Medical Futility: Its Meaning and Ethical Implications
Abstract
The notion of medical futility has quantitative and qualitative roots that offer a practical approach to its definition and application. Applying these traditions to contemporary medical practice, we propose that when physicians conclude (either through personal experience, experiences shared with colleagues, or consideration of published empiric data) that in the last 100 cases a medical treatment has been useless, they should regard that treatment as futile. If a treatment merely preserves permanent unconsciousness or cannot end dependence on intensive medical care, the treatment should be considered futile. Unlike decision analysis, which defines the expected gain from a treatment by the joint product of probability of success and utility of outcome, our definition of futility treats probability and utility as independent thresholds. Futility should be distinguished from such concepts as theoretical impossibility, such expressions as "uncommon" or "rare," and emotional terms like "hopelessness." In judging futility, physicians must distinguish between an effect, which is limited to some part of the patient's body, and a benefit, which appreciably improves the person as a whole. Treatment that fails to provide the latter, whether or not it achieves the former, is "futile." Although exceptions and cautions should be borne in mind, we submit that physicians can judge a treatment to be futile and are entitled to withhold a procedure on this basis. In these cases, physicians should act in concert with other health care professionals, but need not obtain consent from patients or family members.
References
- 1.
Younger S . Who defines futility? JAMA. 1988;260:2094-5. CrossrefMedlineGoogle Scholar - 2.
Lantos J ,Singer P , andWalker R . The illusion of futility in clinical practice. Am J Med. 1989;87:81-4. CrossrefMedlineGoogle Scholar - 3. . Deciding to Forego Life-Sustaining Treatment: A Report on the Ethical, Medical, and Legal Issues in Treatment Decisions. Washington DC: U.S. Government Printing Office; 1983:60-89. Google Scholar
- 4.
Jonsen A . What does life support support? Pharos. 1987;50(1):4-7. Google Scholar - 5. Child Abuse and Neglect Prevention and Treatment. Washington, DC: U.S. Department of Health and Human Services, Office of Human Development Services; 1985: Federal Register 50:14887-8. Google Scholar
- 6.
Blackhall L . Must we always use CPR? N Engl J Med. 1987;317:1281-5. CrossrefMedlineGoogle Scholar - 7.
Tomlinson T andBrody H . Ethics and communication in do-not-resuscitate orders. N Engl J Med. 1988;318:43-6. CrossrefMedlineGoogle Scholar - 8.
Lo B . Life-sustaining treatment in patients with AIDS: challenge to traditional decision-making. In: Juengst ET, Koenig BA, eds. The Meaning of AIDS, v 1. New York: Praeger; 1989:86-93. Google Scholar - 9.
Rosenberg C . The therapeutic revolution: medicine, meaning, and social change in nineteenth-century America. Perspect Biol Med. 1977;20:485-506. CrossrefMedlineGoogle Scholar - 10.
Wanzer S ,Adelstein S , andCranford R . The physician's responsibility toward hopelessly ill patients. N Engl J Med. 1984;310:955-9. CrossrefMedlineGoogle Scholar - 11.
Weinstein M andFineberg H . Clinical Decision Analysis. Philadelphia: W.B. Saunders; 1980. Google Scholar - 12.
Amundsen D . The physician's obligation to prolong life: a medical duty without classical roots. Hastings Cent Rep. 1978;8:23-30. CrossrefMedlineGoogle Scholar - 13.
Jonsen A . The Old Ethics and the New Medicine. Cambridge: Harvard University Press; 1990. Google Scholar - 14. Hippocratic corpus, the art. In: Reiser SJ, Dyck AJ, Curran WJ, eds. Ethics in Medicine: Historical Perspectives and Contemporary Concerns. Cambridge, Massachusetts: MIT Press; 1977:6-7. Google Scholar
- 15. Plato. In: Grube GM, transl. Republic. Indianapolis: Hackett Publishing; 1981:76-7. Google Scholar
- 16.
Beecher H . The powerful placebo. JAMA. 1955;159:1602-6. CrossrefMedlineGoogle Scholar - 17.
Murphy D ,Murray A ,Robinson B , andCampion E . Outcomes of cardiopulmonary resuscitation in the elderly. Ann Intern Med. 1989;111:199-205. LinkGoogle Scholar - 18.
Lantos J ,Miles S ,Silverstein M , andStocking C . Survival after cardiopulmonary resuscitation in babies of very low birth weight. N Engl J Med. 1988;318:91-5. CrossrefMedlineGoogle Scholar - 19.
Freiman J ,Chalmers T ,Smith H , andKuebler R . The importance of beta, the type II error and sample size in the design and interpretation of the randomized control trial. Survey of 71 "negative" trials. N Engl J Med. 1978;299:690-4. CrossrefMedlineGoogle Scholar - 20.
Bedell S ,Delbanco T ,Cook E , andEpstein F . Survival after cardiopulmonary resuscitation in the hospital. N Engl J Med. 1983;309:569-76. CrossrefMedlineGoogle Scholar - 21.
Gordon M andHurowitz E . Cardiopulmonary resuscitation of the elderly. J Am Geriatr Soc. 1984;32:930-4. CrossrefMedlineGoogle Scholar - 22. Life-Sustaining Technologies and the Elderly. Washington, DC: U.S. Congress, Office of Technology Assessment; 1987: publication OTA-BA-306, 167-201. Google Scholar
- 23.
Johnson A ,Tanser P ,Ulan R , andWood T . Results of cardiac resuscitation in 552 patients. Am J Cardiol. 1967;20:831-5. CrossrefMedlineGoogle Scholar - 24.
Taffet G ,Teasdale T , andLuchi R . In-hospital cardiopulmonary resuscitation. JAMA. 1988;260:2069-72. CrossrefMedlineGoogle Scholar - 25.
Knaus W ,Draper E ,Wagner D , andZimmerman J . APACHE II: a severity of disease classification system. Crit Care Med. 1985;13:818-29. CrossrefMedlineGoogle Scholar - 26.
Knaus W ,Draper E ,Wagner D , andZimmerman J . An evaluation of outcome from intensive care in major medical centers. Ann Intern Med. 1986;104:410-8. LinkGoogle Scholar - 27.
Imbus S andZawacki B . Autonomy for burned patients when survival is unprecedented. N Engl J Med. 1977;297:308-11. CrossrefMedlineGoogle Scholar - 28.
Plum F andPosner J . The Diagnosis of Stupor and Coma. 3d ed. Philadelphia: F.A. Davis; 1980. Google Scholar - 29.
Cranford R . The persistent vegetative state: the medical reality (getting the facts straight). Hastings Cent Rep. 1988;18:27-32. CrossrefMedlineGoogle Scholar - 30.
Katz J . The Silent World of Doctor and Patient. New York: Free Press; 1984. Google Scholar - 31.
Emery D andSchneiderman L . Cost-effectiveness analysis in health care. Hastings Cent Rep. 1989;19:8-13. CrossrefMedlineGoogle Scholar - 32.
Yarborough M . Continued treatment of the fatally ill for the benefit of others. J Am Geriatr Soc. 1988;36:63-7. CrossrefMedlineGoogle Scholar - 33.
Perkins H . Ethics at the end of life: practical principles for making resuscitation decisions. J Gen Intern Med. 1986;1:170-6. CrossrefMedlineGoogle Scholar - 34.
Miles S . Futile feeding at the end of life: family virtues and treatment decisions. Theor Med. 1987;8:293-302. CrossrefMedlineGoogle Scholar - 35.
Jecker N . Anencephalic infants and special relationships. Theor Med. 1990 [In press]. CrossrefGoogle Scholar - 36.
Jecker N . The moral status of patients who are not strict persons. J Clin Med. 1990 [In press]. Google Scholar - 37.
Schneiderman L andSpragg R . Ethical decisions in discontinuing mechanical ventilation. N Engl J Med. 1988;318:984-8. CrossrefMedlineGoogle Scholar - 38.
Daniels N . Why saying no to patients in the United States is so hard: cost containment justice, and provider autonomy. N Engl J Med. 1986;314:1380-3. CrossrefMedlineGoogle Scholar
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Author, Article, and Disclosure Information
Lawrence J. Schneiderman,
From the School of Medicine, University of California, San Diego, La Jolla, California; and the University of Washington School of Medicine, Seattle, Washington. For current author addresses, see end of text.
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