Futility Clarified

For a nice summary, and numerous examples, see Helft P. R. Siegler M. and Lantos J. , “The Rise and Fall of the Futility Movement”, New England Journal of Medicine 343, no. 4 (2000): 293–296.

Brody B. and Halevy A. , “Is Futility a Futile Concept?” Journal of Medicine and Philosophy 20, no. 2 (1995): 123–144.

Most notably and recently, Mohindra R. K. , “Medical Futility: A Conceptual Model”, Journal of Medical Ethics 33, no. 2 (2007): 71–75.

See, for example, Brody H. , “Medical Futility: A Useful Concept?” Medical Futility and the Evaluation of Life-Sustaining Interventions, Zucker M. B. and Zucker H. D. , eds. (Cambridge, U.K.: Cambridge University Press, 1997): at 1–14. Brody there argues that the right way to resolve disputes is to appeal to the metaphor of conversations. Again, a nice overview of this history is provided in Helft, Siegler, and Lantos, supra note 1.

Available at <http://tlo2.tlc.state.tx.us/statutes/docs/HS/content/htm/hs.002.00.000166.00.htm> (last visited July 2, 2009).

See Troug R. D. , “Tackling Medical Futility in Texas”, New England Journal of Medicine 357, no. 1 (2007): 1–3.

Halevy A. and Brody B. , “A Multi-Institutional Collaborative Policy on Medical Futility”, JAMA 276, no. 7 (1996): 571–574, at571.

Schneiderman L. J. Jecker N. S. and Jonsen A. R. , “Medical Futility: Its Meaning and Ethical Implications”, Annals of Internal Medicine 112, no. 12 (1990): 949–954, at952.

American Heart Association, “Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiac Care”, JAMA 268, no. 16 (1992): 2171–2298, at2238.

American Thoracic Society, “Withholding and Withdrawing Life-Sustaining Therapy”, American Review of Respiratory Disease 144, no. 2, part 1 (1991): 726–731, at728.

Brett A. S. and McCullough L. B. , “When Patients Request Specific Interventions: Defining the Limits of the Physician's Obligations”, New England Journal of Medicine 315, no. 21 (1986): 1347–1351.

I encourage the reader to try this to see both that it is nearly impossible and that it is unnecessary. (I say “nearly” because for some contentious synonymous pairs, there might be some third term which is uncontroversially synonymous with both the other two. One could then use the transitivity of synonymy to construct a direct argument for the contentious synonymy in question.)

The distinction between use and goal is obvious and becoming more explicit in recent discussion of futility. See, for example, Mohindra, supra note 3, and Brody H. , “Bringing Clarity to the Futility Debate: Don't Use the Wrong Cases”, Cambridge Quarterly Healthcare Ethics 7, no. 3 (1998): 269–273.

Leaving open whether meaning is reference or some Fregean sense, Frege is still careful to distinguish coloring (or tone) from both of these. Two synonyms might share sense and reference yet still differ in their coloring, which Frege suggests will be a relevant feature when poetic eloquence is at stake, but not truth-conditions. See Frege G. , “Über Sinn und Bedeutung”, Zeitschrift für Philosophie und Philosophische Kritik 100, (1892): 25–50.

Another issue that might be complex, as discussed earlier, is when it is appropriate to assert a futility claim or, perhaps equivalently, when we can be sure enough of futility to stop treatment.

See Schneiderman , supra note 8, at 952.

Again following from earlier discussion, there is a third possibility. We may be clear on what the word means and clear on the reason(s) we have for applying it, and yet be unclear on whether it is appropriate to assert claims using that word, for example because we think a certain degree of confidence is required before making authoritative assertions.

See Clouser K. D. and Gert B. , “A Critique of Principlism”, Journal of Medicine and Philosophy 15, no. 2 (1990): 219–236.

The difference here is one of logical scope. The claim I make has the modal operator taking wide scope over the universal quantifier: it is not possible that we can write down a short, useful algorithm that covers every medical problem. This is not to be confused with the plausible claim where the quantifier takes wide scope over the modal operator: for any arbitrary clinical problem, it is possible to articulate a short, useful algorithm on how to address it.

The question of goals also rightly falls silent on whether the treatment is life-sustaining or at the end of life, another potential distraction from the correct conceptual analysis, as discussed earlier.

See Halevy and Brody , supra note 7, at 573. This policy is restricted to end of life cases only; an interesting issue I will not explore here is whether something similar but potentially less costly might be implemented for mundane cases of futility, such as refusing to give antibiotics for viral infections. The conceptual issues are the same; the difference is only in severity of potential harm and benefit.