Along with managed care and physician-assisted suicide, futility has been one of the most hotly debated bioethics issues of the past decade. A January 1999 MEDLINE search revealed no less than 386 articles under the subject heading "medical futility," 385 of which were published during the 1990s. Among the authors of those articles, one can find most of the leading scholars in the field of bioethics.

The term "futile" did appear and play an important role in the federal "Baby Doe" regulations of the middle 1980s, but the current debate over futility first emerged in the late '80s and early '90s. Blackhall, Paris, "et al.," and Miles reported that some patients and families were demanding resuscitation efforts and other life sustaining therapies even though their physicians recommended against such therapies on the grounds that they would not be successful [1, 2, 3]. In response to such demands, these authors and other commentators asserted a right of physicians to withhold or withdraw treatment on the grounds of futility, irrespective of patient or family wishes. Published criticisms of their position appeared in short order, and the futility debate was joined.

Much of the debate over futility has focussed on clarifying the meaning of this concept. The etymology of the term offers an instructive example -- "futile" is derived from the Latin "futilis," meaning "leaky." According to Greek myth, the daughters of King Danaus were condemned by the gods to carry water in sieves. Sieves are leaky, and thus their task was futile. As this example illustrates, we judge a task to be futile when we are highly confident that it cannot achieve its desired end. Caplan has pointed out that futility judgments are about "odds and ends," that is, a futile effort must have very low "odds" of achieving the desired "ends" [4]. Each futility judgment, then, has both a quantitative and a qualitative aspect. Quantitatively, we must assess the (un)likelihood of the effort achieving its end, and qualitatively, we must determine what is the intended end or goal of the effort.

In order to apply the concept of futility to medical treatments, various authors have proposed both quantitative and qualitative criteria for futile medical treatment; a catalogue of these criteria has been developed by Brody and Halevy [5]. Among the earliest and best known criteria are those proposed by Schneiderman, Jecker and Jonsen, namely, a treatment is futile if it has failed in the last 100 cases or if it Amerely preserves permanent unconsciousness or cannot end dependence on intensive medical care [6].

Several arguments figure prominently in the cases made by proponents and opponents of the appeal to futility in medical decision-making. To understand the futility debate, therefore, one must become familiar with these arguments. Consider, first, three arguments offered by proponents of physician appeals to futility, based on professional integrity, professional expertise, and responsible stewardship of scarce resources.

The argument from professional integrity asserts that physicians should not be required to provide treatments that they believe to be useless or harmful. Forcing physicians to do so would violate their moral integrity and would reduce them, as Paris and Reardon observe, to "an extension of the patient's (or family's) whim, fantasy or unrealizable hopes and desires" [7].

The argument from professional expertise points out that patients rely on their physicians' expertise to determine what are reasonable treatment alternatives and to present these to patients. Alternatives judged by the physician to be futile do not constitute reasonable treatment alternatives, and thus should not be offered to the patient. Presenting treatment alternatives to patients, despite their futility, is more likely to confuse patients than to enhance their ability to make treatment choices.

A third pro-futility argument appeals to the physicians' role as a responsible steward of scarce medical resources. Providing futile treatment wastes scarce resources, since it cannot achieve its desired end. Physicians should not provide futile care, thereby conserving valuable resources for use when they can have beneficial consequences.

Now consider three arguments offered by opponents of the appeal to futility: arguments from patient autonomy, uncertainties of prognosis, and lack of social consensus.

The argument from patient autonomy notes that patients and physicians sometimes have very different opinions about what kind of life is worth preserving or what odds of achieving a desired outcome are worth pursuing. When this is the case, the argument continues, physicians should not be allowed simply to impose their views on patients through an appeal to futility. Such a unilateral withdrawal of treatment would be a kind of abandonment of the patient. Physicians should, instead, discuss treatment options with their patients and should help to achieve the patients' goals.

A second anti-futility argument appeals to uncertainties of prognosis. This argument points out that, in order to reach a treatment decision based on futility, physicians must be highly confident that the intended goal of treatment, be it patient survival or improvement in the patient's quality of life, cannot be achieved. Recent studies of available prognostic measures, however, conclude that such measures usually cannot predict outcomes such as short-term mortality with a high degree of probability, even in very seriously ill patients [8, 9, 10]. Thus, physicians lack the necessary scientific basis to make unilateral treatment decisions on the grounds of futility.

A third counter-argument calls attention to the lack of a social consensus regarding futility judgments. According to this argument, acceptance and implementation of criteria for foregoing futile treatment should be based, not on individual judgments, but on a broad social consensus. Such a consensus about futility criteria has not yet emerged, however, as illustrated by the ongoing debate in the medical, bioethical and legal literature [11]. Lacking such a consensus, unilateral judgments about futility should not be imposed on unwilling patients.

With powerful arguments like the above on both sides of the issue, the debate over futility rages on. When a question of futility arises in a clinical setting, forging an agreement among caregivers, the patient, and the patient's family about the proper course of action is the preferred outcome, but agreement is sometimes elusive. In cases of intractable disagreement, it is morally difficult simply to impose either position on the opposing side. To avoid that outcome, however, we must look to other authoritative voices for direction. Legislative bodies, courts, community organizations, professional associations, health care institutions, or health insurance providers might take on this task, but given the persistent and strong differences of opinion about futility judgments, forging consensus about what treatments are futile is likely to be a slow and incremental process.

(This article is based in part on a longer article Moskop J. Ethics controversies in a changing medical environment: managed care, futility and assisted death. Forthcoming in "Ann Behav Sci Med Ed" 1999; 5, 2)

REFERENCES

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