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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 of benefiting the patient. A treatment that merely produces a physiological effect on a patient's body does not necessarily confer any benefit that the patient can appreciate.
What are the ethical obligations of physicians when an intervention is clearly futile?
The goal of medicine is to help the sick. You have no obligation to offer treatments that do not benefit your patients. Futile interventions are ill advised because they often increase a patient's pain and discomfort in the final days and weeks of life, and because they can expend finite medical resources.
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.
Who decides when a particular treatment is futile?
The ethical authority to render futility judgments rests with the medical profession as a whole, not with individual physicians at the bedside. Thus, futility determinations in specific cases should conform with more general professional standards of care.
While a patient may decide that a particular outcome is not worth striving for (and consequently reject a treatment), this decision can be based on personal preferences and not necessarily on futility.
What if the patient or family requests an intervention that the health care team considers futile?
In such situations, 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. It is important to approach such conversations with compassion for the patient and grieving family. 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 a point of personal closure. For example, a futile intervention for a terminally ill patient may be continued temporarily in order to allow time for a loved one arriving from another state to see the patient for the last time.
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.
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