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Futility Clarified

Published online by Cambridge University Press:  01 January 2021

Eric Chwang
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Extract

Futility has had a rough time in recent medical ethics literature. From about 1987 to 1996, various writers and groups tried to define futility within the context of medical treatment, but without success. Baruch Brody and Amir Halevy give an excellent summary of the morass in their 1995 article “Is Futility a Futile Concept?” where they argue that none of the then-proposed definitions succeed. While a smattering of other attempted definitions have appeared since then, for the most part writers about futility have found it more profitable to stop trying to define futility and instead move in a different direction, that of figuring out how to resolve disputes where patient families want more treatment which clinicians think is futile. This is, for example, the approach taken by the Texas Advance Directives Act (1999), which was the first futility legislation in North America and is often seen as an appropriate template. The idea embodied in this influential legislation is that our energies should be focused on creating a process which we can use to resolve difficult cases, and which everyone finds legitimate, rather than in trying to find a definition which everyone finds legitimate.

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Independent
Information
Journal of Law, Medicine & Ethics , Volume 37 , Issue 3 , Fall 2009 , pp. 487 - 495
Copyright
Copyright © American Society of Law, Medicine and Ethics 2009

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References

For a nice summary, and numerous examples, see Helft, P. R., Siegler, M. and Lantos, J., “The Rise and Fall of the Futility Movement”, New England Journal of Medicine 343, no. 4 (2000): 293–296.CrossRefGoogle Scholar
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See, for example, Brody, H., “Medical Futility: A Useful Concept?” Medical Futility and the Evaluation of Life-Sustaining Interventions, Zucker, M. B. and Zucker, H. D., eds. (Cambridge, U.K.: Cambridge University Press, 1997): at 1–14. Brody there argues that the right way to resolve disputes is to appeal to the metaphor of conversations. Again, a nice overview of this history is provided in Helft, Siegler, and Lantos, supra note 1.Google Scholar
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I encourage the reader to try this to see both that it is nearly impossible and that it is unnecessary. (I say “nearly” because for some contentious synonymous pairs, there might be some third term which is uncontroversially synonymous with both the other two. One could then use the transitivity of synonymy to construct a direct argument for the contentious synonymy in question.)Google Scholar
The distinction between use and goal is obvious and becoming more explicit in recent discussion of futility. See, for example, Mohindra, supra note 3, and Brody, H., “Bringing Clarity to the Futility Debate: Don't Use the Wrong Cases”, Cambridge Quarterly Healthcare Ethics 7, no. 3 (1998): 269–273.CrossRefGoogle Scholar
Leaving open whether meaning is reference or some Fregean sense, Frege is still careful to distinguish coloring (or tone) from both of these. Two synonyms might share sense and reference yet still differ in their coloring, which Frege suggests will be a relevant feature when poetic eloquence is at stake, but not truth-conditions. See Frege, G., “Über Sinn und Bedeutung”, Zeitschrift für Philosophie und Philosophische Kritik 100, (1892): 25–50.Google Scholar
Another issue that might be complex, as discussed earlier, is when it is appropriate to assert a futility claim or, perhaps equivalently, when we can be sure enough of futility to stop treatment.Google Scholar
See Schneiderman, et al., supra note 8, at 952.Google Scholar
Again following from earlier discussion, there is a third possibility. We may be clear on what the word means and clear on the reason(s) we have for applying it, and yet be unclear on whether it is appropriate to assert claims using that word, for example because we think a certain degree of confidence is required before making authoritative assertions.Google Scholar
See Clouser, K. D. and Gert, B., “A Critique of Principlism”, Journal of Medicine and Philosophy 15, no. 2 (1990): 219–236.CrossRefGoogle Scholar
The difference here is one of logical scope. The claim I make has the modal operator taking wide scope over the universal quantifier: it is not possible that we can write down a short, useful algorithm that covers every medical problem. This is not to be confused with the plausible claim where the quantifier takes wide scope over the modal operator: for any arbitrary clinical problem, it is possible to articulate a short, useful algorithm on how to address it.Google Scholar
The question of goals also rightly falls silent on whether the treatment is life-sustaining or at the end of life, another potential distraction from the correct conceptual analysis, as discussed earlier.Google Scholar
See Halevy, and Brody, , supra note 7, at 573. This policy is restricted to end of life cases only; an interesting issue I will not explore here is whether something similar but potentially less costly might be implemented for mundane cases of futility, such as refusing to give antibiotics for viral infections. The conceptual issues are the same; the difference is only in severity of potential harm and benefit.Google Scholar