No chance, no value or no way: Reassessing the place of futility in healthcare and bioethics

Abstract

Throughout its history, and particularly in the modern age, medicine has fought to conquer disease and to “tame” death. There have been remarkable successes. Yet clearly there are limits to the reach of medicine that are influenced by context and time. In other words, there are points beyond which medicine should not go—either because it will not be effective in achieving its goals (however these are defined) or because it will cause more harm than benefit. While there is general agreement that medicine is, and should be, limited—there is little consensus on how this point can be defined, who has the authority to define it, what the implications are of such judgements, and what processes should be enacted both to guide decision-making and to resolve contest around the ends and goals of medicine. Three decades of debate on medical futility have provided little clarity and have produced a plethora of definitions, procedures, and conceptual models, with futility being both hailed as the way to preserve medical professionalism (Schneiderman and Jecker 1993) and rejected as largely unworkable in clinical practice (Halevy and Brody 1996). A review of this literature illustrates how futility is conceptually and practically challenging. It attempts to reconcile evidence and ethics, medical professionalism, and patient-centred care while acknowledging increasing patient expectations and the growth of technologies that extend the transition between life and death.