The politics of medical futility.

• Author: Taylor, Robert M.

There is much disagreement about the meaning of medical futility. Recent arguments focus on whether futility can be defined in a consistent and coherent way. Those who believe that futility does have a precise meaning argue that physicians have the right and responsibility to refuse to provide, or even discuss, the use of futile therapy with patients or their families.(1) Others argue that many of the proposed definitions of futility reflect physicians' personal and idiosyncratic values, which are often employed to deny legitimate therapeutic choices to patients and families.(2)

Much of the disagreement results from semantic relativity. Futility means different things to different people, who then argue with one another as if they were talking about the same thing. Few authors accept the intutive notion that a futile therapy is one that never works. More typical are such definitions as therapy that is "medically or economically inappropriate"(3) or that "merely preserves permanent unconsciousness or cannot end dependence on intensive medical care."(4)

The concept of medical futility is based on the assertion that we can reliably predict that certain medical treatments will provide no benefit for particular patients and should therefore be withheld. For example, cardiopulmonary resuscitation (CPR) is clearly futile for a patient who suffers cardiac arrest as a direct result of irreversible exsanguination. This is an example of what has been referred to as "physiologic futility" because the treatment in question can reliably be predicted to have no physiologic effect and therefore is undeniably nonbeneficial.(5) Almost everyone would agree that this example represents a legitimate case of medical futility. Yet it is a trivial case precisely because CPR is futile: a decision to provide or withhold CPR is really of little consequence, since the patient will quickly die regardless of whether it is provided.

Even more trivial, and absurd, examples have been offered, such as the "futility" of performing a heart transplant for a patient dying of liver failure. Such examples are sometimes employed to demonstrate the authority of physicians to make clinical judgments about what range of treatments should be offered to particular patients.

If futility were only about such cases as these, there would be little to debate. Few would bother to argue that physicians are obligated to provide, or offer, treatments that are not directed against the patient's disease or that will have no physiologic effect.

However, because futility has also been invoked in less obvious and more controversial situations, the debate continues. A major source of controversy results from disagreements among different observers as to whether the predictable physiologic effect of a treatment is actually a benefit. For example, it is clear that, in general, tube feeding will predictably prolong the life of a permanently unconscious patient. However, whereas such a patient's family may believe that prolonging the life of their relative is beneficial, that patient's physician may disagree. To assert that it is futile to provide tube feedings for a permanently unconscious patient is to assert that prolonging the patient's life is not a benefit. In such situations, claims of futility imply not that the therapy is ineffective, but rather that any effect is nonbeneficial. Thus the futility debate frequently reduces to: What effects count as benefits, and who decides which benefits are worth pursuing? Perhaps more correctly, the futility debate represents an attempt to avoid addressing these questions.

It is our assertion that futility assessments are an attempt to avoid confronting a more difficult problem: Can we create just mechanisms to limit the use of expensive treatments of marginal benefit in order to assure that we can provide adequate medical care for all members of our society?

One of the problems with much of the current discussion of futility is the lack of historical reference. We believe that resolving the futility debate depends on an understanding of the history of the concept.

The History of Futility

Before the 1980s, evidence that a therapy was ineffective was typically presented to identify an area requiring further research. There was no attempt to define areas of therapeutic futility that would be held outside any hope of progress. The futility debate began in the 1980s with the publication of articles that documented the general ineffectiveness of cardiopulmonary resuscitation (CPR) in specific groups of patients but reached novel conclusions about the implications of this finding.

In the first decade after the introduction of CPR in 1960, several articles were published reporting relatively poor outcomes after CPR for hospitalized patients and also for certain subgroups of patients.(6) The authors of these articles generally acknowledged the limits of CPR but focused on the potential for improved outcomes. After the 1960s, however, authors began to suggest that further improvement in the success of CPR might not be possible.(7) In 1983 Bedell et al. reported a very low rate of survival-to-discharge after CPR for certain groups of patients, concluding that the poor outcomes reflected irremediable limitations on the value of CPR in these groups. They wrote, "Our findings ... may serve as a helpful guide to physicians and to patients and their families who are concerned about the likelihood of a successful outcome after an attempt at resuscitation."(8) Several subsequent studies confirmed that...