Futility – the doctor's dilemma

Patient autonomy, the dominating ethical principle that controls clinical decision making, evolved as a right of patients to be protected from inappropriate and unwanted application of life-extending medical technology. This principle reflects an ethical and legal consensus that serves to define the rights of patients and to set a standard against which physician and institutional actions can be judged.

Unfortunately, no comparable ethical consensus or body of law exists when the issue is not the right of patients to refuse treatment but instead is the limit to their rights to receive treatments. This issue appears when treatments under consideration have little chance to succeed or, on balance, provide little or no advantage to patients compared with the burdens that accompany their implementation. The term medical “futility” has come to encompass this group of problematic treatments.

In the clinical setting, the issue of futility can generally be described as follows: When is the value of a treatment or procedure sufficiently small or uncertain that it can be considered to be futile and, accordingly, the right of patients to choose it should be limited? Who decides that a medical treatment is futile, and what would be an equitable mechanism to establish and put into effect such determinations?