Medical futility is a timely topic and one fraught with ethical implications. Case managers in every level of care have been witness to medical treatment efforts that will likely yield no real promise of additional quality of life. At times, the push for these interventions comes from the patient and/or family; other times, providers offer treatment as a tool of hope, even when previous trials have not yielded good outcomes-or worse, have appeared to spiral the disease into more decay.
The reader may ask what this has to do with the primary theme of this issue: avoidable readmissions. It is a small leap between those who could/should be utilizing palliative treatments but are not, and readmissions to acute care. That being said, however, this topic lends itself to the most ethical of quandaries-and there are no black-and-white answers at the back of a book on ethics: only considerations for thoughtful "next steps." In the end, the patient/family unit must share in the decisions. Ms. Terra provides provocative considerations, not answers. It is not an "easy read," but one that will provoke thought when these cases arise.
Every day clinicians are asked to determine the efficacy of medical treatment. Ethical as well as pragmatic concerns influence these decisions. The basic premise for the provision of health care implies that there is an illness, treatment, and a subsequent improvement in health, a return to wellness or recovery from injury. Jonsen, Siegler, and Winslade (1998, p. 14) contend that although delivery of appropriate medical care generally abides by the fundamental principles of ethics-autonomy, beneficence, justice and nonmaleficence-the ethical aspects of medical intervention can sometimes become problematic. The determination of medically futile treatment is one such ethical dilemma. Medical futility is generally defined as treatment or clinical interventions that are not likely to result in benefit to the patient or produce the expected outcome. Much of the debate around this issue is driven by the question of a patient's right to demand treatment that may be against the advice of their physician or considered to have little or no effectiveness (Tan, Chun, & Kim, 2003).
Physicians, ethics committees, and health care administrators (HCA), as experts and in the role of care providers, all contribute to the decision-making process when medical futility exists and strive to arrive at a correct and ethical decision. Applying the concept of medical futility poses significant ethical and moral quandaries. Central to any discussion about limiting or withholding medical intervention is the essential nature of clinical utility and the ethical tenets of justice and autonomy. The determination of futile treatment is often arrived at when it is suggested that care be withheld or limited (Jonsen et al., 1998). Compounding the issue is the reality that often, treatment that is considered futile may be the only hope a patient has for improvement in health or prolonging of life.
Medical futility is generally defined as treatment or clinical interventions that are not likely to result in benefit to the patient or produce the expected outcome.
Increasingly, acute care facilities and medical practitioners are faced with the request by patients and their surrogates to deliver care that might be deemed unnecessary or perhaps even harmful. When conflict arises, this issue can be brought before the Ethics Committee of the facility; discussion can ensure the rights of all parties observed. An organization might also consider the development of a policy that acknowledges these potential requests and attempt to define a process by which initial disagreements might be managed. In any case, the issue is considered a clinical decision and should not be made on the basis of resource allocation. Most arguments involving medical futility ignore factors of resource allocation (Gampel, 2006).
The appearance of cost, consideration of socioeconomic status, age, gender, or other nonclinical factors as primary determinants in clinical decision-making is, at best, socially unacceptable. Invocation of medical futility should not be confused with resource allocation. One of the key ethical theorists, John Mill (1806-1873), first purported the idea of utilitarianism. Although not discounting the just and equitable treatment of all patients, this theory directs that actions should be the result of the consequences or outcomes, rather than a sense of personal or societal duty. Utilitarianism would hold that medical care not be offered when the likelihood of a desired effect is absent or limited, thereby conserving resources so they are available for cases where intervention will benefit the patient.
On the surface this idea of rationing health care or expending resources for the many as opposed to the few might suffice to uphold a determination of medical futility yet at the same time is not supported in terms of patient justice. The concept of "patient justice," as discussed by Morrison (2011), implies that all patients who have the same health care concerns should be treated in a like manner, yet treatment for one patient may be withheld or not offered while a patient with the same condition does receive the service. The clinical decision of medical futility is made primarily by the attending physician(s) or health care team and must be made only after careful consideration of medical fact (Tonelli, 2007).
Can making a determination for futility and thereby limiting or withdrawing treatment ever be considered "just"? Husted and Husted (1991) discuss the justifiable nature of an ethical decision, using key points to weight the decision, and asserting this lends credence to its justifiable nature. The key components address
1. the appropriateness of the decision to the situation at hand,
2. that it accomplishes the goal without causing undue harm, and
3. that this outcome is foreseeable by the agent or agents who have made the determination.
There must be a clear relationship between the decision, the action, and the result that the agent can explain to others in a rationale manner. Using this approach and process, making a determination of futility may meet the triggers for being a justifiable decision.
On a pragmatic level, these decisions are also influenced by social justice and what is known as "community standard of care." Treatment that may be offered in a U.S. teaching facility with a highly technological environment would not be offered in a more rural environment or in another country. John Rawls (1921-2002), another major ethics theorist, would support expenditure of resources to those in a "lesser position in society" (Morrison, 2011, p. 13), asserting that we, as a society, are judged by how we treat our members. This theory does not discount other core foundations of ethics such as autonomy or nonmaleficence but can seem in conflict with Mills' (1806-1873) theory of consequentialism and decision making based upon serving the greater good.
Invocation of medical futility should not be confused with resource allocation.
The HCA may very well be in a position of supporting the development of or implementing policies that limit medical care or treatment. These actions display social responsibility-maintaining the bottom line is necessary if a facility is to remain viable and able to offer continued service to the community. These actions do not necessarily imply a lack of justice and can be considered an act of nonmaleficence (Morrison, 2011). Justice and nonmaleficence are both served if medical intervention is deemed futile and if the intent is to prevent harm and subsequently serve the patient. There is also an obligation to act in a manner that spares suffering and avoids further harm to patients. This may take the form of withdrawing treatment, or simply not offering the resource in the first place, especially when the burden and risk of the care outweigh the benefits or expected outcome (Randall & Downie, 1999). This pillar of ethical nonmaleficence can become entangled with the concept of autonomy in futility determinations.
The question might be, whose autonomy is at risk; the patient, the caregiver(s), the HCA, the surrogate, or the physician? Here lies the crux of determining futility and the difficulties inherent in the definition. The community is divided on the issue. Morrison (2011) addresses medical decision-making as a venue for justice and beneficence, cautioning us to remember nonmaleficence, but holding patient autonomy at the core. This perspective places the autonomy of the patient above that of the care provider and is a fulcrum for argument and philosophical debate regarding futility and the decision-making process.
Tonelli (2007) argues that the concept of futility is useful to the clinician but cannot be pragmatically brought to the bedside because of varied definitions and the essential uncertainty inherent in medicine. "Despite an apparent acceptance of the existence of medical futility interventions, physicians simply cannot agree on when they have a futile case in front of them" (p. 84). To that end, policy, models, and processes have been developed to assist in decision making while preserving the concepts of professional and personal (patient) autonomy. Several entities have put the concept of medical futility into a framework that can be consistently applied at the bedside, while reducing the infringement on autonomy (see Halvey & Brody, 1998, Tan et al., 2003, and Terra, 2006, for frameworks).
Rather than frameworks, some use definitions to guide care. Strict definitions of futility can be found in a dictionary and can be defined as something incapable of producing any results; useless, ineffectual, or vain or lacking in purpose (Gampel, 2006). To deem something incapable of producing result in the practice of medicine is problematic, in general. All action will cause some effect; the key is whether the effect will be the desired one. To manage this point, health care practitioners and administrators have evolved the futility definition to mean that the desired results (such as restoring wellness) are impossible or virtually impossible to achieve, or that no meaningful purpose can be achieved.
The appearance of cost, consideration of socioeconomic status, age, gender, or other nonclinical factors as primary determinants in clinical decision making is, at best, socially unacceptable.
In summary, "The requirement to agree on the defined goal of treatment before making a declaration of futility should force doctors to deal with this heretofore hidden issue of value" (Mohindra, 2006, p. 75). In this way, the objective of the physician-patient relationship-promoting the patient's welfare-is retained and respect for patient autonomy is upheld. The decision to offer a given treatment or intervention is left in the hands of the physician who, if deeming the intervention of limited or no benefit, is not required to begin or suggest intervention supporting the ethical concept of nonmaleficence. Lastly, administrators must remain socially responsible and ensure that justice is served, not only for the patient, but the health care professionals who work in the organization. Through collaborative effort, a health care organization can provide excellent, compassionate health care, as well as engage in medical practice that benefits the community and, above all, does no harm.
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