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Perspectives in Biology and Medicine

A A Eduard Verhagen
Requests for life-prolonging treatments can cause irresolvable conflicts between health-care providers and surrogates. The Multiorganization Policy Statement (Bosslet et al. 2015) with recommendations to prevent and manage these conflicts creates a good opportunity to examine how end-of-life decisions are made in Dutch neonatal intensive care units and how medical futility is defined. The Dutch equivalent of medical futility in the context of NICU care has grown and developed rather independently, within the typical legal, ethical, and cultural framework of Dutch society...
2018: Perspectives in Biology and Medicine
Robert M Veatch
In response to the criticism of Schneiderman and colleagues (2017) that two recent policy statements of professional medical organizations referred to some medical treatment that were traditionally called "futile" by the terms "inappropriate" or "potentially inappropriate," this critique accepts their claim challenging these terms as being hopelessly ambiguous. However, this critique rejects the conclusion they all share that clinicians or hospitals should have the unilateral authority to refuse to provide treatments that will plausibly achieve the end that the patient or surrogate is pursuing...
2018: Perspectives in Biology and Medicine
Connie M Ulrich
Futility is a term that is distressing for many, but it is a concept that merits revisiting for its normative, empirical, and ethical value in understanding end-of-life issues. Ethical concerns surrounding aggressive care and the suffering of patients at end of life are frequently cited as significant ethical issues within institutional settings, leading to clinicians' moral distress. The author responds to the essay on "The Abuse of Futility" by Schneiderman, Jecker, and Jonsen (2017), who support the continual use of futility language with patients and families...
2018: Perspectives in Biology and Medicine
Robert D Truog
Debate about the concept of medical futility is often polarized around two views. One is that futility is simply an acknowledgment of the limitations of modern medicine, a corollary of the fact of human mortality. The other is that futility is a judgment that is always grounded in a particular set of values, and that medical professionals have no right to impose their value judgments on patients and families who do not share their perspective. This essay argues that these dichotomous views can be reconciled by appreciating the importance of the context in which the dialogue occurs...
2018: Perspectives in Biology and Medicine
Thaddeus Mason Pope
The primary objective of this article is to defend the vocabulary in the Multiorganization Policy Statement. The Multiorganization Statement narrows but does not abolish the term futility. Rather, it offers a richer and more precise vocabulary that facilitates better ethical decision-making. The secondary objective of this article is to defend the continuing utility of the terms and concepts "quantitative futility" and "qualitative futility" defended by Schneiderman, Jecker, and Jonsen (2017).
2018: Perspectives in Biology and Medicine
Michael Nair-Collins
Conflicts between providers and patients or their families surrounding end-of-life care are both regrettable and extremely challenging, interpersonally and ethically, for all involved. These conflicts often implicate the concept of medical futility. The concept of futility is too often conflated with distinct concepts that are more ethically salient, including the fiduciary responsibility to assess surrogate decision-making, and distributive justice. By distinguishing these concepts from futility, it becomes clear that there are some situations in which forgoing life-sustaining treatment over objection is permissible, and perhaps even obligatory...
2018: Perspectives in Biology and Medicine
Cheryl Misak
The argument in this paper is that the position of Schneiderman, Jecker, and Jonsen (2017) suffers from the very flaws of which they accuse the Multiorganization Policy Statement, and that all the ethical and conceptual arguments speak in favor of the collaborative, deliberativist position that underlies the Multiorganization Statement. That position is that we should abandon self-sealing definitions of futility, which disguise the value judgments inherent in them, in favor of the evolving, collaborative process of decision-making...
2018: Perspectives in Biology and Medicine
Laura Miller-Smith
Futility has wrongly been applied over the past decades to clinical scenarios where treatment disputes exist, but where true physiological futility is not certain. This particularly applies to the pediatric critical care arena, where a major source of ethical debate and moral concern surrounds decisions about appropriateness of treatment, and not necessarily futility. In the pediatric intensive care unit, Schneiderman and colleagues' (2017) definitions of quantitative and qualitative futility are rarely applicable...
2018: Perspectives in Biology and Medicine
Franklin G Miller
Judgments of futility are always relative to some goal. In light of that proposition, continued treatment for those diagnosed as "brain dead" is not necessarily futile.
2018: Perspectives in Biology and Medicine
John Lantos
This paper discusses the inevitable ambiguity of the language that we use to describe events that are rare and emotionally devastating. A search for precision in such circumstances may distract from more important issues. Neither families nor doctors need more precise language. Instead, they need more trust, more emotional transparency, and a recognition by doctors of the tragic nature of the decision they face.
2018: Perspectives in Biology and Medicine
Alexander A Kon
In 1997, the Society for Critical Care Medicine (SCCM) published a statement regarding futile and inadvisable treatments. Recently, five critical care organizations published a consensus statement supporting and expanding upon the 1997 SCCM statement, and the SCCM issued a companion statement defining futile and potentially inappropriate interventions. In all of these statements, there is agreement that the term futile should be used only when an intervention cannot accomplish the intended physiologic goal...
2018: Perspectives in Biology and Medicine
Samantha F Knowlton, Joseph J Fins
Futility disputes are more likely to be resolved-and relational breaches repaired-by engaging in a process that fosters communication between clinicians, patients, and families. This essay calls for mediative fluency. The preemptive use of a futility definition can stifle conversation when it is needed most, exacerbating the very power imbalances and associated health disparities that often precipitate futility disputes. When clinicians, patients, and families engage in dialogue, clinicians can appreciate what motivates requests for what is thought to be futile care, and patients and families can better understand the limits of available therapies...
2018: Perspectives in Biology and Medicine
VĂ©ronique Fournier
This article offers a comparative perspective of the controversy about the use of the term futility as presented by Schneiderman and colleagues (2017). The English concept of "medical futility" has no semantic equivalent in the French language. The traditional term used to translate it was "therapeutic obstinacy," which changed to "unreasonable obstinacy" when the first end-of-life law was adopted in 2005. The change was done in order to demedicalize the concept and make it less objective and less scientific...
2018: Perspectives in Biology and Medicine
Robert L Fine
This essay offers a brief history of futility, in both sociocultural and medical contexts, with some personal reflection on the disappearance and reappearance of medical futility during the author's 40-plus years in medicine. It discusses the creation of the Texas Advance Directives Act (TADA), which, even with its flaws, creates the only legal safe harbor for physicians engaged in futility disputes. It also offers reflection on the commendable Multiorganization Policy Statement on "potentially inappropriate treatment" yet comes to the same conclusion as Schneiderman...
2018: Perspectives in Biology and Medicine
Chris Feudtner, Pamela G Nathanson
The concepts of medical futility and "potentially inappropriate" interventions aim to describe particular decision-making situations and assist in making ethically sound decisions. This article explores how both of these concepts simplify the rather more complicated decision-making task in ways that often hinder their ability to be helpful, and potentially allow for unstated biases to influence decisions. Instead of searching for a single unifying phrase or concept, acknowledging and explicitly working with the numerous judgments and decisions that comprise a high-stakes medical treatment decision will do more to advance ethically sound decision-making...
2018: Perspectives in Biology and Medicine
Arthur R Derse
Though futility may be difficult to consensually define as a description of the limits of medicine, the term futility as it applies to quantitative futility is useful and apt. The term conveys a sometimes harsh but truthful reality for patients and families. When talking with patients and families, conveying the concept of futility might be more compassionately expressed as an inability to provide a curative medical benefit to the patient, with a concomitant commitment to provide comfort care. The ultimate arbiter of quantitative futility should be the medical profession...
2018: Perspectives in Biology and Medicine
Larry R Churchill
Futility is a medical judgment, but more importantly it is a prognostic gesture for shaping relationships among doctors, patients, and their families. As such, the need for a concept of futility, or something like it, is personally and socially important to all of us. It is one of medicine's essential tools for teaching about finitude and mortality.
2018: Perspectives in Biology and Medicine
Daniel Callahan
Pragmatically speaking, there is a stronger case for using the language of "futility" than "potentially appropriate" for end-of-life care. The latter obscures the reality of death as a part of human life. Do patients die because death always wins in the end? Or do they die because physicians run out of ways to treat them? In the end, modern medicine has made the conquest of death its de facto goal. That is a fundamental error, one which the language of "potentially appropriate" is unwittingly supportive of.
2018: Perspectives in Biology and Medicine
Howard Brody
Schneiderman, Jecker, and Jonsen (2017) correctly take issue with a recent multi-society statement that attempts to replace most uses of the term futility with "inappropriate treatment." However, they mistakenly categorize any treatment of permanent unconsciousness as futile. Futility can be readily defined as an intervention that will not work, and it is always an incomplete statement unless one specifies the goal one hopes to achieve.
2018: Perspectives in Biology and Medicine
Allan S Brett, Laurence B McCullough
For nearly three decades, clinicians and bioethicists have debated about use of the term futile to describe end-of-life medical interventions that clinicians believe are no longer warranted. In clinical practice, the term is most often invoked when a family of a dying or permanently unconscious patient insists upon such interventions, despite the medical team's belief or recommendation that they be withheld or withdrawn. This essay argues that each of the commonly used terms for these interventions (futile, inappropriate, and nonbeneficial) captures an important, different, and complementary facet of these conflicts in end-of-life medical care...
2018: Perspectives in Biology and Medicine
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