The concept of futility is sometimes regarded as a cloak for medical paternalism in that it rolls together medical and value judgments. Often, despite attempts to disambiguate the concept, that is true and it can be applied in such a way as to marginalize the real interests of a patient. I suggest we replace it with a conceptual toolkit that includes physiological futility, substantial benefit (SB), and the risk of unacceptable badness (RUB) in that these concepts allow us to articulate (...) what is at stake in ethical judgments where outcomes are crucial in determining what should be done. (shrink)