A few years ago a battered infant was admitted to a California hospital. After a period of observation and testing, the physicians concluded that the infant had been beaten so badly that his brain was almost completely destroyed, leaving him permanently unconscious. The hospital had just adopted a policy specifying that life-sustaining treatment for permanent unconsciousness was futile and, therefore, not indicated. According to this policy, after suitable subspecialty consultations and deliberations, including efforts to gain parental agreement and documentation of (...) unanimous ethics committee support, the patient's physician had the authority to discontinue life-sustaining treatment. The infant's physician wished to do this. The mother, however, who was the prime battery suspect, insisted that the baby be kept alive. (shrink)

ABSTRACTIt is becoming increasingly common for doctors to appeal to futility judgments as the basis for certain types of clinical decisions, such as the decision to withhold CPR. The clinical use of futility judgments raises two basic questions regarding futility. First, how is the concept of futility to be understood? Secondly, once we have a clearer understanding of futility, what role should determinations of futility play in clinical decision‐making? Much of the discussion about the concept of futility has centered on (...) the value‐ladenness of futility judgments. I argue that futility determinations need to be distinguished from two other types of value‐based judgments, namely, identification of the goals of treatment and treatment decisions based on an assessment of the benefits and burdens of treatment. If this distinction is sound, it suggests a very limited role for futility determinations in clinical decisionmaking, a role which should serve to promote communication between doctor and patient. (shrink)

Recognition of conscientious objection seems reasonable in relation to controversial and contentious issues, such as physician assisted suicide and abortion. However, physicians also advance conscience‐based objections to actions and practices that are sanctioned by established norms of medical ethics, and an account of their moral force can be more elusive in such contexts. Several possible ethical justifications for recognizing appeals to conscience in medicine are examined, and it is argued that the most promising one is respect for moral integrity. It (...) is also argued that an appeal to conscience has significant moral weight only if the core ethical values on which it is based correspond to one or more core values in medicine. Finally, several guidelines pertaining to appeals to conscience and their ethical evaluation are presented. (shrink)

Hospital futility policies are ethically defensible, but they require the proper understanding of futility and should be embedded in a larger process for making decisions about limiting treatment.

Why do some physicians continue to treat patients who are clearly dying or persistently unconscious, while others consider medical intervention to be futile past a certain point? No doubt, medical decisions vary in part because clinical information is often ambiguous in individual cases and because it may support more than one reasonable interpretation of a patient's chances for survival or improvement if a particular treatment is administered. Also, cases vary considerably to the extent that a patient's or a family member's (...) preferences for treatment are communicated, understood, and implemented. But, beyond these contingencies, patients at the end of life may receive more, less, or different treatment because physicians themselves are social actors, individuals who bring to bear on their clinical decisions a variety of personal attitudes, values, concerns, and interests. Legal defensiveness, religious vitalism, authoritarianism, intolerance of ambiguity, and other traits may influence physicians’ behavior, but each may be concealed under the rubric of what is “medically indicated” or “medically appropriate.”. (shrink)

Why do some physicians continue to treat patients who are clearly dying or persistently unconscious, while others consider medical intervention to be futile past a certain point? No doubt, medical decisions vary in part because clinical information is often ambiguous in individual cases and because it may support more than one reasonable interpretation of a patient's chances for survival or improvement if a particular treatment is administered. Also, cases vary considerably to the extent that a patient's or a family member's (...) preferences for treatment are communicated, understood, and implemented. But, beyond these contingencies, patients at the end of life may receive more, less, or different treatment because physicians themselves are social actors, individuals who bring to bear on their clinical decisions a variety of personal attitudes, values, concerns, and interests. Legal defensiveness, religious vitalism, authoritarianism, intolerance of ambiguity, and other traits may influence physicians’ behavior, but each may be concealed under the rubric of what is “medically indicated” or “medically appropriate.”. (shrink)

Why do some physicians continue to treat patients who are clearly dying or persistently unconscious, while others consider medical intervention to be futile past a certain point? No doubt, medical decisions vary in part because clinical information is often ambiguous in individual cases and because it may support more than one reasonable interpretation of a patient's chances for survival or improvement if a particular treatment is administered. Also, cases vary considerably to the extent that a patient's or a family member's (...) preferences for treatment are communicated, understood, and implemented. But, beyond these contingencies, patients at the end of life may receive more, less, or different treatment because physicians themselves are social actors, individuals who bring to bear on their clinical decisions a variety of personal attitudes, values, concerns, and interests. Legal defensiveness, religious vitalism, authoritarianism, intolerance of ambiguity, and other traits may influence physicians’ behavior, but each may be concealed under the rubric of what is “medically indicated” or “medically appropriate.”. (shrink)

“There's glory for you!”“I don't know what you mean by ‘glory,’ ” Alice said.Humpty Dumpty smiled contemptuously. “Of course, you dont—till I tell you. I meant ‘there's a nice knock-down argument.’”“But ‘glory’ doesn't mean a ‘nice knock-down argument,” Alice objected.“When I use a word,” Humpty Dumpty said, in rather a scornful tone, “it means just what I choose it to mean—neither more nor less.”“The question is,” said Alice, “whether you can make words mean so many different things.”“The question is,” said (...) Humpty Dumpty, “which is to be master, that's all.”When applied bioethics confronts the topic of futility, the question of who is to be master turns out to be central. Indeed, much of the literature on futility has focused on exactly this question: who gets to define the terms of the debate? Who gets to decide that treatment is “futile” and therefore allowably withheld or withdrawn? (shrink)

“There's glory for you!”“I don't know what you mean by ‘glory,’ ” Alice said.Humpty Dumpty smiled contemptuously. “Of course, you dont—till I tell you. I meant ‘there's a nice knock-down argument.’”“But ‘glory’ doesn't mean a ‘nice knock-down argument,” Alice objected.“When I use a word,” Humpty Dumpty said, in rather a scornful tone, “it means just what I choose it to mean—neither more nor less.”“The question is,” said Alice, “whether you can make words mean so many different things.”“The question is,” said (...) Humpty Dumpty, “which is to be master, that's all.”When applied bioethics confronts the topic of futility, the question of who is to be master turns out to be central. Indeed, much of the literature on futility has focused on exactly this question: who gets to define the terms of the debate? Who gets to decide that treatment is “futile” and therefore allowably withheld or withdrawn? (shrink)

Howard Brody expresses concern that citing the “two cases that put futility on the map,” namely Helga Wanglie and Baby K, may be providing ammunition to the opponents of the concept of medical futility. He in fact joins well-known opponents of the concept of medical futility in arguing that it is one thing for the physician to say whether a particular intervention will promote an identified goal, quite another to say whether a goal is worth pursuing. In the latter instance, (...) physicians are laying themselves open “to the criticism of taking on basic value judgments that are more appropriately left to patients and their surrogates.” Brody states that in both the Wanglie and Baby K cases, the “basic value judgments” had to do with the worthiness of maintaining unconscious life via medical technology. He classifies this as “a question of professional integrity—but not a question of futility,” adding that “more than semantics hinges on this distinction.” The “more than semantics” factor is a pragmatic, even political one. Failure to make this distinction renders physicians “that much more suspect and less trustworthy in the public debate.”. (shrink)

Summary Principles Timely support for patients and people close to them, and effective, sensitive communication are essential. Decisions must be based on the individual patient's circumstances and reviewed regularly. Sensitive advance discussion should always be encouraged, but not forced. Information about CPR and the chances of a successful outcome needs to be realistic. Practical matters Information about CPR policies should be displayed for patients and staff. Leaflets should be available for patients and people close to them explaining about CPR, how (...) decisions are made and their involvement in decisions. Decisions about attempting CPR must be communicated effectively to relevant health professionals. In emergencies If no advance decision has been made or is known, CPR should be attempted unless: the patient has refused CPR; the patient is clearly in the terminal phase of illness; or the burdens of the treatment outweigh the benefits. Advance decision making Competent patients should be involved in discussions about attempting CPR unless they indicate that they do not want to be. Where patients lack competence to participate, people close to them can be helpful in reflecting their views. Legal issues Patients' rights under the Human Rights Act must be taken into account in decision making. Neither patients nor relatives can demand treatment which the health care team judges to be inappropriate, but all efforts will be made to accommodate wishes and preferences. In England, Wales and Northern Ireland relatives and people close to the patient are not entitled in law to take health care decisions for the patient. In Scotland, adults may appoint a health care proxy to give consent to medical treatment. Health professionals need to be aware of the law in relation to decision making for children and young people.IntroductionWhy policies are neededCardiopulmonary resuscitation can be attempted on any person whose cardiac or respiratory functions cease. Failure of these functions is part of dying and thus …. (shrink)

Among those who criticize the concept of a common refrain is that we really have no idea what futility means. For example, physicians seem to disagree on whether a treatment being futile means that it has a less than 5% chance of working or a 20% chance of working. If the concept is so unclear, then it seems a thin reed upon which to base a momentous ethical decision—namely, that the physician's judgment should be allowed to override the wishes of (...) the competent patient or the patient's duly appointed surrogate. (shrink)

This paper reviews the concept of professional autonomy from anhistorical perspective. It became formalised in the United Kingdom onlyafter a long struggle throughout most of the nineteenth century. In itspure form professional autonomy implies unlimited powers to undertakemedical investigations and to prescribe treatment, irrespective of cost.Doctors alone should determine the quality of care and the levels ofremuneration to which they should be entitled. In the second half of thetwentieth century a steady erosion of professional autonomy occurred inthe United Kingdom. The (...) level of remuneration has been restricted formost doctors for nearly fifty years, whilst the costs of health carehave steadily reduced the doctor's ability to provide unrestricted carewithin the health care system. Reorganisation of the National HealthService in 1983 and 1991 has substantially eroded professional autonomy,to the point where research developments, clinical judgement and ethicalstandards are all now being placed at risk. (shrink)

This paper distinguishes four major types of futility (physiological, imminent demise, lethal condition, and qualitative) that have been advocated in the literature either in a patient dependent or a patient independent fashion. It proposes five criteria (precision, prospective, social acceptability, significant number, and non-agreement) that any definition of futility must satisfy if it is to serve as the basis for unilaterally limiting futile care. It then argues that none of the definitions that have been advocated meet the criteria, primarily because (...) their proponents have not paid sufficient attention to the problematic nature of the data supporting the use of their definitions. (shrink)

In this paper, I consider the thesis advanced by Lawrence J. Schneiderman and Nancy S. Jecker that physicians should be forbidden from offering futile treatments to patients. I distinguish between a version of this thesis that is trivially true and Schneiderman and Jecker's more substantive version of the thesis. I find that their positive arguments for their thesis are unsuccessful, and sometimes quite misleading. I advance an argument against their thesis, and find that, on balance, their thesis should be rejected. (...) I briefly argue that a resolution of the debate about medical futility will require addressing deeper issues about value. (shrink)

ABSTRACT It is becoming increasingly common (at least in the United States) for doctors to appeal to futility judgments as the basis for certain types of clinical decisions, such as the decision to withhold CPR. The clinical use of futility judgments raises two basic questions regarding futility. First, how is the concept of futility to be understood? Secondly, once we have a clearer understanding of futility, what role should determinations of futility play in clinical decision‐making? Much of the discussion about (...) the concept of futility has centered on the value‐ladenness of futility judgments. I argue that futility determinations need to be distinguished from two other types of value‐based judgments, namely, identification of the goals of treatment and treatment decisions based on an assessment of the benefits and burdens of treatment. If this distinction is sound, it suggests a very limited role for futility determinations in clinical decisionmaking, a role which should serve to promote communication between doctor and patient. (shrink)

Medical criteria rooted in evidence-based medicine are often seen as a value-neutral ‘trump card’ which puts paid to any further debate about setting priorities for treatment. On this argument, doctors should stop providing treatment at the point when it becomes medically futile, and that is also the threshold at which the health purchaser should stop purchasing. This paper offers three kinds of ethical criteria as a counterweight to analysis based solely on medical criteria. The first set of arguments concerns futility, (...) probability and utility; the second, justice and fairness; the third, consent and competence. The argument is illustrated by two recent case studies about futility and priority-setting: the US example of ‘Baby Ryan’ and the UK case of ‘Child B’. (shrink)