Medical Futility
What is Futility?
Basic common sense idea: “It won’t work”
Always an incomplete thought: “It won’t
work to accomplish what goal?”
Any medical futility judgment is a mixed
fact and value statement
Statistical probability of outcome
Whether outcome is a “benefit”
How confident one is of predictions
Can Futility Be Value-Free?
“No chance of survival to hospital
discharge if perform CPR”-- clearly value
laden because assumes that relevant goal
is to survive to discharge
Therefore, define “futility” in physiologic
terms-- any chance that CPR will restore
spontaneous heartbeat and respiration
(even if only for a few moments)?
Is Physiology Value-Free?
Physiologic futility criteria take the value
stance that the proper and desirable
goal of medicine is physiologic function
independent of whether the patient
considers such function to be a benefit
Conclude: There cannot be a truly valuefree definition of futility
Why an ethical issue?
“Typical ethics case” in 1975: Patient or
family wished to stop aggressive
treatment; physicians felt obligated to
keep treating
“Typical ethics case” in 2000: Physicians
feel obligated to stop aggressive
treatment; patient or family demands
ongoing aggressive care
Futility: Principles
Respect for autonomy: Patient or agent
has a right to decide on what care to
accept or refuse
Is it ever the case that physician’s
prediction of futility is so firm that it
should override usual presumption in
favor of patient choice?
What Principles May
Override?
Physician vs. patient autonomy: does it
matter on what basis physician wishes
to withhold therapy?
Justice: futile therapy is a waste of money
and others are in need of care (Murphy)-is this core idea of futility or is it a
secondary consideration?
Role of Futility in Justice
“The reason we should give physicians
the discretion to refuse to provide futile
care is so that the system can save
money”
“If we have limited money for medical
care and have to ration care, it makes
sense to eliminate totally futile care first,
before we start to limit very expensive yet
beneficial care”
Physician/Nurse Integrity
Joanne Lynn’s observation: Nursing staff
required to provide ongoing intensive care
which seemed incapable of improving the
patient’s status (but which was often
painful) described themselves as feeling
like they were forced to act as “moral
monsters”
Integrity
Wholeness
Related more to virtue theory than other
approaches
My moral actions, attitudes, and values
are coherent and coordinated over time
Compare: “moral chameleon” (M.
Benjamin)
Levels of Integrity
Personal: My own “private” moral values
are reflected in my attitudes and
behaviors
Professional: The core values of my
profession are reflected in my attitudes
and behaviors
Futility and Professional
Integrity
Unprofessional to:
Cause harm without benefit
Portray oneself fraudulently
Setting out to do what doesn’t work
violates these professional duties
Requires a firm grounding in professional
consensus as to “what doesn’t work”
The Real World
Most futility disputes resolved by effective
communication over time
Rubin example of S.E. Asian woman:
often goal clarification suffices to remove
source of dispute
Cases that go to court are therefore
highly atypical
Are These Futility Cases?
Wanglie: 80yo woman on respirator in
PVS, family stated that unconscious life is
still of value
Baby K: Infant born with anencephaly,
needed intermittent intensive care with
respirator, mother demanded that hospital
continue to admit and support
Arguments Against Futility
Factual: Too much uncertainty or slippage
in deciding what works and what does not
work
Value: Futility seems to be a power play
allowing physicians and end-run around
respect for patient autonomy
CPR Counter-Argument
Do physicians and nurses have the right
to decide when to stop CPR based on
their own determination of futility,
independent of family wishes?
If so then seems logically required that at
least in some cases they could decide not
to start CPR on same grounds
Veatch’s Argument
Based heavily on position that no
physician can truly decide what counts as
a benefit to any given patient-- even in
“ideal” situation where physician and
patient come from identical value
communities
Rejoinder: Does Veatch ever buy gifts for
his family?