This chapter addresses the close association between withholding and withdrawing futile life-sustaining medical treatments and assisting patients with hastening ending their lives. Section 12.2 sets forth a definition of medical futility and places this concept in the broader context of bioethical principles of autonomy, beneficence, nonmaleficence and justice. Section 12.3 draws out futility’s ethical implications and considers the view that physicians are ethically permitted to refrain from medically futile treatments, should be encouraged to refrain, or have (...) a duty to refrain. Section 12.4 examines ethical arguments that physicians also have a positive duty to assist patients with terminal conditions who are imminently dying to end their lives. It explores ethical arguments for assisted dying that appeal to the physicians’ significant responsibility and relationship with patients, the claimed moral equivalence of actions and omissions, and the medical goal of helping patients have a peaceful and dignified death. (shrink)

It probably should not be surprising, in this time of soaring medical costs and proliferating technology, that an intense debate has arisen over the concept of medical futility. Should doctors be doing all the things they are doing? In particular, should they be attempting treatments that have little likelihood of achieving the goals of medicine? What are the goals of medicine? Can we agree when medical treatment fails to achieve such goals? What should the physician do (...) and not do under such circumstances? Exploring these issues has forced us to revisit the doctor-patient relationship and the relationship of the medical profession to society in a most fundamental way. Medical futility has both a quantitative and qualitative component. I maintain that medical futility is the unacceptable likelihood of achieving an effect that the patient has the capacity to appreciate as a benefit. Both emphasized terms are important. A patient is neither a collection of organs nor merely an individual with desires. Rather, a patient (from the word to suffer ) is a person who seeks the healing (meaning to make whole ) powers of the physician. The relationship between the two is central to the healing process and the goals of medicine. Medicine today has the capacity to achieve a multitude of effects, raising and lowering blood pressure, speeding, slowing, and even removing and replacing the heart, to name but a minuscule few. But none of these effects is a benefit unless the patient has at the very least the capacity to appreciate it. Sadly, in the futility debate wherein some critics have failed or refused to define medical futility an important area of medicine has in large part been neglected, not only in treatment decisions at the bedside, but in public discussions—comfort care—the physician’s obligation to alleviate suffering, enhance well being and support the dignity of the patient in the last few days of life. (shrink)

Objectives Medical futility at the end of life is a growing challenge to medicine. The goals of the authors were to elucidate how clinicians define futility, when they perceive life-sustaining treatment (LST) to be futile, how they communicate this situation and why LST is sometimes continued despite being recognised as futile. Methods The authors reviewed ethics case consultation protocols and conducted semi-structured interviews with 18 physicians and 11 nurses from adult intensive and palliative care units at a (...) tertiary hospital in Germany. The transcripts were subjected to qualitative content analysis. Results Futility was identified in the majority of case consultations. Interviewees associated futility with the failure to achieve goals of care that offer a benefit to the patient's quality of life and are proportionate to the risks, harms and costs. Prototypic examples mentioned are situations of irreversible dependence on LST, advanced metastatic malignancies and extensive brain injury. Participants agreed that futility should be assessed by physicians after consultation with the care team. Intensivists favoured an indirect and stepwise disclosure of the prognosis. Palliative care clinicians focused on a candid and empathetic information strategy. The reasons for continuing futile LST are primarily emotional, such as guilt, grief, fear of legal consequences and concerns about the family's reaction. Other obstacles are organisational routines, insufficient legal and palliative knowledge and treatment requests by patients or families. Conclusion Managing futility could be improved by communication training, knowledge transfer, organisational improvements and emotional and ethical support systems. The authors propose an algorithm for end-of-life decision making focusing on goals of treatment. (shrink)

Partly because physicians can “never say never,” partly because of the seduction of modern technology, and partly out of misplaced fear of litigation, physicians have increasingly shown a tendency to undertake treatments that have no realistic expectation of success. For this reason, we have articulated common sense criteria for medical futility. If a treatment can be shown not to have worked in the last 100 cases, we propose that it be regarded as medically futile. Also, if the treatment (...) fails to restore consciousness or alleviate total dependence on intensive care, we propose such treatment be judged futile. This definition provides clear end points and encourages the profession to review data from the past and perform, prospective clinical studies that not only report treatments that work but also treatments that do not work. We have also argued that, in a variety of settings, physicians have no ordinary ethical obligation to offer futile interventions. Although physicians should inform, and discuss all decisions to withhold or withdraw medical treatments with patients, they need not obtain the patient's permission to desist from futile interventions. (shrink)

Our response to death may differ depending on the patient’s age. We may feel that death is a sad, but acceptable event in an elderly patient, yet feel that death in a very young patient is somehow unfair. This paper explores whether there is any ethical basis for our different responses. It examines in particular whether a patient’s age should be relevant to the determination that an intervention is medically futile. It also considers the responsibilities of health professionals and the (...) rights of family members in situations where an interventions is clearly futile. (shrink)

The concept of medical futility has come to be seen in some quarters as a value-neutral trump card when dealing with issues of power and conflicting values in medicine. I argue that this concept is potentially useful, but only in a social context that provides a normative framework for its use. This social context needs to include a broad consensus about the purpose of medicine and the nature of the physician-patient relationship.

This paper introduces the medical factual matrix as a new and potentially valuable tool in medical ethical analysis. Using this tool it demonstrates the idea that a defined medical intervention can only be meaningfully declared futile in relation to a defined goal of treatment. It argues that a declaration of futility made solely in relation to a defined medical intervention is inchoate. It recasts the definition of goal futility as an intervention that cannot alter (...) the probability of the existence of the important outcome states that might flow from a defined intervention. The idea of value futility and the extent of physician obligations in futile situations are also addressed. It also examines the source of substantive conflicts which commonly arise within the doctor-patient relationship and the ensuing power relations that operate between doctor and patient when questions of futility arise. (shrink)

Like the authors of some of the other responses to Schneiderman, Jecker, and Jonsen, I too was one of the group that produced “An Official ATS/AACN/ACCP/ESICM/SCCM Policy Statement: Responding to Requests for Futile and Potentially Inappropriate Treatments in Intensive Care Units”. Furthermore, ethical and legal issues surrounding futile and potentially inappropriate medical treatment have been a primary focus of my scholarship for more than a decade. Schneiderman, Jecker, and Jonsen offer a strong critique of the Multiorganization Statement, but they (...) do not describe it with sufficient precision. There are points of true normative disagreement between the... (shrink)

So-called futile care : the experience of the Unied States -- The reality of medical futility in Brazil -- Medical futility and end-of-lfe issues in Belgium -- The concept of medical futility in Venezuela -- Medical futility in Russian Federation -- Medical futility in Australia -- Medical futility in Japan -- Ethical issues and policy in medical futility in China -- Medical futility in Korea (...) -- Medical futility from Swiss perspective -- Medical futility in Turkey -- Medical futility in the Untited Arab Emirates -- Medical futility in Iran. (shrink)

Some patients have no chance of surviving if not treated, but very little chance if treated. A number of medical ethicists and physicians have argued that treatment in such cases is medically futile and a matter of physician discretion. This paper is a critical examination of that position. According to Howard Brody and others, a judgment of medical futility is a purely technical matter, and one which physicians are uniquely qualified to make. Although Brody later retracted these (...) claims, he held fast to the view that physicians need not consult the patient or his family to determine their values before deciding not to treat. This is because professional integrity dictates that treatment shouldn't be undertaken. The argument for this claim is that medicine is a profession and a social practice, and thus capable of breaches of professional integrity. Underlying professional integrity are two moral principles, one concerning harm, the other fraud. Both point to the fact that when the odds of survival are very low treatment is a violation of professional integrity. The details of this skeletal argument are exposed and explained, and the full argument is subjected to criticism. On a number of counts, it's found wanting. If anything, professional integrity points to the opposite conclusion. (shrink)

Why do we persist in the relentless pursuit of artificial nourishment and other treatments to maintain a permanently unconscious existence? In facing the future, if not the present world-wide reality of a huge number of persistent vegetative state (PVS) patients, will they be treated because of our ethical commitment to their humanity, or because of an ethical paralysis in the face of biotechnical progress? The PVS patient is cut off from the normal patterns of human connection and communication, with a (...) life unlike other forms of human existence. Why the struggle to justify ending a life which, it is said, has suffered an irreversible loss of the content of consciousness? Elsewhere, the authors have addressed the ethical controversies and confusion engendered by ambiguous terminology, misuse of medical facts and the differing interpretations of what constitutes 'effective' treatment: in particular, the issue of whether in fact artificial nutrition and hydration is a medical treatment, or simply part of the obligatory care owed to all patients, permanently unconscious or not. In this paper, we intend to argue that recent analyses of medical futility, its meaning and ethical implications, despite an absence of public consensus, permit some tentative re-evaluation of our ethical obligations to the PVS patient. (shrink)

Conflicts surrounding the provision of life-sustaining treatment create difficult ethical and interpersonal challenges for providers, patients, and families or other surrogates alike. These conflicts implicate a constellation of ethical concepts, including distributive justice, harms and wrongs to patients, fiduciary obligations to patients, standards for surrogate decision-making, and medical futility. Recently, several critical care societies published a policy statement on conflicts at the end of life, and advocated for a new concept, “potentially inappropriate treatment”. They argued that in some (...) circumstances, after due process, physicians and hospitals should have the authority to... (shrink)

Some patients have no chance of surviving if not treated, but very little chance if treated. A number of medical ethicists and physicians have argued that treatment in such cases is medically futile and a matter of physician discretion. This paper critically examines that position.According to Howard Brody and others, a judgment of medical futility is a purely technical matter, which physicians are uniquely qualified to make. Although Brody later retracted these claims, he held to the view (...) that physicians need not consult the patient or his family to determine their values before deciding not to treat. This is because professional integrity dictates that treatment should not be undertaken. The argument for this claim is that medicine is a profession and a social practice, and thus capable of breaches of professional integrity.Underlying professional integrity are two moral principles, one concerning harm, the other fraud. According to Brody both point to the fact that when the odds of survival are very low treatment is a violation of professional integrity.The details of this skeletal argument are exposed and explained, and the full argument is criticised. On a number of counts, it is found wanting. If anything, professional integrity points to the opposite conclusion. (shrink)

The transition from the paternalistic paradigm of the Hippocratic tradition to the present model of shared decision making has altered the patient–doctor relationship. This change has engendered conflicts between patients and physicians, especially in pediatric medicine, where the patients are depen­dent on their parents because of their inability to consent to an intervention independently. Navigating this complex relationship can become particularly fraught when medical futility is invoked. This situation is complicated further by the divergent approaches to shared decision (...) making among physicians and the ethical perspectives these positions reflect. Catholic doctrine on the role of parents in medical-ethical decision making provides insight into navigat­ing these difficult clinical issues and ideologies. (shrink)

This article elucidates the premises and limited meaning of medical futility in order to formulate an ethically meaningful definition of the term, that is, a medical intervention’s inability to deliver the benefit for which it is designed. It uses this definition to show the two ways an intervention could become medically futile, to recommend an even more limited usage of medical futility, and to explain why an intervention need not be futile in order to be (...) withdrawn over patient-based objections. If an intervention retains some benefit, then patients or surrogates might legitimately consider that benefit in their case and request the intervention. Physicians might still be justified in declining it on the grounds that the burdens greatly outweigh the benefits, but not on the grounds of futility. Finally, the article uses bioethics research and healthcare litigation to clarify the meaning of futility in practice and recommends alternative language when possible. (shrink)

Abstract Medical futility is commonly understood as treatment that would not provide for any meaningful benefit for the patient. While the medical facts will help to determine what is medically appropriate, it is often difficult for patients, families, surrogate decision-makers and healthcare providers to navigate these difficult situations. Often communication breaks down between those involved or reaches an impasse. This paper presents a set of practical strategies for dealing with cases of perceived medical futility at (...) a major cancer center. Content Type Journal Article Pages 1-8 DOI 10.1007/s10730-011-9168-3 Authors Colleen M. Gallagher, Section for Integrated Ethics in Cancer Care, Unit 1430, The University of Texas MD Anderson Cancer Center, P.O. Box 301402, Houston, TX 77230-1402, USA Ryan F. Holmes, St. Louis University, St. Louis, MO, USA Journal HEC Forum Online ISSN 1572-8498 Print ISSN 0956-2737. (shrink)

As medical technology has advanced, the question of medical futility has become a topic of intense debate both within the medical community and within society as a whole. However, a unanimous definition thereof is yet to be decided—some commentators are sceptical as to whether an agreement will ever be reached—and this continues to lead to difficulties, tension, and even legal action when a treating physician disagrees with a patient and/or a patient’s family regarding care and treatment (...) options. Although living in a pluralistic society presents one of the major reasons as to why, despite 30 years of intense discussion, no consensus has been made; the issue of medical futility will always be complex as it is, by nature, multifaceted, and numerous elements—including possible risks, evidence of the probability of benefit, the wishes of the patient (and family), professional standards, and cost—interact. Nevertheless, the global medical community has seen the development of two distinctly different approaches to medical futility: one in which the autonomy of patients is of paramount importance in the decision whether or not to pursue a treatment; and one in which beneficence and primum non nocere—first do no harm—are almost entirely the clinician’s prerogative, and whereby he/she has a duty to refuse any treatment for which the potential risks outweigh the potential benefits for the patient. Recently, however, there has been a rejection of this dichotomous view of medical futility and the apparent “power struggle” between physician and patient, and a positive movement towards a more collaborative decision-making process that highlights the necessity of communication, aiming to result in the obtainment of the best possible outcome for each patient as an individual. (shrink)

Ableist attitudes and structures regarding disability are increasingly recognized across all sectors of healthcare delivery. After Dobbs, novel questions arose in the USA concerning how to protect reproductive autonomy while avoiding discrimination against and devaluation of disabled persons. As a case study, we examine the Louisiana’s Department of Public Health August 1st Emergency Declaration, “List of Conditions that shall deem an Unborn Child ‘Medically Futile.’” We raise a number of medical, ethical, and public health concerns that lead us to (...) argue the declaration should be rescinded. The ethically objectionable declaration provides valuable lessons concerning how to uphold both reproductive and disability justice in a post-Dobbs landscape. (shrink)

In situations where experience shows that a particular intervention will not benefit a patient, common sense seems to suggest that the intervention should not be used. Yet it is precisely in these situations that a peculiar ethic begins to operate, an ethic that Eddy calls “the criterion of potential benefit.” According to this ethic, “a treatment is appropriate if it might have some benefit.” Thus, the various maxims learned in medical school instruct physicians that “‘an error of commission is (...) to be preferred to an error of omission,’ or ‘when in doubt, cut it out’ or ‘if but one patient is helped, then the treatment is worthwhile.’”. (shrink)

I’m writing to underscore one point, which should be obvious, but which all too often has been neglected in the literature on medical futility. The futility of an action or an intervention is always relative to some goal. Consider the classical example of futility: carrying water in a sieve. If your goal is to transport a quantity of water without spilling some or all of it, then it is futile to do so by placing it in (...) a sieve. But we can readily imagine children carrying water in the backyard in a sieve, enjoying the water spilling out on the grass and trickling down their legs. It’s not futile to serve that goal of having fun. The salience of this point can be tested by examining its relevance to... (shrink)

Over the past 50 years, technical advances have taken place in medicine that have greatly increased the possibilities of life-prolonging intervention. The increased possibilities of intervening have brought along new ethical questions. Not everything that is technically possible is appropriate in a specific case: not everything that could be done should be done. In the 1980s, a new term was coined to indicate a class of inappropriate interventions: “medically futile treatment”. A debate followed, with contributions from the USA and several (...) western European countries. A similar debate later took place in Mediterranean countries, although with a different terminology. The purpose of this article is to provide an up-to-date and systematic analysis of the concept of futility, and to draw some conclusions on its operationalisation in medical practice. While the concept of “medical futility” in theory applies to all kinds of medical intervention that might be performed without being medically indicated—things such as certain medical screenings and cosmetic surgery—in practice the literature on “futility” deals only with life-saving and life-sustaining medical interventions. This article deals with this more limited application of the concept of “futility”. (shrink)

Despite substantial controversy, the use of futility judgments in medicine is quite common, and has been backed by the implementation of hospital policies and professional guidelines on medical futility. The controversy arises when health care professionals (HCPs) consider a treatment futile which patients or families believe to be worthwhile: should HCPs be free to refuse treatments in such a case, or be required to provide them? Most physicians seem convinced that professional autonomy protects them from being forced (...) to provide treatments they judge medically futile, given the lack of patient benefit as well as the waste of medical resources involved. The argument from professional autonomy has been presented in a number of articles, but it has not been subjected to much critical scrutiny. In this paper I distinguish three versions of the argument: 1) that each physician should be free to exercise his or her own medical judgment; 2) that the medical profession as a whole may provide futility standards to govern the practice of its members; and 3) that the moral integrity of each physician serves as a limit to treatment demands. I maintain that none of these versions succeeds in overcoming the standard objection that futility determinations involve value judgments best left to the patients, their designated surrogates, or their families. Nor do resource considerations change this fact, since they should not influence the properly patient-centered judgment about futility. (shrink)

Religious faith and medicine combine harmoniously in Buddhist views, each in its own way helping Buddhists enjoy a more fruitful existence. Health care providers need to understand the spiritual needs of patients in order to provide better care, especially for the terminally ill. Using a recently reported case to guide the reader, this paper examines the issue of medical futility from a Buddhist perspective. Important concepts discussed include compassion, suffering, and the significance of the mind. Compassion from a (...) health professional is essential, and if medical treatment can decrease suffering without altering the clarity of the mind, then a treatment should not be considered futile. Suffering from illness and death, moreover, is considered by Buddhists a normal part of life and is ever-changing. Sickness, old age, birth, and death are integral parts of human life. Suffering is experienced due to the lack of a harmonious state of body, speech, and mind. Buddhists do not believe that the mind is located in the brain, and, for Buddhists, there are ways suffering can be overcome through the control of one’s mind. (shrink)

Objectives: To present an analysis of “futility” that is useful in the clinical setting.Design: Literature review.Material and methods: According to Medline more than 750 articles have been published about medical futility. Three criteria singled out 43 of them. The authors' opinions about futility were analysed using the scheme: “If certain conditions are satisfied, then a particular measure is futile” and “If a particular measure is futile, then certain moral consequences are implied”.Results: Regarding conditions, most authors stated (...) that judgments about futility should be made by physicians. The measure was usually some kind of medical treatment, and the goals related to quality of life, physiological improvement, or prolongation of life. The probability of success in reaching the goal was in most cases described in semiquantitative terms. Regarding consequences, the authors stated that health care professionals may withhold or withdraw a futile measure, most often after a dialogue with the patient , but sometimes without informing the patient , or with one-way information . Over time more and more articles recommend that the patient should be involved in joint decision making. Based on this literature review a clinical model was developed.Conclusions: The model, requiring that conditions and consequences should be made explicit, may, in “futility situations”, facilitate both the collection of the necessary information and make the moral implications visible. It also makes communication about measures considered to be futile possible without using such ambiguous terms as “futile”. (shrink)

Mr. F. Smith was a 63-year-old man admitted to the Veterans Administration hospital with fever, respiratory distress, and a possible recurrent pneumonia. He had entered a community hospital with pneumonia approximately 18 months earlier. His 80 pack-year tobacco history and 10-year emphysema history complicated the clinical course on the first admission, and his status worsened to the point of respiratory failure. He suffered a cardiac arrest while on a ventilator in an intensive care unit. He was asystolic for approximately 5 (...) minutes but was resuscitated. (shrink)

The debate about medical futility is no longer in its infancy. Scholarly literature on this seemingly intractable problem is voluminous. The list of widely publicized cases in which physicians have wanted to discontinue life-sustaining medical treatment that families demand has grown to include not just Helga Wanglie, but also Baby Rena, Baby L, Jane Doe, Joseph Finelli, Baby K, and Teresa Hamilton. A futility case has now been decided at the appellate court level.Commentators have generated three (...) kinds of proposals for resolving these conflicts. One group contends that the problem can be solved within the physician-patient-family relationship. While some in this group view professional authority broadly enough to warrant unilateral judgments by physicians that interventions desired by the patient or family should not be provided, others contend that physician authority does not extend that far, and that any resolution must be constrained by informed consent requirements. (shrink)

The debate about medical futility is no longer in its infancy. Scholarly literature on this seemingly intractable problem is voluminous. The list of widely publicized cases in which physicians have wanted to discontinue life-sustaining medical treatment that families demand has grown to include not just Helga Wanglie, but also Baby Rena, Baby L, Jane Doe, Joseph Finelli, Baby K, and Teresa Hamilton. A futility case has now been decided at the appellate court level.Commentators have generated three (...) kinds of proposals for resolving these conflicts. One group contends that the problem can be solved within the physician-patient-family relationship. While some in this group view professional authority broadly enough to warrant unilateral judgments by physicians that interventions desired by the patient or family should not be provided, others contend that physician authority does not extend that far, and that any resolution must be constrained by informed consent requirements. (shrink)