Futilitarianism: knowing how much is enough in end-of-life health care

Abstract

The concept of futility is frequently invoked by doctors as providing ethical justification for the unilateral witholding/withdrawal of treatment of marginal benefit. The term now appears in many institutional policies. Yet it provokes controversy in its application, often being characterized as an unwarranted infringement of patient autonomy. This paper explores the substance of assertions of futility and attempts to dissect out the issues commonly intertwined in appeals to the concept. An ethical analysis of its component parts is presented using a principle-based approach to derive appropriate duties of care applicable in specific scenarios. The usefulness of the concept of futility is challenged and an alternative model is offered to deal with the ethical dilemmas posed by the availability of treatments of marginal benefit.

An evolutionary concept analysis of futility in health care

“…Quantitative futility assesses the overall benefit to the patient as a whole (Schneiderman & de Ridder, ). For example, providing CPR to a patient in a persistent vegetative state does not reverse their cognitive dysfunction if there is a return of spontaneous circulation (Dunphy, ).…”

“…This form of futility is often identified as non‐beneficial treatment. Even though the effect occurs physiologically, the intended somatic end‐goal remains unachieved (see Table ) (Brody & Halevy, ; Dunphy, ). While some individuals see quantitative and physiologic as overlapping, they are distinct attributes of futility in health care (Schneiderman & de Ridder, ).…”

Clinical practice guidelines for communicating prognosis and end‐of‐life issues with adults in the advanced stages of a life‐limiting illness, and their caregivers

“… the patient is aware that he or she is dying and has already expressed a wish for care that is aimed at comfort rather than prolonging life; the patient prefers not to discuss end‐of‐life care and requests that the doctor or caregiver make any decisions relating to his or her health care; and the patient is clearly in the terminal phase of a progressive life‐limiting illness and the doctor thinks that the harm of the discussion may outweigh the benefits 154 , 155 …”

Life expectancy discussions in a multisite sample of Australian medical oncology outpatients

“…154,155 However, not discussing "no CPR" orders with patients or caregivers in this latter circumstance may be open to contest and • Explain that most commonly the person's condition will gradually deteriorate over time, but that there may also be sudden events that no one can predict (eg, pneumonia or some other intercurrent problem).…”