The modern debate on whether—and why—physicians and hospitals can refuse patient or family demands for treatment on grounds of “futility” will be reaching its 20th anniversary this year (Blackhall, 1987). The early debate focused on the use of CPR, for good historical and clinical reasons, and CPR probably remains the primary target of hospital policy. But the reach of the arguments over futility extends well beyond this context, most vividly illustrated by the case of Helga Wanglie and the many commentaries (...) it spawned (Brody, 1998; Schneiderman, 1998; Trotter, 1999). There seems no obvious reason in principle that questions about futility cannot be raised about virtually any form of treatment that patients or families might demand, including such things as chemotherapy for cancer (Tomlinson, 2001). Still, we might fairly ask what new dimensions and complexities the futility question acquires when it moves onto decisions about treatments other than CPR. This is what I would like to do in this essay. I will use dialysis as the case in point, although I hope to extract lessons from the dialysis example that will be pertinent to other forms of life-sustaining treatment, like ventilators. (shrink)

In Wrong Medicine, Lawrence J. Schneiderman, M.D., and Nancy S. Jecker, Ph.D., address issues that have occupied the media and the courts since the time of Karen Ann Quinlan. The authors examine the ethics of cases in which medical treatment is offered--or mandated--even if a patient lacks the capacity to appreciate its benefit or if the treatment will still leave a patient totally dependent on intensive medical care. In exploring these timely issues Schneiderman and Jecker reexamine the doctor-patient relationship and (...) call for a restoration of common sense and reality to what we expect from medicine. They discuss economic, historical, and demographic factors that affect medical care and offer clear definitions of what constitutes futile medical treatment. And they address such topics as the limits on unwanted treatment, the shift from the "Age of Physician Paternalism" to the "Age of Patient Autonomy," health care rationing, and the adoption of new ethical standards. (shrink)

Who should decide? In When Doctors Say No, philosopher and bioethicist Rubin examines this controversial issue.

In a recent issue of CambridgeQuarterlyofHealthcareEthics, Howard Brody and Lawrence Schneiderman offer contrasting opinions about how to apply the concept of in medicine. Brody holds that are those in which it is reasonably certain that a given intervention when applied for the purpose of attaining a specific clinical goal. To determine which actions are futile, Brody prescribes a division of labor. Patients are charged with choosing the goals of treatment while physicians are charged with determining whether specific treatments will be (...) effective in achieving these goals. Though physicians do not choose specific goals, Brody thinks they have a prerogative to decide whether they can, in good conscience, aid in the achievement of specific patient goals. Let us use to denote choosing between alternative goals and to denote choices about whether one will assist in the pursuit of particular goals. Brody's position is essentially that patients are positive validators and that physicians are negative validators. Brody concludes that treatments that are effective in achieving patients' goals are not futileFutilitypromote a goal that both agree is desirable.”. (shrink)