Beyond Futility

“Futility” is one of the latest buzzwords to enter into bioethics jargon. The tragic case presented by Brian S. Carter and Julie Sandling forces us to consider the utility of this concept in our approach to medical decision making. In particular, the authors ask whether continued intravenous (IV) nutrition or even a liver-bowel transplant should be considered “futile” for a child with the syndrome of megacystis-microcolon-intestinal hypoperistalsis. Implicit within this question of futility is the assumption that an objective answer is possible. If only we could collect enough information, if only we could think clearly enough about the issues, then we could determine whether these therapeutic approaches are futile. Many believe that such a determination is possible in some circumstances. Some hospital policies, for example, state that CPR may be withheld from a patient if resuscitation would be futile. Since futility is viewed as an objective “fact” in this setting, a do-notresuscitate (DNR) order may be written without the agreement of the patient or family. The American Medical Association Council on Judicial and Ethical Affairs has endorsed this view. Some go even further, and claim that when resuscitation is futile, a DNR order may be written without even informing the patient or family. Futility allows at least the appearance of an objective foundation for resolving complex and difficult cases. If IV therapy or a liver-bowel transplant is futile for this child, then her Native American tribe would not have to be consulted. These therapies could be withheld without the mother’s consent, thereby absolving her of any responsibility for a potentially difficult and painful decision. Clearly, futility is often seen as an attractive approach for arriving at decisions that caregivers believe to be justified. The increasing use of the concept of futility in court decisions and policy statements is a reflection of our wish for such objectivity and certainty. Unfortunately, futility is not the objective concept that we would like it to be. Futility hides many assumptions about both probability and values. In addition, futility all too often masquerades as a justification for covert rationing of medical resources. I believe that futility is one new buzzword we would be better off without.