Futility II
Michael A. Gillette, Ph.D.

In order to continue the discussion of futility that was begun in the last newsletter, two important tasks must be successfully completed. First, it must be understood just what futile care is. In order to have any profitable conversation about the moral implications of futility, we must have a clear picture in our minds of what, exactly, it is about which we are speaking. Second, we must consider what the ethical relevance of futility is once we have a clear understanding of the concept.

I would like to begin the project of considering futility by accomplishing the second task first. It seems obvious that if a particular treatment's being futile or not being futile is morally irrelevant, then we can eliminate the need to get any precise sort of definition of the concept. A better understanding might be interesting, but it would not be imperative to have that understanding in order to make responsible decisions regarding the provision of care.

On the other hand, if it becomes clear that the concept of futility plays an important role in defining the ethical obligations of clinicians and facilities, then we would be heavily invested in the project of understanding better what futility is all about.

For the purposes of the moment, therefore, let us loosely understand futility as having something to do with care that is not going to work even if it is provided, and leave the work of tightening up that definition until later.

On the face of it, there seem to be two reasons why it might be important to know whether a particular treatment modality is futile or not, and why the condition of futility would release a clinician from provision of the care in question.

The first and most obvious reason to think that no moral obligation exists to provide care that is futile, is cost containment. The second and less obvious reason to deny that a clinician has the obligation to provide futile care is that the provision of such care might actually be counter to the patient's own well being. It is possible that in some particular situation a type of therapy that is not going to do any good might also present the chance of doing some harm. A clinician's obligation to "do no harm" is therefore invoked in order to overrule any request for futile therapy.

Uncharacteristically, I will take the first of these two arguments first, and then move on to the second.

As noted, the first argument that might be generated to support the claim that futile care ought not to be provided, or at least that a clinician does not have an obligation to provide care if it is futile, has to do with the issue of cost containment. This argument would likely take the following form. In this world of scarce medical resources and insufficient health care dollars to go around, it would be irresponsible to provide care to a specific individual when that care will not provide a benefit to that person, and when it could be used for the benefit of another. It would be irresponsible, the argument continues, to sentence two people to suffering when only one person must suffer. The first person cannot be helped (at least not with the therapy under scrutiny) so his suffering cannot be relieved no matter what happens. The second person can be saved, but doing so requires shifting our attention away from person one and placing it on person two.

This argument, compelling as it sounds, is actually rather fragile. It depends on some very specific assumptions for its survival. First, it depends on the assumption that the mere shifting of attention away from person one toward person two does no harm to person one in-and-of-itself. Second, it depends on the fact that there actually is a person two who will be helped if only we shift our attention away from person one.

Obviously, the medical profession depends upon a certain level of trust that patients have for the health care system, and it is likely this trust could be shaken if low probability cases are routinely ignored. As if the concern for patient/physician trust were not already a serious enough matter, we must also consider whether direct emotional harm is done when a patient is denied care because he is considered "hopeless".

Although this argument requires further discussion, it actually begs some questions that we are not prepared to answer this month. For instance, is patient trust a reasonable goal in the provision of care that will have no physiological benefit? Is the emotional well being of a patient an important enough medical concern that it must be weighed in when considering the efficacy of specific treatment modalities? The reason that these questions are beyond the scope of this month's column is that they force us to consider more carefully what futility means, and that is the first task that I have already put off until second.

It would be sufficient for our present purposes, I believe, to point out that the cost containment argument will only work when failure to provide care would actually free up resources that could actually be used by another patient, and when such resources cannot be provided in any other way than by refusing them to the first patient. Having this important clarification in mind, let us assume that such situations do exist, and that we are able to recognize them reliably. The next step in the argument will come next month.