Last updated on: 6/9/2008 2:21:00 PM PST
Are Futility Policies Good for Patients?
General Reference (not clearly pro or con)
Paul Helft, MD, Director of Fairbanks Center for Medical Ethics, Mark Siegler, MD, Professor at the University of Chicago and John Lantos, MD, Professor at the University of Chicago, wrote in their July 27, 2000 article, "The Rise and Fall of the Futility Movement," published in the New England Journal of Medicine:
"The movement to establish a policy on futile treatment was an attempt to convince society that physicians could use their clinical judgment or epidemiologic skills to determine whether a particular treatment would be futile in a particular clinical situation. The idea was that once such a determination had been made, the physician should be allowed to withhold or withdraw the treatment, even over the objections of a competent patient."
July 27, 2000 - Paul Helft, MD
John D. Lantos, MD
Mark Siegler, MD
Grace Huffman, MD, Associate Medical Director at Brooke Grove Retirement Village, wrote in her Oct. 1, 1999 article, "Considering Futility of Care: Report of a Fair Process," that appeared in the American Family Physician:
"Defining when medical care is considered 'futile' for critically ill patients continues to be a challenging and controversial dilemma for physicians. The Council on Ethical and Judicial Affairs of the American Medical Association recently recommended a process by which determinations about futility may be made for patients with life-threatening illnesses. However, the Council was careful to avoid specifying what does and does not constitute futile medical care.
Claims of futility often increase when the patient, the physician and family members disagree on the goals of treatment... The law does not appear to favor either side consistently. In some cases, the court has sided with the patient's (or proxy's) right to choose care that has not been recommended by the physician. In other cases, the court has agreed that physicians do not have to provide care that is considered medically futile."
Oct. 1, 1999 - Grace Huffman, MD
Tom Tomlinson, PhD, Director of the Center for Ethics and Humanities in the Life Sciences at Michigan State University, and Diane Czlonka, Staff member of the Michigan State University College of Human Medicine, wrote in their May, 1995 article "Futility and Hospital Policy," that appeared in the Hastings Center Report:
"There are two fundamental considerations that support hospital authority over futile or grossly harmful interventions: the moral integrity of the health professions, and the obligation to enable autonomous choices by patients. Physicians and nurses have an obligation to help rather than hurt their patients by what they do. If health professionals could never say no to patient or family demands for interventions, they could not have control over the consequences of the procedures they perform. Without this control, physicians and nurses could not fulfill their moral obligation to promote the patient's welfare, an obligation that is fundamental to ethical practice...
The second consideration arguing for physician authority over futile treatment only has the appearance of paradox. The appearance is that limiting the patient's power to demand futile treatments must undermine his autonomy rather than enable it. The appearance is deceiving … Autonomy is enabled or enhanced only when there is a real choice being offered between significantly different options. In cases where resuscitation is genuinely futile, the choice between attempting resuscitation or not is a bogus choice, and the offer of it is a deception…
When the only way to authorize a DNR [do not resuscitate] order under hospital policy is by the consent of patients or their representatives, discussions about futile resuscitation are inherently misleading offers of bogus choices, increasing the likelihood that a choice will be made in favor of futile treatment. Adamant demands for futile resuscitation are less likely when the goal of discussion is not to have the patient or family make a choice, but rather to gain their understanding and acceptance of the choice already made and presented by the physician against attempting resuscitation. But creating the context for that sort of discussion requires a policy that grants physicians the authority to make such a decision. "
May, 1995 - Diane Czlonka
Tom Tomlinson, PhD
Peter Clark, PhD, John McShain Chair in Ethics at Saint Joseph’s University in Philadelphia, wrote in his 2000 article, "Medical Futility in Pediatrics: Is It Time For A Public Policy?" that appeared in the Journal of Public Health Policy:
"The medical futility debate comes down to a conflict between patient autonomy versus physician beneficence and distributive justice... If a physician believes, after carefully considering the patient's medical status, values, and goals, that a particular medical treatment is futile because it violates the principles of beneficence and justice, then the physician is ethically and professionally obligated to resist administering this treatment. This justification of medical treatments on the basis of physiological effectiveness, weighing the benefits and burdens, and the appropriate use of medical resources, is firmly rooted in the history of medicine and ethical tradition.
For years physicians have been criticized for being reluctant to admit to patients that death was imminent. Death has been viewed by the medical profession as the enemy and the ultimate failure to be defeated. In the past, physicians tried to overcome the obstacle of death by trying a new technology or a new medication. Any medical alternative was better than facing the inevitability of death. However, with the passage of time, a number of voices within the medical and ethical establishment began to challenge physicians to see that a peaceful, dignified death was a medical ideal just as important as prolonging and extending life. Acceptance of this new ideal has led physicians to strike a balance between aggressive treatment and palliative care. As part of this balance, physicians have come to realize that in the process of any disease there is a point when further treatment is nonbeneficial and not in the patient's best interest. "
2002 - Peter Clark, PhD,
Nancy Jecker, PhD, Professor of Medical History and Ethics at the University of Washington School of Medicine, wrote in her 1995 article "Medical Futility and Care of Dying Patients," that appeared in the Western Journal of Medicine:
"Despite their appeal, futile treatments should have no place in the humane care of dying patients. Although continuing to apply futile measures can offer a comfortable illusion, it is only by acknowledging, and moving beyond, futility that the dying process can become more dignified. Thus, when patients and families are no longer preoccupied with futile attempts to prolong life, they can turn their attention to preparing emotionally for death and to making practical decisions about the value of different settings for dying, such as the hospital, home, or hospice. When health professionals are no longer preoccupied by futile technologies, they can focus instead on spending time with the patient and minimizing the patient's pain and discomfort. When those who surround the patient stop fighting for 'everything' to be done, they can express love and concern in a more direct and meaningful way. Only by redirecting our collective efforts in these ways will physicians help patients and make care of the dying a more honest and compassionate part of medical practice. "
1995 - Nancy Jecker, PhD
Wesley Smith, JD, Consultant to the International Anti-Euthanasia Task Force, wrote in his 1998 article "Futile Care Theory and Medical Fascism: The Duty to Die," that appeared in the magazine Heterodoxy:
"Futile Care Theory goes something like this: When a patient reaches a certain predefined stage of age, illness, or injury, any further treatment other than comfort care shall be deemed 'futile' and shall therefore be withheld, regardless of the desires of the patient or family. The personal values and morals of the patient are no longer relevant. End of story, and often, end of life.
If Futile Care Theory were an objective concept, this would not be cause for alarm...
But this objective approach is not what Futile Care Theory is all about. Rather, as preached by the medical intelligentsia, the notion of futility is based on the perceived subjective value—or better stated, the lack thereof—of the patient’s life. In this context, futilitarianism becomes an exercise in raw social Darwinism in that it views some patients’ lives as having so little quality, value, or worth that the treatment they request is not worth the investment of resources or emotion it would cost to provide."
1998 - Wesley J. Smith, JD
Karla Dial, Managing Editor of the School Reform News at The Heartland Institute, wrote in her 2004 article "A Duty to Die?," that appeared in Citizen magazine:
"A utilitarian attitude...has led many hospitals to adopt what's known as 'futile care' or 'futility' policies--those that determine the circumstances under which patients may be denied costly life-saving or -sustaining treatments. When someone is deemed to fall into the 'futile' category, family members often find hospitals pressuring them for permission to end the patient's life--and sometimes taking them to court if they refuse...
A growing number of people from all kinds of disciplines--medicine, bioethics, disability rights and consumer advocacy--are concerned about these policies. The problem is, no one knows how many hospitals have adopted them because many have done so in secret. The first time most people encounter one is in the hospital, when a loved one's life is on the line.
Adding to the problem is new research showing brain-injured patients--whether comatose, deemed to be in 'persistent vegetative states,' or 'minimally conscious'--may have a good deal more awareness of their surroundings than most doctors realize. And that makes dismissing their care as 'futile' a slippery slope that could eventually, and perhaps all too soon, lead to legalized murder."
Jan. 2004 - Karla Dial
Not Dead Yet President Diane Coleman was quoted in a Jan. 2004 article titled, "A Duty to Die?," that appeared in Citizen Magazine:
"There’s physiologic futility, and then quality-of-life futility, where health care providers are wanting to say, ‘Your quality of life isn’t good enough to justify us spending all these resources on you.'
This makes people with disabilities very nervous. I haven’t been able to get all the physical therapy that would have been beneficial to me because it won’t cure me. And if it doesn’t cure you, insurance companies often say you can’t have it.
In futile care, they’re taking that a step further, but the message is very familiar to people with disabilities. It’s not news to us that health professionals judge our quality of life to be far less than how we judge it ourselves. The view that our lives are futile is frightening, no matter who holds it."
Jan. 2004 - Not Dead Yet
Nancy Valko, President of Missouri Nurses for Life, wrote in her Easter 2003 article, "Futility Politices and the Duty to Die," that appeared in Voices Online Edition:
"When I first saw 'Jack' last September, he was lying unconscious in an ICU with a ventilator to help him breathe. It had been two weeks since a truck struck the 60 year-old and his injuries were devastating -- including broken bones, blunt-force trauma and a severe head injury...
But over time, Jack improved and was able to breathe on his own. Eventually it became evident to all that Jack was starting to respond. Just before Thanksgiving -- a little more than two months after his accident -- Jack became fully awake. He is now in a rehabilitation facility near his home in Illinois where the staff is working to strengthen his arms and legs, which were broken in the accident. Now, no one meeting him would ever guess that he had had a brain injury.
Even doctors and nurses who ordinarily disdain religion often call cases like Jack's 'miracles'. Of course, for many in healthcare, it's easier to believe in miracles than to accept that they were wrong and a life could have been unnecessarily or prematurely lost...
Unfortunately, families like Jack's who choose to continue treatment despite a 'hopeless' prognosis are increasingly being denied that choice because of 'futile care' policies being adopted in many hospitals throughout the country.
And such 'futile care' principles have so permeated much of medicine today that there are even cases of elderly or terminally ill patients expected to have months of life remaining whose doctors didn't want to prescribe medications such as antibiotics because the person was going to die sooner or later anyway."
2003 - Nancy Valko, RN