futility; they believe that attempting this does not necessarily justify imposing decisions to forgo life-sustaining therapy on patients.

Regardless of its policy outcome, this important debate is leading to a reexamination of the nature of a patient's entitlement to health care and of the ends of medicine. It has two aspects. A definitional debate examines rhe concept of medical futility and its derived clinical criteria.

Type
Article
Information
Law, Medicine and Healthcare , Volume 20 , Issue 4 , Winter 1992 , pp. 310 - 315
Copyright
Copyright © American Society of Law, Medicine and Ethics 1992

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

It is useful to restrict the definition of futility to a medical determination, rather than a patient's conclusion. There are well established principles and laws supporting a patient's right to refuse therapies which she considers futile, disproportionately burdensome, or morally objectionable with or without the concurrence of her physician. The current debate focuses on the circumstance of a physician's conclusion that a therapy is futile, either absent a patient's own preference or in the face of a dissenting conclusion by a patient or proxy.Google Scholar
Brock, D.W., Wartman, S.A., “When Competent Patients Make Irrational Choices.” New Engl J Med 1990; 322: 1595–1599.Google Scholar
Brett, A.S., McCullough, L.B., “When Patients Request Specific Interventions: Defining the Limits of the Physician's Obligation.” N Engl J Med 1986; 315(21): 1347–1351; Center, Hastings, Guidelines on the Termination of Life-Sustaining Treatment and the Care of the Dying, Briarcliff Manor, NY 1987, p. 32; Tomlinson, T., Brody, H., “Futility and the Ethics of Resuscitation”, JAMA 1990; 264(10): 1276–80; Youngner, S.J., “Futility in Context,” JAMA 1989; 264(10): 1295–96.Google Scholar
Paris, J.J., Crone, R.K., Reardon, F. “Physician's Refusal of Requested Treatment: The Case of Baby L.” New Engl J Med 1990; 322(14): 1012–1015; Miles, S.H., “Informed Demand for Non-Beneficial Medical Treatment,” New Eng J Med 1991: 325; 512–15; Reid, A., “After Transplant, a Fight over Care,” Boston Sunday Globe, June 23, 1991, pp. A21, 23; Ross, L., “Family Says Treatment Withheld,” Florida Times Union, May 23, 1991, pp. A1–2.CrossRefGoogle Scholar
See Tomlinson, et al., supra note 2; see Paris, et al., supra note 3; Blackhall, L., “Must We Always Do CPR?” New Eng J Med 1987; 317(20): 1281–84; Braithwaite, S., Thomasina, D.C., “New Guidelines on Foregoing Life-Sustaining Treatment in Incompetent Patients: An Anti-Cruelty Policy,” Annals Int Med 1986; 104: 711–15; Hackler, C.J., Hiller, F.C., “Family Consent to Orders not to Resuscitate,” JAMA 1990; 264(10): 1281; Moore, F.D., “The Desperate Case: (Costs, Applicability, Research, Ethics),” JAMA 1989; 261(10): 1483–84.Google Scholar
Weiser, B., “A Question of Letting Go,” Washington Post, July 14, 1991, PP. A1, 18–19; Smothers, R.D., “Atlanta Court Bars Efforts to End Life Support for Stricken Girl, 13,” New York Times Oct. 18, 1991, p. A10; In re Doe, Super. Ct., Fulton Cnty, Ga. CAF D-93064.Google Scholar
See Tomlinson, et al., supra note 2; Schneiderman, L.J., Jecker, N.S., Jonsen, A.R., “Medical Futility: Its Meaning and Ethical Implications,” Annals Int Med 1990; 112: 949–54.Google Scholar
Eckholm, E., “Patients and Insurers Clash on Therapy's Outer Limits,” New York Times, September 19, 1991, A1, A12.Google Scholar
See Tomlinson, et al., supra note 2.Google Scholar
See Schneiderman, et al., supra note 6.Google Scholar
Chervernak, F.A., McCullough, L.B., “Justified Limits on Refusing Intervention,” Hastings Center Report 1991; 21(2): 12–17.Google Scholar
Pearlman, R.A., Miles, S.H., Arnold, R.M., “Empiric Research in Medical Ethics,” J Theoret Med 1991; Murphy, D.J., Matchar, D.B., “Life-Sustaining Therapy: A Model for Appropriate Use,” JAMA 1990; 264: 2103–08; Knaus, W.A., Wagner, D.P., Lynn, J., “Short-Term Mortality Predictions for Critically Ill Hospitalized Adults: Science and Ethics,” Science 1991; 254;389–94.Google Scholar
See Schneiderman, et al., supra note 6; Lantos, J.D., Miles, S.H., Silverstein, M.D. et al., “Survival after Cardiopulmonary Resuscitation in Babies of Very Low Birth Weight,” New Eng J Med 1988; 318(2): 91–5; Youngner, S.J., “Who Defines Futility?” JAMA 1988; 260(14): 2094–5.Google Scholar
American Thoracic Society, “Withholding and Withdrawing Life-Sustaining Therapy,” Annals Int Med 1991; 115(6): 478–486; Task Force on Ethics, Society of Critical Care Medicine, “Consensus Report on the Ethics of Foregoing Life-Sustaining Treatments in the Critically Ill,” Critical Care Med 1990; 18: 1435–39.CrossRefGoogle Scholar
See Schneiderman, , supra note 6.Google Scholar
Council on Ethical and Judicial Affairs, AMA, “Guidelines for the Appropriate Use of Do-Not-Rcsuscitate Orders,” JAMA 1991; 265: 1868–71; Faber-Langendoen, K., “Resuscitation of Patients with Metastatic Cancer: Is Transient Benefit Still Futile?” Archives Int Med 1991; 151: 235–9.Google Scholar
See Miles, , supra note 3.Google Scholar
See Hackler, et al., supra note 4; see AMA, supra note 15; see Faber-Langendoen, , supra note 15; Murphy, D.J., “Do-Not-Resuscitate Orders: Time for Reappraisal in Long-Term Care Institutions,” JAMA 1988; 260(14): 2098–2101; Taffett, G.E., Teasdale, T.A., Luchi, R.J., “In Hospital Cardiopulmonary Resuscitation,” JAMA 1988; 260: 2069–72.Google Scholar
Jecker, N.S., “Knowing When to Stop: The Limits of Medicine,” Hastings Center Report 1991; 21(3): 5–8; Amundsen, D.W., “The Physician's Obligation to Prolong Life: A Medical Duty without Classical Roots,” Hastings Center Report 1978; 8: 23–30; Kass, L.R., Toward a more Natural Science: Biology and Human Affairs, New York, Free Press, 1985; see also Tomlinson, et al., supra note 4 and Schneiderman, et al., supra note 6.Google Scholar
See Murphy, et al., supra note 11.Google Scholar
Presidents Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research, Deciding to Forego Life-sustaining Treatment, US Government Printing Office, 1983, p.240; See Brock, et al., supra note 1; Farber, S.J., “Ethics of Life Support and Resuscitation,” N Eng J M 1988; 318: 1757.Google Scholar
Callahan, D., “Medical Futility, Medical Necessity: The Problem-Without-A-Name,” Hastings Center Report 1991; 21(July): 30–35.CrossRefGoogle Scholar
Callahan, D., Setting Limits: Medical Goals in an Aging Society. Simon and Schuster, New York, 1987.Google Scholar
See American Thoracic Society and Task Force on Ethics, supra note 13.Google Scholar
Applebaum, G.E., King, J.E., Finucane, T.E., “The Outcome of CPR Initiated in Nursing Homes,” J Am Geriatr Soc 1990; 38: 197–200; Council on Ethical and Judicial Affairs, AMA, Decisions Near the End of Life, 1991; see also Hacler, et al., supra note 4; Lantos, et al., supra note 12; and Taffett, et al., supra note 17.CrossRefGoogle Scholar
Miles, S. H., Driscoll, J., McCusker, M., “CPR in Nursing Homes: Policy and Clinical Realities,” Minnesota Med 1991; 74: 31–35; see also Taffett, et al., supra note 17 and Applebaum, et al., supra note 24.Google Scholar
See Tomlinson, et al., supra note 2, Chervernak, et al., supra note 10.Google Scholar
Department of Veterans Affairs, Withholding and Withdrawal of Life-Sustaining Treatment, M-2, Part I, Chapter 31.03.b(2).Google Scholar
See AMA, supra note 15.Google Scholar
See Taffett, et al., supra note 17, and Braithwaite, et al., supra note 4.Google Scholar
Angell, M., “The Case of Helga Wanglie. A New Kind (Right to Die) Case,” N Engl J Med. 1991; 325: 511–512.CrossRefGoogle Scholar
See Hackler, et al., supra note 4; Kass, , supra note 18; and Applebaum, et al., supra note 24.Google Scholar
Weber, M., The Development of Bureaucracy and its Relation to Law (translated from Wirtschaft, und Gesellshaaft, , 1922) in Weber: Selections in Translation. Ed Runciman, W.G. (trans by Mathews, E.) Cambridge University Press, 1978. p 351.Google Scholar
Lantos, J.D., Singer, P.A., Walker, R.M. et al., “The Illusion of Futility in Clinical Practice,” Amer J Med 1989; 87: 81–84.CrossRefGoogle Scholar
See Hackler, et al., supra note 4.Google Scholar
See Blackhall, , supra note 4.Google Scholar
See Tomlinson, et al., supra note 2; Youngner, et al., supra note 2; Murphy, et al., supra note 11; and AMA, supra note 15.Google Scholar
Miles, S.H., “Between a Dream and a Poem: Relational Perspectives on the Wanglie Case,” Kennedy Inst Ethics J. 1992; 2(1): 61–72; see Farber, supra note 20; see Weber, supra note 43.CrossRefGoogle Scholar
See Paris, et al., supra note 3.Google Scholar
See Miles, , supra note 3.Google Scholar
See Callahan, , supra note 22.Google Scholar
Bellah, R.N., Madsen, R., Sullivan, W.M. et al., The Good Society, Alfred A. Knopf, New York, 1991, pp. 10–11.Google Scholar
Ellul, J., The Technological Society, Vintage Books, 1964, New York.Google Scholar
Calabresi, G., Bobbitt, P., Tragic Choices. Norton & Co. New York, 1978.Google Scholar
Aaron, H., Schwartz, W.B., “Rationing Health Care: The Choice before Us,” Science 1990; 247: 418–422.CrossRefGoogle Scholar
Danis, M., Churchill, L., “Autonomy and the Common Weal,” Hastings Center Report 1991; 21(1): 25–32.CrossRefGoogle Scholar
Bellah, R.N., Madsen, R., Sullivan, W.M. et al., “Culture and Character” (pp. 27–39) in Habits of the Heart, University of California Press, 1985.Google Scholar
Berlin, I., “Two Concepts of Liberty,” and (from the Introduction) “Positive versus Negative Liberty,” in Four Essays on Liberty, Oxford University Press, 1969; 118–172, xxxvii-lv; see also Paris, et al., supra note 3, and Chervernak, et al., supra note 10.Google Scholar
Jonsen, A., “Bentham in a Box: Technology Assessment and Health Care Allocations,” Law Med Health Care 1986; 14: 172–174.CrossRefGoogle Scholar
Veatch, R.M., “Justice and the Economics of Terminal Illness,” Hastings Center Report 1988; 18(4): 34–40; see also Brock, et al., supra note 1; Murphy, et al., supra note 11; and Farher, supra note 20.CrossRefGoogle Scholar
See Ellul, , supra note 41.Google Scholar
Olick, R.S., “Brain Death, Religious Freedom, and Public Policy: New Jersey's Landmark Legislative Initiative,” Kennedy Institute of Ethics Journal 1991; 1:4: 275–292.CrossRefGoogle Scholar
Marsh, F.H., Staver, A., “Physician Authority for Unilateral DNR orders,” J Legal Med 1991; 12: 115–165.CrossRefGoogle Scholar
Brophy v. New England Sinai Hospital, 398 Mass. 417;497 NE 2d 626 (1986); see also Paris, et al., supra note 3; Miles, supra note 3; Reid, supra note 3; Ross, supra note 3; Weiser, supra note 5; and Smothers, supra note 5.Google Scholar
Council on Ethical and Judicial Affairs, American Medical Association. Decisions to Forego Life-Sustaining Treatment for Incompetent Patients, 1991; see also AMA, supra note 15; Faber-Langendoen, supra note 15; Jecker, supra note 18; and AMA, supra note 24.Google Scholar
See Paris, et al., supra note 3; Miles, supra note 3; Hackler, et al., supra note 4; and Schneiderman, et al., supra note 6.Google Scholar