Despite substantial controversy, the use of futility judgments in medicine is quite common, and has been backed by the implementation of hospital policies and professional guidelines on medical futility. The controversy arises when health care professionals (HCPs) consider a treatment futile which patients or families believe to be worthwhile: should HCPs be free to refuse treatments in such a case, or be required to provide them? Most physicians seem convinced that professional autonomy protects them from being forced to provide treatments they judge mentally futile, given the lack of patient benefit as well as the waste of medical resources involved. The argument from professional autonomy has been presented in a number of articles, but it has not been subjected to much critical scrutiny. In this paper I distinguish three versions of the argument: 1) that each physician should be free to exercise his or her own medical judgment; 2) that the medical profession as a whole may provide futility standards to govern the practice of its members; and 3) that the moral integrity of each physician serves as a limit to treatment demands. I maintain that none of these versions succeeds in overcoming the standard objection that futility determinations involve value judgments best left to the patients, their designated surrogates, or their families. Nor do resource considerations change this fact, since they should not influence the properly patient-centered judgment about futility.
There has recently been a revival of interest in 'naturalizing' ethics. A naturalization seeks to vindicate ethical realism -the idea that ethical judgments can be true reflections of a moral reality-without violating the naturalist constraint that science sets the limits of ontology. 2 The recent revival has been prompted by examples of successful scientific reduction (e.g. temperature, water), and by the emergence of new, nonreductive naturalist strategies (e.g. for biological and mental properties). In this paper, I argue against such naturalist approaches to ethics. My argument builds on the traditional one offered by G.E. Moore, namely that a naturalization would fail to respect an existing difference between the meanings of moral and naturalistic terms. I defend this line of argument against the common claim that it cannot block 'synthetic' property identities, ones grounded not in meaning equivalences but in empirical discoveries (as in the cases of temperature and water). I then go on to show that the Moorean argument can make trouble even for recent revisionist and nonreductive naturalist approaches.
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