Futility IV
Michael A. Gillette, Ph.D.

For the reader who has been following our discussion over the last several months concerning the futility of care, it has become increasingly clear that the ethical issues involved in this area are complicated. Previously, the issue arose as to whether it is always morally obligatory to provide medical care to a person who needs that care. In response to this question, it was suggested that futile care need not be provided. The basic argument in support of this position suggested that if the care is futile, its provision will do no good for the patient, and that such care is not needed and not required.

In order to determine the success of this line of reasoning it became necessary to formulate a good definition of futility. After painstaking effort and careful response to counterexamples, the following version of a definition was created.

Definition Four:
Provider X employing treatment Y to patient Z is futile if and only if: Y does not provide any benefit to Z

The problem with this definition is that it seems to be too broad. According to this definition, a treatment cannot be considered futile unless it does absolutely no good for the patient. This means that if a treatment has the effect of making a patient feel better, even if no strictly medical benefit accrues, the treatment is not futile. This limits the use of the definition to cases where a patient is unable to experience any benefit whatsoever from the proposed treatment. Such cases are few and far between. According to this way of thinking, a treatment could only be completely futile if the patient is unconscious or brain dead, or if the patient does not want the therapy.

The counter example to this line of reasoning should be obvious. Suppose I go to my physician and request that she provide a very expensive but medically inappropriate treatment for my condition. On the assumption that side effects from the procedure are not a danger, it would still be plausible for my physician to refuse to provide the treatment simply because it is not indicated. That particular treatment will do nothing to address my present illness, and is therefore futile. If I adopt definition four, however, I can claim that the treatment would provide me with hope, albeit misplaced hope, but that such a benefit is valuable to me. The care is not futile.

One additional problem with definition four is that it does not consider the situations in which the provision of care to patient Z does not provide benefit to Z, but to some other party. The most common example of this would be the use of life-support technologies on a patient who is brain dead for the sole purpose of giving the patient's family time to deal with the difficult fact that they have lost a loved-one. I have personally been involved in several cases in which a physician empowers a family to make the decision to withdraw artificial life support, and may allow the family to extend the decision making process over a several day period. This is often times considered the humane response to a difficult situation and is, therefore, not a futile use of technology. Definition four seems incapable of taking this sort of instance into account.

The process of offering possible definitions, subjecting them to criticism, reformulating definitions and shooting them down again probably seems tedious and pointless. Although I believe that the process actually has merit, I will not satiate my philosophical appetite in this way any further. It should be clear at this point that a careful definition of futility; one that takes into account all of the possible ways in which we might use the term, is difficult if not impossible to develop. That fact, however, does not end this conversation.

One thing that I think we can learn from the foregoing discussion is that the concept of futility is far more nebulous than we might have originally thought, and that it probably isn't the actual idea that we are relying on when we decide that "enough medicine is enough" or that the use of a particular treatment modality is unjustified.

In the interests of moving this discussion forward, I suggest that perhaps as much as 99% of the time that we refer to the concept of futility in order to justify a judgment that further medical interventions are unjustified, it isn't really absolute futility to which we appeal. I suggest that what we are really talking about is something that might be better thought of as 'relative futility'.

This assertion is based on the idea that we would probably not consider futility at all if resources were unlimited. The times when we consider futility are not accidentally contemporaneous with the times when money is short or resources and staffing are scarce. This fact leads me to believe that what we really mean most of the time when we say 'this treatment is futile' or 'this use of technology is useless', is that 'this treatment would benefit someone else more than this particular patient' or 'we could achieve more if we put our efforts elsewhere'.

If this claim is true, then its implications are immense. If this claim is true, then most of the lengthy discussion of futility that takes place in the medical and medical ethics worlds is off track. The topic is really one of distributive justice. The question really is not "is it worth treating this person?", but rather "is it worth treating this person rather than that one"? Now that is a question which presents special problems for the MH and MR populations!