Futility I
Michael A. Gillette, Ph.D.

Since it is well known that practice makes perfect, this month's practical ethics will contain another case study designed to show how the procedural approach to medical ethics that I have previously outlined can be useful in the clinical setting. This month, we will consider a case that I recently discussed at an educational session at Northern Virginia Mental Health Institute:

Review the background information:
Mr. C is a 54 year old white male who is married and has three children. Mr. C has private health insurance which has covered his long history of Schizoid Personality Disorder. Mr. C has become increasingly detached from his family, has voluntarily accepted treatment and indicates a desire to continue in therapy. Treatment has included a combination of chemical and psychotherapeutic measures and has been successful to a moderate degree. Even with therapy, however, Mr. C's condition has continued to deteriorate. Aggressive and long term therapy would now be necessary to produce even moderate results. In addition to his psychiatric problems, Mr. C experiences chronic renal failure, and is now in acute renal failure. He is not a candidate for transplant and is considered "terminally ill" by his nephrologist. Both Mr. C and his family desire to engage in continued psychiatric treatment. Given his terminal condition, however, it is unlikely that this costly and involved therapy would be effective. Does Mr. C have the right to demand psychiatric therapy in this situation?

Respond by listing arguments:
Futility of Care: In this case it seems clear that the treatment being requested is not going to be effective in terms of the goals specifically identified with the treatment modality in question. It has already been admitted that in order to produce even moderate results with regard to Mr. C's personality disorder, long-term therapy would be required. Since Mr. C is terminally ill, he simply does not have the opportunity to benefit from this therapy. The therapy, therefore, cannot possibly succeed and may be considered futile. It is not morally required of any physician to provide care that is futile.

Cost Containment:Since this care is not going to be successful, it is reasonable to avoid having to incur costs in its provision. Even if the care would be covered by a private insurance plan, it is not rational to spend funds that are scarce in order to provide useless treatments.

Patient Autonomy: The patient in this case suffers from a disease process that admits to a specific and identifiable course of treatment. Furthermore, this patient has paid his own money to procure an insurance policy that covers this type of care. While he is likely to die before any appreciable benefit of treatment can be attained, Mr. C simply has the right to demand care. This right is not contingent on whether the care would be successful.

Reduce the arguments to those that are most central:
Eliminate Patient Autonomy: All other things being equal it is true that a patient has a right to make certain demands on health care providers. Those demands, however, are limited. A patient does not, under normal circumstances, have the right to demand that physicians provide treatments that are not indicated. A patient may not demand unnecessary surgery, for instance, and claim that he has a right that his physician provide it. Therefore, the question of patient autonomy only makes sense after it is determined whether the care is medically appropriate. The issue of patient autonomy must be put-off until after a discussion of futility and cost containment. At that point, the argument is likely to be moot.

Eliminate Cost Containment:
Cost Containment suffers a similar fate as does patient autonomy. All other things being equal, cost containment does not create a legitimate basis upon which to refuse care to a specific individual. This basic premise may not be true, however, in cases where no good is to be generated by the health care expenditure. In a world where health care dollars are scarce, it would seem irresponsible to "waste" money on treatments that have no reasonable hope of benefiting patients. It is also possible to argue that relative levels of success may be appropriate considerations when there are identifiable other patients who will suffer if treatment is offered to Mr. C. In this case, unlike that of organ procurement for instance, there is no other patient who will specifically be denied care if Mr. C receives it. Therefore, the only cost containment issue to consider will hinge on whether the care in question is truly a "wasteful". In order to settle that question, we must consider whether the care is futile.

Recast the conflict based on the central issue:
Clearly we must now answer the question "is treatment of Mr. C's psychological condition futile"? Everything will hinge on the answer we give to that question, and so we shall turn to that discussion next month.