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Medical Futility. What is Futility?. Basic common sense idea: “It won’t work” Always an incomplete thought: “It won’t work to accomplish what goal?” Any medical futility judgment is a mixed fact and value statement Statistical probability of outcome Whether outcome is a “benefit”

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what is futility
What is Futility?
  • Basic common sense idea: “It won’t work”
  • Always an incomplete thought: “It won’t work to accomplish what goal?”
  • Any medical futility judgment is a mixed fact and value statement
    • Statistical probability of outcome
    • Whether outcome is a “benefit”
    • How confident one is of predictions
can futility be value free
Can Futility Be Value-Free?
  • “No chance of survival to hospital discharge if perform CPR”-- clearly value laden because assumes that relevant goal is to survive to discharge
  • Therefore, define “futility” in physiologic terms-- any chance that CPR will restore spontaneous heartbeat and respiration (even if only for a few moments)?
is physiology value free
Is Physiology Value-Free?
  • Physiologic futility criteria take the value stance that the proper and desirable goal of medicine is physiologic function independent of whether the patient considers such function to be a benefit
  • Conclude: There cannot be a truly value-free definition of futility
why an ethical issue
Why an ethical issue?
  • “Typical ethics case” in 1975: Patient or family wished to stop aggressive treatment; physicians felt obligated to keep treating
  • “Typical ethics case” in 2000: Physicians feel obligated to stop aggressive treatment; patient or family demands ongoing aggressive care
futility principles
Futility: Principles
  • Respect for autonomy: Patient or agent has a right to decide on what care to accept or refuse
  • Is it ever the case that physician’s prediction of futility is so firm that it should override usual presumption in favor of patient choice?
what principles may override
What Principles May Override?
  • Physician vs. patient autonomy: does it matter on what basis physician wishes to withhold therapy?
  • Justice: futile therapy is a waste of money and others are in need of care (Murphy)-- is this core idea of futility or is it a secondary consideration?
role of futility in justice
Role of Futility in Justice
  • “The reason we should give physicians the discretion to refuse to provide futile care is so that the system can save money”
  • “If we have limited money for medical care and have to ration care, it makes sense to eliminate totally futile care first, before we start to limit very expensive yet beneficial care”
physician nurse integrity
Physician/Nurse Integrity
  • Joanne Lynn’s observation: Nursing staff required to provide ongoing intensive care which seemed incapable of improving the patient’s status (but which was often painful) described themselves as feeling like they were forced to act as “moral monsters”
integrity
Integrity
  • Wholeness
  • Related more to virtue theory than other approaches
  • My moral actions, attitudes, and values are coherent and coordinated over time
  • Compare: “moral chameleon” (M. Benjamin)
levels of integrity
Levels of Integrity
  • Personal: My own “private” moral values are reflected in my attitudes and behaviors
  • Professional: The core values of my profession are reflected in my attitudes and behaviors
futility and professional integrity
Futility and Professional Integrity
  • Unprofessional to:
    • Cause harm without benefit
    • Portray oneself fraudulently
  • Setting out to do what doesn’t work violates these professional duties
  • Requires a firm grounding in professional consensus as to “what doesn’t work”
the real world
The Real World
  • Most futility disputes resolved by effective communication over time
  • Rubin example of S.E. Asian woman: often goal clarification suffices to remove source of dispute
  • Cases that go to court are therefore highly atypical
are these futility cases
Are These Futility Cases?
  • Wanglie: 80yo woman on respirator in PVS, family stated that unconscious life is still of value
  • Baby K: Infant born with anencephaly, needed intermittent intensive care with respirator, mother demanded that hospital continue to admit and support
arguments against futility
Arguments Against Futility
  • Factual: Too much uncertainty or slippage in deciding what works and what does not work
  • Value: Futility seems to be a power play allowing physicians and end-run around respect for patient autonomy
cpr counter argument
CPR Counter-Argument
  • Do physicians and nurses have the right to decide when to stop CPR based on their own determination of futility, independent of family wishes?
  • If so then seems logically required that at least in some cases they could decide not to start CPR on same grounds
veatch s argument
Veatch’s Argument
  • Based heavily on position that no physician can truly decide what counts as a benefit to any given patient-- even in “ideal” situation where physician and patient come from identical value communities
  • Rejoinder: Does Veatch ever buy gifts for his family?