Futile treatment: the ethicist’s perspective

When doctors are confronted with making treatment decisions in the context of a terminally ill patient, the way forward is often difficult and confused. Bringing an ethics perspective to bear on the problem can help to resolve what the essential issues are, in turn enabling a clearer path to appropriate decisions by the people who ought to be making those decisions. In many cases where further treatment of a patient may be thought to be futile, such as John’s case, described by Koczwara,1 the central ethical question is whether treatment is medically inappropriate or futile, and whether, as a consequence, it may be withdrawn or withheld against the wishes of his family.

There are many different terms that are used to describe treatment that medical professionals feel should not be provided, even if the patient or family request it.2 Sometimes, as in John’s case, it is called “futile”;1 at other times it is referred to as “inappropriate”, “non-beneficial”3 or “not indicated”.4 These terms suggest that there is a simple yes or no answer — treatment is either futile or it is not — and that this answer can be readily determined. However, in practice there are often disagreements between different medical professionals and between clinicians and families about whether treatment is futile. These disagreements partly stem from differences in assessment of the facts, including the nature of a patient’s illness and the prognosis with treatment. But they are also crucially based on different assessments of the goals of treatment, and on what would best reflect the interests of the patient. A doctor might regard treatment as futile if it is unlikely to lead to the patient being discharged alive from hospital, while a patient may see the same treatment as not futile if it gives him a chance of living long enough to see a new grandchild. One important step, wherever there are disputes, is to identify the goals of treatment for each party.5,6

What happens in the case where the patient or their surrogate decisionmaker may well have identified a different goal from clinicians? There are ultimately only two ethical reasons for refusing to provide treatment that a patient or his or her surrogate is requesting (Box).2 The first reason for refusal is that providing treatment would harm the patient. Either the chance or duration of survival is so small, or the quality of life is so poor (or both) that the physician judges that the harms of treatment outweigh the benefits. The second reason is that providing treatment would harm other patients. Where there are limited health care resources, providing treatment would mean that other patients who stand a greater chance of benefit are prevented from accessing it.7 Sometimes, perhaps often, both of these reasons will apply.

Ultimately, many cases are resolved by consultation and discussion. However, it is ethical for clinicians to refuse to provide treatment either where this would be contrary to the best interests of the patient, or where resources are insufficient. Giving attention to the reason for judging treatment to be futile may help in identifying the best way to resolve a dispute.

Resolving disputes about treatment judged to be medically inappropriate or futile*

* Adapted from Curr Opin Anaesthesiol 2011; 24: 160-165.2 Used with permission.