Background Health care professionals have to judge the appropriateness of treatment in critical care on a daily basis. There is general consensus that critical care interventions should not be performed when they are inappropriate. It is not yet clear which chances of survival are considered necessary or which risk for serious disabilities is acceptable in quantitative terms for different stakeholders to start intensive care treatment. Methods We performed an anonymous online survey in a random sample of 1,052 participants recruited via (...) email invitation and social media. Age, sex, nationality, education, professional involvement in health care, critical care medicine and treatment decisions in critical care medicine as well as personal experience with critical illness were assessed as potential influencing variables. Participants provided their opinion on the necessary chances of survival and the acceptable risk for serious disabilities to start a high-risk or uncomfortable therapy for themselves, relatives or for their patients on a scale of 0–100%. Results Answers ranged from 0 to 100% for all questions. A three-peak pattern with different distributions of the peaks was observed. Sex, education, being a health care professional, being involved in treatment decisions and religiosity influence these opinions. Male respondents and those with a university education would agree that a risky and uncomfortable treatment should be started even with a low chance of survival for themselves, relatives and patients. More respondents would choose a lower necessary chance of survival when deciding for patients compared to themselves or relatives to start a risky and uncomfortable treatment. On the other hand, the majority of respondents would accept only a low risk of severe disability for both themselves and their patients. Conclusion No cut-off can be identified for the necessary chances of survival or the acceptable risk of disability to help quantify the “inappropriateness” of critical care treatment. Sex and education are the strongest influencing factors on this opinion. The large variation in personal opinions, depending on demographic and personality variables and education needs to be considered in the communication between health care professionals and patients or surrogates. (shrink)

This essay reviews the Roman Catholic moral tradition surrounding treatments at the end of life together with the challenges presented to that tradition by the Texas Advance Directives Act. The impact on Catholic health care facilities and physicians, and the way in which the moral tradition should be applied under this statute, particularly with reference to the provision dealing with conflicts over end-of-life treatments, will be critically assessed. I will argue, based on the traditional treatment of end-of-life issues, that Catholic (...) physicians and institutions should appeal to the conflict resolution process of the Advance Directives Act only under a limited number of circumstances. The implications, under the Texas statute, of varied interpretations of Pope John Paul II's recent allocution on artificial feeding and hydration in the persistent vegetative state will also be considered. (shrink)

ZusammenfassungBei den meisten Patienten, die heute erwartet an einer unheilbaren Krankheit versterben, wird vor ihrem Tod eine bewusste Entscheidung zum Therapieverzicht getroffen. Während dem Therapieverzicht auf Wunsch des Patienten ein wichtiger Stellenwert in der medizinethischen Diskussion zukommt, hat der Umgang mit Forderung nach „unangemessener“ Maximaltherapie bislang weniger Beachtung gefunden. In einer empirischen Studie zur Einbeziehung von Patienten in Entscheidungen zum Therapieverzicht konnten wir zeigen, dass etwa ein Drittel der Patienten auch bei infauster Prognose Lebenszeit durch Maximaltherapie gewinnen möchte. Diese Patienten (...) wurden im Gegensatz zu Patienten mit palliativem Therapieziel häufig nicht in Entscheidungen zur Therapiebegrenzung einbezogen. Hier werden die ethischen Implikationen dieser Praxis untersucht und gefragt, ob ein Therapieverzicht am Lebensende auch gegen den Wunsch des Patienten ethisch zu rechtfertigen ist oder ob Ärzte dem Wunsch des Patienten nach Lebenszeitgewinn auch bei infauster Prognose durch Maximaltherapie nachkommen sollen. Vor dem Hintergrund der gängigen Konzepte zur Rechtfertigung eines einseitigen Therapieverzichts, die für sich genommen zu kurz greifen, wird ein alternatives Entscheidungsmodell vorgestellt, das vier bewertungsrelevante Kriterien vorsieht: die Wirksamkeit einer Maßnahme, die Autonomiefähigkeit des Patienten, die patientenseitige Nutzenbewertung und die Kosten für die Solidargemeinschaft. Je nachdem, welche Kriterien erfüllt sind, rechtfertigen sie eine Entscheidung zum Therapieverzicht oder eine Fortsetzung der Therapie entsprechend dem Patientenwillen. (shrink)

Contrary to the widespread concern about over-treatment at the end of life, today, patient preferences for palliative care at the end of life are frequently respected. However, ethically challenging situations in the current healthcare climate are, instead, situations in which a competent patient requests active treatment with the goal of life-prolongation while the physician suggests best supportive care only. The argument of futility has often been used to justify unilateral decisions made by physicians to withhold or withdraw life-sustaining treatment. However, (...) we argue that neither the concept of futility nor that of patient autonomy alone is apt for resolving situations in which physicians are confronted with patients' requests for active treatment. Instead, we integrate the relevant arguments that have been put forward in the academic discussion about ‘futile’ treatment into an ethical algorithm with five guiding questions: (1) Is there a chance that medical intervention will be effective in achieving the patient's treatment goal? (2) How does the physician evaluate the expected benefit and the potential harm of the treatment? (3) Does the patient understand his or her medical situation? (4) Does the patient prefer receiving treatment after evaluating the benefit-harm ratio and the costs? (5) Does the treatment require many resources? This algorithm shall facilitate approaching patients' requests for treatments deemed futile by the physician in a systematic way, and responding to these requests in an ethically appropriate manner. It thereby adds substantive considerations to the current procedural approaches of conflict resolution in order to improve decision making among physicians, patients and families. (shrink)

In early 2020, a number of countries developed and published intensive care triage guidelines for the pandemic. Several of those guidelines, especially in the UK, encouraged the explicit assessment...

Volume 19, Issue 10, October 2019, Page 63-65.

The use of do not resuscitate (DNR) orders in Dutch hospitals was studied as part of a nationwide study on medical decisions concerning the end of life. DNR decisions are made in 6 per cent of all admissions, and 61 per cent of all in-hospital deaths were preceded by a DNR decision. We found that in only 14 per cent of the cases had the patients been involved in the DNR decision (32 per cent of competent patients). The concept of (...) futility is analysed as these findings are discussed. We conclude that determining the effectiveness of resuscitation is a medical judgement whereas determining the proportionality (burden/benefit ratio) of it requires a discussion between doctor and patient (or his or her surrogates). Since the respondents in the cases without patient involvement gave many reasons for their decision that went beyond determining effectiveness, we conclude that more patient involvement would have been desirable. (shrink)

Lawrence P. Ulrich; A Reaction to the Consensus Statement of the Working Group on Roman Catholic Approaches to Determining Appropriate Critical Care, Christian.

As assisted reproductive technologies become increasingly popular, debate has intensified over the ethical justification for restricting access to ART based on various medical and non-medical factors. In 2010, the Australian state of Victoria enacted world-first legislation that denies access to ART for all patients with certain criminal or child protection histories. Patients and their partners are identified via a compulsory police and child protection check prior to commencing ART and, if found to have a previous relevant conviction or child protection (...) order, are given a “presumption against treatment.” This article reviews the legislation and identifies arguments that may be used to justify restricting access to ART for various reasons. The arguments reviewed include limitations of reproductive rights, inheriting undesirable genetic traits, distributive justice, and the welfare of the future child. We show that none of these arguments justifies restricting access to ART in the context of past criminal history. We show that a “presumption against treatment” is an unjustified infringement on reproductive freedom and that it creates various inconsistencies in current social, medical, and legal policy. We argue that a state-enforced policy of restricting access to ART based on the non-medical factor of past criminal history is an example of unjust discrimination and cannot be ethically justified, with one important exception: in cases where ART treatment may be considered futile on the basis that the parents are not expected to raise the resulting child. (shrink)

Pellegrino has argued that end-of-life decisions should be based upon the physician's assessment of the effectiveness of the treatment and the patient's assessment of its benefits and burdens. This would seem to imply that conditions for medical futility could be met either if there were a judgment of ineffectiveness, or if the patient were in a state in which he or she were incapable of a subjective judgment of the benefits and burdens of the treatment. I argue that a theory (...) of futility according to Pellegrino would deny that latter but would permit some cases of the former. I call this the circumspect view. I show that Pellegrino would adopt the circumspect view because he would see the medical futility debate in the context of a system of medical ethics based firmly upon a philosophy of medicine. The circumspect view is challenged by those who would deny that one can distinguish objective from subjective medical judgments. I defend the circumspect view on the basis of a previously neglected aspect of the philosophy of medicine -- an examination of varieties of medical judgment. I then offer some practical applications of this theory in clinical practice. (shrink)

We report the results of a randomized trial to assess the impact of an innovative ethics curriculum on the knowledge and confidence of 85 medical house officers in a university hospital programme, as well as their responses to a simulated clinical case. Twenty-five per cent of the house officers received a lecture series, 25 per cent received lectures and case conferences, with an ethicist in attendance, and 50 per cent served as controls. A post-intervention questionnaire was administered. Knowledge scores did (...) not differ among the groups. Confidence regarding ethical issues was significantly greater in the aggregate intervention group compared to the control group. Confidence regarding procedural issues related to ethics was significantly higher for the EI group than for the controls. Responses to a simulated case showed that significantly fewer house officers in the EI group would intubate a patient for whom such therapy would be futile. We conclude that ethics education can have an impact on house officers' confidence and their responses to a simulated case, and that the EI was more effective than the LI. Such results have implications regarding the implementation of ethics education during residency. (shrink)

Futility is not a purely medical concept. Its subjective nature requires a balanced procedural approach where competing views can be aired and in which disputes can be resolved with procedural fairness. Law should play an important role in this process. Pure medical models of futility are based on a false claim of medical sovereignty. Procedural approaches avoid the problems of such claims. This paper examines the arguments for and against the adoption of a procedural approach to futility determination.

Volume 19, Issue 10, October 2019, Page 61-63.

This paper attempts to provide a descriptive theoretical overview of the medical futility debate. I will first argue that quantitative data cannot alone resolve the medical futility debate. I will then examine two aspects of medical futility, which I call the prospective and immediate, respectively. The first involves making prospective factual and value judgments about the efficacy of proposed medical interventions, while the latter involves making value judgments about ongoing medical conditions where the clinical data are clear. At stake is (...) the nature and scope of individual rights. Thus, I maintain there is an undeveloped aspect to the medical futility debate and, briefly, analyze two political perspectives which give rise to different understandings of medical futility. The view that I will defend is that only a system with defined collective goals can accommodate a normative concept of medical futility. These larger questions are the value options which, if unaddressed, may be settled by default of economic grounds. (shrink)

Objective: Even when critically ill patients are almost certain to die from their illnesses, there is generally an element of prognostic uncertainty. Little is known about how physicians handle this uncertainty in conversations with surrogate decision makers. We sought to evaluate whether and how physicians discuss prognostic uncertainty with surrogate decision makers of patients who are highly likely, but not certain, to die. Design: We audiotaped and transcribed discussions between clinicians and surrogate decision makers at two major California teaching hospitals (...) from 2006 through 2008. Physicians completed a questionnaire addressing their prognostic estimates for patients' survival to hospital discharge. Participants: We included physicians and surrogates of 12 incapacitated, critically ill patients. Measurements: We analyzed transcripts of discussions in which physicians' estimates of patients' chances of hospital survival were 1% to 5%; we coded whether physicians disclosed the prognostic uncertainty and, if so, how they conveyed that death was highly likely but not certain. Results: Physicians' estimates of short-term survival were 1% to 5% for 12 of the 70 patients enrolled in the original study. In 8 of 12 cases, physicians conveyed prognostic uncertainty by using probabilistic language or by an explicit mention of uncertainty. In four cases, physicians made at least one statement that either implied or was ambiguous about whether death was certain. Conclusion: We observed variability in how physicians handle prognostic uncertainty in their discussions with surrogates of patients who are highly likely, but not certain, to die, including some circumstances in which physicians stated or implied that death was certain. (shrink)

It probably should not be surprising, in this time of soaring medical costs and proliferating technology, that an intense debate has arisen over the concept of medical futility. Should doctors be doing all the things they are doing? In particular, should they be attempting treatments that have little likelihood of achieving the goals of medicine? What are the goals of medicine? Can we agree when medical treatment fails to achieve such goals? What should the physician do and not do under (...) such circumstances? Exploring these issues has forced us to revisit the doctor-patient relationship and the relationship of the medical profession to society in a most fundamental way. Medical futility has both a quantitative and qualitative component. I maintain that medical futility is the unacceptable likelihood of achieving an effect that the patient has the capacity to appreciate as a benefit. Both emphasized terms are important. A patient is neither a collection of organs nor merely an individual with desires. Rather, a patient (from the word to suffer ) is a person who seeks the healing (meaning to make whole ) powers of the physician. The relationship between the two is central to the healing process and the goals of medicine. Medicine today has the capacity to achieve a multitude of effects, raising and lowering blood pressure, speeding, slowing, and even removing and replacing the heart, to name but a minuscule few. But none of these effects is a benefit unless the patient has at the very least the capacity to appreciate it. Sadly, in the futility debate wherein some critics have failed or refused to define medical futility an important area of medicine has in large part been neglected, not only in treatment decisions at the bedside, but in public discussions—comfort care—the physician’s obligation to alleviate suffering, enhance well being and support the dignity of the patient in the last few days of life. (shrink)

Patient and family demands for the initiation or continuation of life-sustaining medically non-beneficial treatments continues to be a major issue. This is especially relevant in intensive care units, but is also a challenge in other settings, most notably with cardiopulmonary resuscitation. Differences of opinion between physicians and patients/families about what are appropriate interventions in specific clinical situations are often fraught with highly strained emotions, and perhaps none more so when the family bases their desires on religious belief. In this essay, (...) I discuss non-beneficial treatments in light of these sorts of disputes, when there is a clash between the nominally secular world of fact- and evidence-based medicine and the faith-based world of hope for a miraculous cure. I ask the question whether religious belief can justify providing treatment that has either no or a vanishly small chance of restoring meaningful function. I conclude that non-beneficial therapy by its very definition cannot be helpful, and indeed is often harmful, to patients and hence cannot be justified no matter what the source or kind of reasons used to support its use. Therefore, doctors may legitimately refuse to provide such treatments, so long as they do so for acceptable clinical reasons. They must also offer alternatives, including second opinions, as well the option of transferring the care of the patient to a more accommodating physician or institution. (shrink)

For many years a debate has raged over what constitutes futile medical care, if patients have a right to demand what doctors label as futile, and whether physicians should be obliged to provide treatments that they think are inappropriate. More recently, the argument has shifted away from the difficult project of definitions, to outlining institutional policies and procedures that take a measured and patient-by-patient approach to deciding if an existing or desired intervention is futile. The prototype is the Texas Advance (...) Directives Act, but similar procedures have been widely implemented both with and without the protection of the law. While this method has much to recommend it, there are inherent moral flaws that have not received as much discussion as warranted. Because these strategies adopt a semblance of procedural justice, it is assumed that the outcomes of such proceedings will be both correct and fair. In this paper, I argue that there are three main irremediable defects in the policy approach: there is the potential for arbitrary decision-making about futility in specific cases; there are structural, pre-ordained consequences for ethnic minorities who would be disproportionately affected by the use of these procedures; and the use of rationing justifications to support the use of these policies. These flaws detract so much from any benefit that could be derived that they make such strategies more harmful than helpful. (shrink)

Objectives: To present an analysis of “futility” that is useful in the clinical setting.Design: Literature review.Material and methods: According to Medline more than 750 articles have been published about medical futility. Three criteria singled out 43 of them. The authors' opinions about futility were analysed using the scheme: “If certain conditions are satisfied, then a particular measure is futile” and “If a particular measure is futile, then certain moral consequences are implied”.Results: Regarding conditions, most authors stated that judgments about futility (...) should be made by physicians. The measure was usually some kind of medical treatment, and the goals related to quality of life, physiological improvement, or prolongation of life. The probability of success in reaching the goal was in most cases described in semiquantitative terms. Regarding consequences, the authors stated that health care professionals may withhold or withdraw a futile measure, most often after a dialogue with the patient , but sometimes without informing the patient , or with one-way information . Over time more and more articles recommend that the patient should be involved in joint decision making. Based on this literature review a clinical model was developed.Conclusions: The model, requiring that conditions and consequences should be made explicit, may, in “futility situations”, facilitate both the collection of the necessary information and make the moral implications visible. It also makes communication about measures considered to be futile possible without using such ambiguous terms as “futile”. (shrink)

This paper introduces the medical factual matrix as a new and potentially valuable tool in medical ethical analysis. Using this tool it demonstrates the idea that a defined medical intervention can only be meaningfully declared futile in relation to a defined goal of treatment. It argues that a declaration of futility made solely in relation to a defined medical intervention is inchoate. It recasts the definition of goal futility as an intervention that cannot alter the probability of the existence of (...) the important outcome states that might flow from a defined intervention. The idea of value futility and the extent of physician obligations in futile situations are also addressed. It also examines the source of substantive conflicts which commonly arise within the doctor-patient relationship and the ensuing power relations that operate between doctor and patient when questions of futility arise. (shrink)

Consent ought to be required to withhold treatment that is in a patient’s best interests to receive. Do not resuscitate orders are examples of best interests assessments at the end of life. Such assessments represent value judgments that cannot be validly ascertained without patient input. If patient input results in that patient dissenting to the DNR order then individual physicians are not justified in overriding such dissent. To do so would give unjustifiable primacy to the values of the individual physician. (...) Therefore patient consent is effectively required to write a DNR order. Patient dissent to a DNR order should trigger a fair process mechanism to resolve the dispute. (shrink)

The American Journal of Bioethics, Volume 11, Issue 7, Page 16-18, July 2011.

Requests by patients or their families for treatment which the patient's physician considers to be "inappropriate" are becoming more frequent than refusals of treatment which the physician considers appropriate. Such requests are often based on the patient's religious beliefs about the attributes of God (sovereignty, omnipotence), the attributes of persons (sanctity of life), or the individual's personal relationship with God (communication, commands, etc). We present four such cases and discuss some of the basic religious tenets of the three Abrahamic faith (...) traditions as they relate to such requests. We suggest that religious reasons for requesting "inappropriate" treatment are "special" and deserve serious consideration. We offer guidance to assist clinicians and clinical ethicists as they attempt to resolve these conflicts, emphasising the importance of understanding the religious beliefs of the patient/surrogate and suggesting the assistance of a religious interpreter. We suggest open discussion with patients and families of both the clinical situation and the theological basis for these requests. We also suggest that clinicians use additional religious doctrines or principles from patients' own traditions to balance the reasons behind the requests. We conclude that most persistent requests for "inappropriate" treatment should be honoured. (shrink)

There have been few empirical studies into what non-medical factors influence physicians and nurses when deciding about admission and discharge of ICU patients. Information about the attitudes of healthcare professionals about this process can be used to improve decision-making about resource allocation in intensive care. To provide insight into ethical problems that influence the ICU admission and discharge process, we aimed to identify and explore ethical dilemmas healthcare professionals are faced with.

In this essay I examine the formal structure of the concept of futility, enabling identification of the appropriate roles played by patient, professional, and society. I argue that the concept of futility does not justify unilateral decisions to forego life-sustaining medical treatment over patient or legitimate surrogate objection, even when futility is determined by a process or subject to ethics committee review. Furthermore, I argue for a limited positive ethical obligation on the part of health care professionals to assist patients (...) in achieving certain restricted goals, including the preservation of life, even in circumstances in which most would agree that that life is of no benefit to the patient. Finally, I address the objection that professional integrity overrides this limited obligation and find the objection unconvincing. In short, my aim in this essay is to see the concept of futility finally buried, once and for all. (shrink)

Some patients have no chance of surviving if not treated, but very little chance if treated. A number of medical ethicists and physicians have argued that treatment in such cases is medically futile and a matter of physician discretion. This paper is a critical examination of that position. According to Howard Brody and others, a judgment of medical futility is a purely technical matter, and one which physicians are uniquely qualified to make. Although Brody later retracted these claims, he held (...) fast to the view that physicians need not consult the patient or his family to determine their values before deciding not to treat. This is because professional integrity dictates that treatment shouldn't be undertaken. The argument for this claim is that medicine is a profession and a social practice, and thus capable of breaches of professional integrity. Underlying professional integrity are two moral principles, one concerning harm, the other fraud. Both point to the fact that when the odds of survival are very low treatment is a violation of professional integrity. The details of this skeletal argument are exposed and explained, and the full argument is subjected to criticism. On a number of counts, it's found wanting. If anything, professional integrity points to the opposite conclusion. (shrink)

Over the past 50 years, technical advances have taken place in medicine that have greatly increased the possibilities of life-prolonging intervention. The increased possibilities of intervening have brought along new ethical questions. Not everything that is technically possible is appropriate in a specific case: not everything that could be done should be done. In the 1980s, a new term was coined to indicate a class of inappropriate interventions: “medically futile treatment”. A debate followed, with contributions from the USA and several (...) western European countries. A similar debate later took place in Mediterranean countries, although with a different terminology. The purpose of this article is to provide an up-to-date and systematic analysis of the concept of futility, and to draw some conclusions on its operationalisation in medical practice. While the concept of “medical futility” in theory applies to all kinds of medical intervention that might be performed without being medically indicated—things such as certain medical screenings and cosmetic surgery—in practice the literature on “futility” deals only with life-saving and life-sustaining medical interventions. This article deals with this more limited application of the concept of “futility”. (shrink)

Why do we persist in the relentless pursuit of artificial nourishment and other treatments to maintain a permanently unconscious existence? In facing the future, if not the present world-wide reality of a huge number of persistent vegetative state (PVS) patients, will they be treated because of our ethical commitment to their humanity, or because of an ethical paralysis in the face of biotechnical progress? The PVS patient is cut off from the normal patterns of human connection and communication, with a (...) life unlike other forms of human existence. Why the struggle to justify ending a life which, it is said, has suffered an irreversible loss of the content of consciousness? Elsewhere, the authors have addressed the ethical controversies and confusion engendered by ambiguous terminology, misuse of medical facts and the differing interpretations of what constitutes 'effective' treatment: in particular, the issue of whether in fact artificial nutrition and hydration is a medical treatment, or simply part of the obligatory care owed to all patients, permanently unconscious or not. In this paper, we intend to argue that recent analyses of medical futility, its meaning and ethical implications, despite an absence of public consensus, permit some tentative re-evaluation of our ethical obligations to the PVS patient. (shrink)

This paper reframes the futility debate, moving away from the question “Who decides when to end what is considered to be a medically inappropriate or futile treatment?” and toward the question “How can society make policy that will best account for the multitude of values and conflicts involved in such decision-making?” It offers a pragmatist moral epistemology that provides us with a clear justification of why it is important to take best standards, norms, and physician judgment seriously and a clear (...) justification of why ample opportunity must be made for patients, families, and society to challenge those standards and norms. (shrink)

Background and Purpose The decision to perform decompressive craniectomy for patients with malignant MCA syndrome can be ethically complex. We investigated factors that clinicians consider in this decision-making process. Methods A survey including clinical vignettes and attitudes questions surrounding the use of hemicraniectomy in malignant MCA syndrome was distributed to 203 neurosurgeons, neurologists, staff and residents, and nurses and allied health members specializing in the care of neurological patients. These were practicing health care providers situated in an urban setting in (...) Canada where access to health care is covered by national policy and is a human right. Results Eighty-eight participants responded to survey. All participants unanimously supported the procedure for young and healthy patients. Advanced age, the presence of aphasia, comorbid medical conditions, and poor baseline functional status were dominant factors associated with increasing reluctance to offer surgical decompression. Patients’ previously expressed wishes were also an important consideration. Eighty-six percent of respondents agreed that withholding surgery is ethically justified if the outcome is perceived as futile. Conclusions Health care providers use similar factors to determine if aggressive management is justified given anticipated burden on patient quality of life and extended impact on society. This convergence can be harnessed beneficially for the transparent communication of medical options in the ethically complex setting of decompressive hemicraniectomy post-stroke. (shrink)

End-of-life care, particularly for patients with advanced dementia, tests the medical covenant, both the integrity and aptness of what physicians have to offer and the fidelity with which they offer it. This article considers five ways of justifying the unilateral withholding of future treatment: (1) an affirmation of professional autonomy; (2) a defense of professional integrity; (3) a parentalist exercise of power on behalf of the patient and/or family; (4) a protection of the interests of third parties (footing the bill); (...) or (5) a protection of the interests of second parties (the physician or other providers). The article concludes with a sixth response to care for the stricken patient and family that seeks to attend more fully to the clinical reality of bonded humans in the throes of disease and death. (shrink)

“Futility” is a word which means the absence of benefit. It has been used to describe an absence of utility in resuscitation endeavours but it fails to do this. Futility does not consider the harms of resuscitation and we should consider the balance of benefit and harm that results from our resuscitation endeavours. If a resuscitation is futile then any harm that ensues will bring about an unfavourable benefit/harm balance. However, even if the endeavour is not futile, by any definition, (...) the benefit/harm balance may still be unfavourable if the harms that ensue are great.It is unlikely that we will ever achieve a consensus definition of futility and certainly not one that is applicable to every patient undergoing resuscitation. In the meantime our use of the term “futile”, in the mistaken belief that it tells us whether it is worth resuscitating or not, has no utility as it will never succeed in telling us this. Furthermore we risk causing offence by use of the term and we risk harming the patient's autonomy by using futility as an overriding force. Instead we should consider the utility of our endeavours, for which an assessment of the harms of resuscitation should be added to our considerations of its benefit. This balance of benefit and harm should then be evaluated as best it can be from the patient's perspective. The words futile and futility should be abandoned by resuscitationists. (shrink)

Philosophers who specialize in bioethics face a distinctive set of challenges in our work: to bring the theoretical insights of philosophical work and methodology to practical dilemmas affecting a diverse group of stakeholders every day. This article describes some of the key contributions that philosophy can make to the field of bioethics. It also identifies some of the pitfalls that can undermine the value of a philosophical approach when used to analyze questions arising in the real world. Recognition of the (...) importance of individual context, practical implications, and social considerations can help successfully bridge the gap between theory and practice. Using this wide-angle lens to view bioethical problems can enable philosophers working in our field to offer insights that are both rigorous and relevant. (shrink)

I analyze the insights present in Elisabeth Kübler-Ross’s seminal work, On Death and Dying that have laid the foundation for contemporary clinical bioethics as it is practiced by clinical ethics co...

Background and objectives: Definitions of medical futility, offered by healthcare professionals, bioethicists and other experts, have been rigorously debated by many investigators, but the perceptions of patients of futility have been explored only by a few. Patients were allowed to discuss their concerns about end-of-life care, so that their ideas about treatment futility or utility could be extrapolated by us.Methods: In this cross-sectional study, in-depth, semistructured interviews were conducted with 30 elderly people who were receiving outpatient care in a large, (...) urban Veterans Affairs medical centre in the US. Each of their healthcare providers was also interviewed. Participants were asked to consider four terms commonly used in advance directive forms and to discuss what these terms meant to them. Audiotapes of the open-ended interviews were transcribed and responses were coded and categorised by constant comparison, a commonly used qualitative method.Results: The following four factors were taken into account by the participants when discussing end-of-life interventions and outcomes: expected quality of life; emotional and financial costs of treatment; likelihood of treatment success; and expected effect on longevity.Conclusions: Although the terms “utility” or “futility” were not generally used by the participants, segments of speech indicating their perceptions of these terms were identified. Treatment was not always discussed in the same way by patients and providers, but seemed to reflect the same four concerns. Therefore, it may be fruitful for providers to focus on these concerns when discussing end-of-life treatment options with their patients. (shrink)

The American Journal of Bioethics, Volume 11, Issue 7, Page 18-20, July 2011.