Medical Futility: Response to Critiques

The physicianpatient relationship has been strikingly transformed during the past several decades. Once characterized by strong medical paternalism, it now reflects strong patient autonomy. During the 1960s, physicians began to see their power being challenged by patients who wanted to take charge of, or at least participate fully in, medical decisions. Although the patient autonomy movement achieved many valued improvements in care, it also raised new ethical problems. Some patients and their families have begun to claim the right to receive whatever aggressive, high-tech medical interventions they wish, even if medical providers judge the interventions to be futile because they have no realistic chance of achieving the goals of medicine. What are the goals of medicine? Can we agree as a profession and as a society when medical treatment fails to achieve such goals? Exploring these questions forces us to re-examine the fundamentals of the physicianpatient relationship. Six years ago, we proposed a definition of medical futility and explored its ethical implications [1]. We started with the premise that physicians are obligated to offer only those treatments that have a reasonable chance of achieving a therapeutic benefit for the patient. In this premise, the terms benefit and patient are important. A patient is not a collection of body parts or merely a person with idiosyncratic desires. Rather, a patient is an ailing person who seeks the healing powers of the physician. The physician's goal is not merely to affect some part of the body but to benefit the patient as a whole. Medicine currently has the ability to achieve multitudinous effects, including increasing and decreasing blood pressure, speeding and slowing the heart rate, destroying cells, infusing oxygen, and transplanting organs. We have argued that none of these effects constitutes a benefit unless the patient has, at the very least, the ability to appreciate them. This circumstance is impossible if, for example, the patient remains in a permanent vegetative state. Neither does an effect qualify as a benefit if it leaves the patient incapable of surviving outside the intensive care unitin other words, completely preoccupied (to use a term that Plato attributed to Asklepios [2]) with illness and treatment and therefore unable to carry out any other life goals. We pointed out that medical futility refers not only to the quantitative probability of success or failure of a treatment but also to the qualitative results that treatment achieves for the patient. In defining the quantitative aspects of medical futility, we proposed that when physicians conclude (either through personal experience, experiences shared with colleagues, or consideration of reported empiric data) that in the last 100 cases, a medical treatment has been useless, they should regard that treatment as futile [1]. We suggested this approach as a commonsense way to respond to the unanswerable question. How can you be absolutely certain the treatment won't work, doctor? Physicians are often pressured into pursuing extreme and absurd interventions as a result of this question. Regarding the qualitative aspect of medical futility, as noted above, we proposed that if a treatment merely preserves permanent unconsciousness or fails to end total dependence on intensive medical care [it] should be regarded as futile [1]. Following earlier authors [3-7], we argued that physicians are not obligated to offer a futile treatment that is demanded by patients or their family members. Later, two of us made the stronger argument that physicians are professionally obligated to resist demands for futile treatments [8]. When we presented these concepts, we stated that we recognizeindeed inviteexamination and challenge of our proposal [1]. In this paper, we revisit our original proposal, add clarifications and modifications that we believe are essential, and respond to major criticisms gleaned from published articles and discussions with colleagues. Clarifications and Modifications Our original proposal [1] stipulated that, in making decisions involving medical futility, individual physicians should act in concert with other health care professionals, but need not obtain consent from patients or family members. However, we did not sufficiently emphasize that acting in concert is not to be done casually; we later asserted that this obligation is grounded in general professional standards of care [9]. We further clarified our position that standards of care, although they are advanced by the health care profession, ultimately require the endorsement of society [9]. Failure to make this process clear in our original proposal led to protests that we were encouraging individual physicians to act unilaterally and arbitrarily [10, 11]. Ironically, it was the arbitrary and unsupported use of the term futile by physicians that stimulated our original proposal; such use either consciously or unconsciously masked unethical reasons for refusing to offer a specific treatment [9]. We did not advocate that individual physicians act on their subjective impressions [12]. On the contrary, we specified that decisions to withhold futile treatments should be made on the basis of the evaluation of empirical experience, including personal clinical experience and experience shared with colleagues, or on the basis of published empirical data. These empirical observations are only the first step and must be coupled with value decisions by the health care profession that are endorsed by society; specifically, ethical judgments must be made on whether the observed outcomes constitute benefits to patients. However, we did not sufficiently emphasize the responsibility of the medical profession to carry out this first step of collecting and providing outcome data through well-conducted clinical trials. For the practicing physician, negative study results are as important as positive study results. Everyone applauds the discovery of new beneficial treatments, and physicians gladly adopt these therapies. However, physicians also need to know when a treatment has been shown to offer no significant likelihood or quality of benefit so that they can avoid causing unnecessary harm [13]. Response to Criticism The main arguments against our proposal can be summarized as follows. Medical Futility Is an Attempt To Increase the Power of the Physician over the Patient and Repeal Recent Hard-Gained Advances in Patient Autonomy The basic premise underlying this argument is that the physician and patient are inexorably locked in a war between doctor and patient over who gets to decide what [14]. In this power struggle, the physician (who has little to lose) possesses expert knowledge and control over technology. By contrast, the patient, whose life may hang in the balance, typically possesses little expert knowledge and no authority over technological interventions [10, 11, 15]. Those who make this argument hold that endorsing the physician's power to declare a treatment futile gives the physician a trump card [12] or conversation stopper [11] that interferes with the meager power the patient retains (the power of persuasion) in the physicianpatient dialogue. We and others have pointed out, however, that the power to make judgments about futility is a necessary part of the physician's duty of beneficence, that is, the duty to use only treatments that provide therapeutic benefits [16-20]. This power resides not with the individual physician's arbitrary whim but with the profession as a whole as it establishes general standards of care. In our view, abuses of power are resolved not by eliminating medical judgment and yielding to unreasonable demands but rather by exercising judgment openly and responsibly according to professional standards [17, 21-23]. Some wishes and needs are clearly beyond the scope of informed consent and the limits of the physician's obligation. For example, a physician treating a patient for severe depression might conclude that if the patient could only get his or her finances in order, the patient would be much less depressed. The physician might be sympathetic to the patient's distress and might even try to recommend help, but surely no one would claim that balancing the patient's bank account is an obligatory medical duty. Physicians are more often under pressure to use the vast array of technologies at their disposal when those technologies may keep organ systems functioning even though the patient is no longer able to appreciate any benefit from these interventions. Means are confused with ends, effects are confused with benefits, and available technologies are confused with obligatory medical therapies. In our experience, requests for futile treatment often represent not an appeal to respect the patient's wishes [24] but rather a misguided effort to express caring for the patient by meeting a perceived duty to do everything when other manifestations of devotion (such as comfort care) would be more appropriate [25, 26]. No Professional or Societal Consensus Has Been Achieved about the Definition of Futility Impatience with the slow pace of resolving such a complex ethical issue has led some critics [27-30] to conclude that efforts to define and apply futility are themselves futile. Studies [31-33] have shown that physicians disagree about quantitative and qualitative thresholds for futility. However, persons with long experience in public opinion research point out that achieving consensus is a gradual and evolving process. It begins with public awareness of an issue, proceeds to understanding by working through the issue (which, in the case of medical futility, will require changing unrealistic expectations about what medicine and science can accomplish), and finally leads to resolution on cognitive, emotional, and moral levels [34]. It is worth remembering that achieving nationwide consensus on a universal definition of