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Author:
Nancy S. Jecker, PhD
Topics addressed:
- What is "medical futility"?
- What are the ethical obligations of physicians when a health care provider judges an intervention is futile?
- Who decides when a particular treatment is futile?
- What if the patient or family requests an intervention that the health care team considers futile?
- What is the difference between futility and rationing?
- What is the difference between a futile intervention and an experimental intervention?
- Is an intervention more likely to be futile if a patient is elderly?
- Why is medical futility controversial?
While you will hear colleagues referring to particular cases or interventions as "futile," the technical meaning and moral weight of this term is not always appreciated. As you will make clinical decisions using futility as a criterion, it is important to be clear about the meaning of the concept. (For a related discussion, see Do-Not-Resuscitate Orders.)
What is "medical futility"?
"Medical futility" refers to interventions that are unlikely to produce any significant benefit for the patient. Two kinds of medical futility are often distinguished:
- Quantitative futility, where the likelihood that an intervention will benefit the patient is exceedingly poor, and
- Qualitative futility, where the quality of benefit an intervention will produce is exceedingly poor.
Both quantitative and qualitative futility refer to the prospect that a specific treatment will benefit (not simply have a physiological effect) on the patient.
Futility does not apply to treatments globally, to a patient, or to a general medical situation. Instead, it refers to a particular intervention at a particular time, for a specific patient. For example, rather than stating, “It is futile to continue to treat this patient,” one would state, “CPR would be medically futile for this patient.”
What are the ethical obligations of physicians when a health care provider judges an intervention is futile?
The goal of medicine is to help the sick. Physicians have no obligation to offer treatments that do not benefit patients. Futile interventions may increase a patient's pain and discomfort in the final days and weeks of life; give patients and family false hope; delay palliative and comfort care; and expend finite medical resources. However, determining which interventions are beneficial to a patient can be difficult, since the patient or surrogate might see an intervention as beneficial while the physician does not. Physicians should follow professional standards, and should consider empirical studies and their own clinical experience when making futility judgments. They should also show sensitivity to patients and families in carrying out decisions to withhold or withdraw futile interventions.
Although the ethical requirement to respect patient autonomy entitles a patient to choose from among medically acceptable treatment options (or to reject all options), it does not entitle patients to receive whatever treatments they ask for. Instead, the obligations of physicians are limited to offering treatments that are consistent with professional standards of care and that confer benefit to the patient.
Who decides when a particular treatment is futile?
Generally the term medical futility applies when, based on medical data and professional experience, a treating health care provider determines that an intervention is no longer beneficial. Because health professionals may reasonably disagree about when an intervention is futile, all members of the health care team would ideally reach consensus. While physicians have the ethical authority to withhold or withdraw medically futile interventions, communicating with professional colleagues involved in a patient’s care, and with patients and family, greatly improves the experience and outcome for all.
What if the patient or family requests an intervention that the health care team considers futile?
You have a duty as a physician to communicate openly with the patient or family members about interventions that are being withheld or withdrawn and to explain the rationale for such decisions. The aim of respectful communication should be to elicit the patient’s goals, explain the goals of treatment, and help patients and families understand how particular medical interventions would help or hinder their goals and the goals of treatment. It is important to approach such conversations with compassion. For example, rather than saying to a patient or family, "there is nothing I can do for you," it is important to emphasize that "everything possible will be done to ensure the patient's comfort and dignity."
In some instances, it may be appropriate to continue temporarily to make a futile intervention available in order to assist the patient or family in coming to terms with the gravity of their situation and reaching closure. For example, a futile intervention for a terminally ill patient may in some instances be continued temporarily in order to allow time for a loved one arriving from another state to see the patient for the last time. However, futile interventions should not be used for the benefit of family members if this is likely to cause the patient substantial suffering, or if the family’s interests are clearly at odds with those of the patient.
If intractable conflict arises, a fair process for conflict resolution should occur. Involvement of an ethics consultation service is desirable in such situations. The 1999 Texas Advance Directives Act provides one model for designing a fair process for conflict resolution.
What is the difference between futility and rationing?
Futility refers to the benefit of a particular intervention for a particular patient. With futility, the central question is not, "How much money does this treatment cost?" or, "Who else might benefit from it?" but instead, "Does the intervention have any reasonable prospect of helping this patient?"
What is the difference between a futile intervention and an experimental intervention?
Making a judgment of futility requires solid empirical evidence documenting the outcome of an intervention for different groups of patients. Futility establishes the negative determination that the evidence shows no significant likelihood of conferring a significant benefit. By contrast, treatments are considered experimental when empirical evidence is lacking and the effects of an intervention are unknown.
Is an intervention more likely to be futile if a patient is elderly?
Futility has no necessary correlation with a patient’s age. What determines whether a treatment is futile is whether or not the treatment benefits the patient. In cases where evidence clearly shows that older patients have poorer outcomes than younger patients, age may be a reliable indicator of patient benefit, but it is benefit, not age, that supports a judgment of medical futility. For patients of all ages, health care professionals should advocate for medically beneficial care, and refrain from treatments that do not help the patient.
Why is medical futility controversial?
While medical futility is a well-established basis for withdrawing and withholding treatment, it has also been the source of ongoing debate. One source of controversy centers on the exact definition of medical futility, which continues to be debated in the scholarly literature. Second, an appeal to medical futility is sometimes understood as giving unilateral decision-making authority to physicians at the bedside. Proponents of medical futility reject this interpretation, and argue that properly understood futility should reflect a professional consensus, which ultimately is accepted by the wider society that physicians serve. Third, in the clinical setting, an appeal to “futility” can sometimes function as a conversation stopper. Thus, some clinicians find that even when the concept applies, the language of “futility” is best avoided in discussions with patients and families. Likewise, some professionals have dispensed with the term “medical futility” and replaced it with other language, such as “medically inappropriate.” Finally, an appeal to medical futility can create the false impression that medical decisions are value-neutral and based solely on the physician’s scientific expertise. Yet clearly this is not the case. The physician’s goal of helping the sick is itself a value stance, and all medical decision making incorporates values.