| Abstract |
Medical futility emerged in the medical vocabulary in the late ‘80s to define a concept as old as medical profession itself: a situation that nothing more can be done. Whereas in the past futility arose from the impotence of medicine to affect the course of disease, the re-emergence of this notion today represents a reaction to the technologic abundance of medicine which has enormously enhanced its power to intervene. A clear understanding of futility has proved to be elusive, however. Attempts to provide a definition not only failed to achieve a consensus within the medical community, but elicited a vehement debate, which peaked in the mid-nineties. In 2000 Helft et al reviewing the number of articles on the topic concluded that the interest on futility has waned, however both the response to their review and Medline search does not support this conclusion. Futile care is still very much an issue in hospital and intensive care units. In this study a review of the literature on medical futility is presented with a focus on the conditions which led to its recent emergence, as well as the dimensions and limitations of medical futility in current medical ethics and practice. The relevant literature was accessed through the PubMed medical database and all opinion papers, which obtained under the terms “futility” and “futile” from 1970 to 2005 were reviewed.
The etymological root of the word futility, the Latin adjective futilis meaning leaky, refers to instruments or actions which are ill-suited for achieving desired ends. The etymological connection of the word “futile” with leaky buckets refers to the Greek myth of Danaides, the 50 daughters of the king of Argus Danaus, who were ordered to murder their husbands on their wedding night. To expiate their crime, they were eternally condemned to an afterlife of attempting to fill with water a leaky jar or using sieves. In analogy with the myth, a futile action in clinical practice could be described
as one that cannot achieve its goals, no matter how often repeated. In this respect, futility refers to both, the probability and the desirability of a therapeutic goal. The concept of futility should be distinguished from conceptual or etymological neighbours. It does not refer to an impossible or implausible therapeutic intervention, implies something more than rare, uncommon or unusual, and does not suggest failure, frustration or faintheartedness. Although a number of simple, everyday clinical decisions, like the prescription of antibiotics for a viral infection could qualify as futile, the concept is mainly reserved for life-sustaining interventions. If they should be attempted, for how long they should be sustained and if the results are worthwhile. These different futility situations could be called futility in process, futility at prognosis and futility in result.
All the participants to the futility debate, regardless of the normative position they endorse, share an acceptance of the fact/value distinction as a rough way of describing different senses of futility. The concept of futility is understood to have at least two broad meanings, a factual and an evaluative, defining a treatment that would just not work and a treatment that would just not be worth it, respectively. The first attempt for a definition came from Hastings Center in 1987, it is purely factual and was called physiologic futility. According to this definition, a treatment is futile only when it fails to produce its physiologic objective. Physiologic futility was critised as too narrow to be of any clinical importance. Howard Brody, a physician and Professor of Ethics and Humanities, attempted to define futile treatment in a broader but strictly factual sense, as a treatment that will not work within reasonable certainty. He did not offer a precise definition, but considered futile interventions a subcategory of the larger category of actions, which violate professional integrity, a notion that it is central in Brody’s theoretical thought on medical ethics. The physician Lawrence
Schneiderman and the scholars Nancy Jecker and Albert Jonsen made a more radical proposal, specifying conditions of futility not only in the factual realm but also in the evaluative one. They defined a treatment as futile either if it has less than 1 chance in 100 of success or if it merely preserves permanent unconsciousness and total dependence on intensive care unit, giving thus a quantitative and a qualitative criterion. The physicians Donald Murphy and Thomas Finucane proposed an operationaling definition which implicated shared social values and cost and defined a treatment as futile when it is so unlikely to succeed that many people –professional and lay persons- would consider it not worth the cost. Different futility approaches point to different philosophical origins and backgrounds. Brody’s approach has a deontological origin with a Kantian notion of autonomy and a Rawlsian notion of the primacy of justice, modified by the contemporary ideas of Michael Sandel’s deontological liberalism. Schneiderman endorses a naively communitarian view of consequencialist origin, giving primacy to medical tradition and the rules of the majority. Murphy and Finucane’s third option is based on the promotion of medical goals within a community with shared values, an approach closer to community theories like Roycean ethical idealism, and on an effective procedure of dialectical ethics for the resolution of conflicts.
The notion of futility has its origins in the ancient past of medicine. The first description of futile medical situations can be traced in the Egyptian text Edwin Smith Surgical Papyrus, dating from the 17th century B.C, where some of the medical cases described are characterised as “ailments not to be treated”. In Ancient Greek medicine both, the quantitative and qualitative notions of futility are described by Hippocrates and Plato, respectively. Christian medical ethics in in Eastern and Western Europe incorporated the tradition of respecting the natural limits of medicine.
Within the scientific spirit of the 17th century, a radical alteration in the nature of medical ethics occurred, which is mostly exemplified with a new medical duty “to preserve life” as defined by the scientist Francis Bacon. During the 18th and 19th centuries the scientific advancement led to a profound redefinition of medicine, a shift from accurate prognosis to accurate diagnosis and the abandonment of the art of the management of the patient as a whole. The technological imperative of the 20th century was to follow.
From the mid-fifties with the development of life-sustaining equipment and intensive care, technology invades medical practice and leads to the medicalisation of life. The social movements of the 60s and 70s set the tone for the demands of reform and setting limits to medicine and for the emergence of autonomy and patients rights. The principle of autonomy has become an ethical absolute for the American civilisation. It was gradually shaped and strengthened through the influential Quinlan, Brophy and Cruzan cases, to reach the “right to death” in the sense of the absolute right not to consent to a treatment even when death is the alternative. Meanwhile, there was much concern from health care managers and administrators that health care services, which have risen rather fast, will become uncontrollable with the ageing of the population. Futility emerged within this context and despite the lack of consensus at the theoretical level, hospitals and Medical Associations responded and developed positional statements and guidelines for the management of relevant issues. Interestingly, the “right to die” changed to a “right to live” as a case of physician-patient conflict which reached the courts for resolution. The law, which has offered clear answers for the resolution of the earlier paradigm, stood hesitantly before the newer. In the USA court decisions with one exception have been in favour of initiating or continuing the disputed treatment, indicating the pervasiveness of the
principle of patient autonomy. However there was a lack of consistent reasoning for the decisions which is illustrative of the lack of social consensus on the issue of futility. In Britain, the notion of futility seems to be incorporated in clinical practise without the need for perplexed theoretical deliberation or elaborate hospital protocols. Court decisions have had more consistent reasoning and have usually been in favour of discontinuation of a treatment deemed futile by medical science and practice.
These differences of the management of the futility issue between the USA and Europe reflect deeper cultural differences and political choices. In the USA a country with emphasis on individual rights and a financially driven health care system, society seems to be hesitant in relation to healthcare if it should be understood as a mere market service or a human service beyond the laws of the market. In Europe there is a more collectivist approach to healthcare and society can more easily endorse concepts of social importance. The futility debate is often framed as a three-part struggle between doctors, patients and healthcare services. Physicians try to reclaim some of their lost control, patients try to extend the limits of their autonomy to every treatment available, and healthcare services to control cost and determine coverage. The views of physicians on the issue of medical futility can be easily traced in the literature either through personal positions expressed by the medical people who took part in the theoretical debate, or through empirical population studies including medical population, which generally is not so hard to be accessed. Patients’ views in terms of population studies, are greatly missing from the discussion of the on futility issue. The few studies of this kind that were carried out have suggested acceptance of the notion of futility from the majority of critically ill patients. The personal views of patients who shared their own or a family member’s experience with serious disease are usually illustrative of their desperation from the lack of limits in therapeutic
interventions. In media, newspapers, television and internet sites, the futility issue is negatively charged. The recent sensitive approach from the arts, literature and cinema, has offered interesting insights, despite the unrealistic dimensions of the situations that are described.
The theoretical debate over medical futility involved almost everything relevant to the concept. Contextual and procedural issues, parallel issues, even hidden intentions on either side have been disputed. The proponents of futility, despite their disagreement on the definition, claim that futility could serve as an ethical basis for rational decision-making in an era of a virtually limitless ability for medical intervention. Moreover, for its supporters, futility today is a matter of professional integrity and medical profession without internal values and acknowledgement of its goals and limits can no longer claim to be a healing profession but rather a commercial enterprise. The opponents criticised futility as an attempt to undermine the authority of patient autonomy regarding decision-making and a professionally disguised subterfuge for cost control.
Today, despite the claims that the futility language has waned, the futility issue remains a leading topic of contemporary medical ethics and one of the top challenges of healthcare issues in terms of societal concerns. Although a broader consensus within medical community has not been achieved, leading medical associations and hospitals have included futility policies in their ethical manuals and guidelines and in certain occasions futility was addressed by case and statutory law. Moreover, the futility debate has produced several insights with important clinical application and drew attention to end-of-life issues. Many contemporary scholars of bioethics are pessimistic that a simple communitarian idea like the one of futility could stand as an
alternative to the technological imperative but as the discussion is still on it may seems premature to exclude the possibility.
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Medical futility : η διαμόρφωση της έννοιας της ανώφελης θεραπείας και ο σύγχρονος ιατρικός προβληματισμός
