Medical futility and the goals of medicine

Abstract

I begin by exploring the distinction between the physiologic, quantitative, and qualitative conceptions of futility. I argue that if medical futility is going to be a useful and appropriate normative tool in the medical lexicon, it should not duplicate and confuse judgments which we already have the tools to make. Hence, I distinguish qualitative futility from the concepts of distributive justice, rationing, harm, and insufficient benefit. Lastly, I consider the argument that providing qualitative futility violates professional integrity. Next I consider the claim that futility judgments are a form of unjustified paternalism. I also explore the relationship of physician imposition of values and the ideas of individual patient well-being, and self-determination. I consider an argument put forth by Thomlinson and Brody that futility judgments actually support autonomy, concluding that their argument must be restricted to individuals whose choices can be shown to be inconsistent with their values and aims. Lastly, I provide a comparison of futility judgments and the ordinary/extraordinary distinction which shows futility to be normatively vague and clinically dangerous. Because of the potential for misuse and confusion, I compare futility and rationing judgments. I argue that rationing decisions are necessary but should be explicit rather than disguised as futility. The consequences of failing to adequately distinguish these two are unfairness to individual patients, and harm to the doctor-patient relationship and societal trust of medicine. I detail a number of models of the physician patient relationship and attempt to determine two things: (1) whether these allow for physician authority to withhold qualitatively futile care, and (2) how well these models can answer this question in the absence of an account of the goals of medicine. I conclude that various accounts offer little specific guidance about the physician's right to withhold qualitatively futile treatment. Finally, in chapter seven I attempt to ground the debate about medical futility in the larger context of a debate about the appropriate ends and goals of medicine, arguing that such limits require an extended social dialogue.