The Futility Debate: The Demand for Life-Sustaining
Therapies
The futility debate focuses on whether a therapy should be used
when a specified goal is unlikely to be achieved. Differences in patients' values,
expectations, and desires make it fruitless to attempt to define futility in terms
of a specific outcome or probability. The ethical goal is to individualize what
some may consider to be futile care by helping individuals weight the benefits and
burdens of the particular situation.[111]
[112]
[113]
Benefits may include prolongation of life
under certain circumstances, improved quality of life (e.g., reduction of pain, the
ability to leave the hospital), and increased enjoyment of life. Burdens may include
the burdens of treatment and outcomes of intractable pain, suffering, disability,
and decrement in the quality of life.[67]
[114]
As may be expected, treatments with greater burdens and worse outcomes, particularly
severe functional and cognitive impairment, often strongly influence patients to
reject treatment.[114]
For example, an otherwise
healthy 4-year-old victim of a motor vehicle accident may prefer to undertake burdensome
therapy because there is a high likelihood of returning to a good functional status.
An 80-year-old man with similar acute injuries but with chronic medical problems
may prefer to forgo particularly burdensome therapy because of the low likelihood
of returning to a desirable functional status. Anesthesiologists should be careful
not to make assumptions about patients' preferences in situations such as these,
but they should seek out the decision-makers necessary to clarify the situation.
The tensions arising from questions regarding futile care often
center on who should be the decision-maker for the noncompetent person.[115]
[116]
Helga Wanglie had severe and irreversible
brain damage after a cardiac arrest.[115]
Although
Wanglie's husband wished for her to continue receiving care, her doctors believed
that further care would be futile in terms of restoring function and petitioned the
court to relieve Wanglie of his surrogacy. The judge ruled that Mr. Wanglie was
Mrs. Wanglie's best surrogate.
In the 1995 Gilgunn case, however, a jury supported a unilateral
declaration of futility. Catherine Gilgunn had multiple medical problems, including
severe brain damage, and was in a coma.[117]
Her
daughter Joan, representing the family, requested everything be done. The Optimum
Care Committee of the hospital agreed with the physicians that providing CPR would
be futile in the sense that it was not a genuine therapeutic option. The legal division
approved the DNR order, because they believed that the physicians were acting in
the patient's best interest. Gilgunn was disconnected from ventilator support and
died a few days later. The jury supported the actions of the physician and hospital
to impose a unilateral DNR order. There was no appeal.
Despite the Gilgunn case, unilateral physician declarations of
futility are insufficiently respectful of patients' autonomy and may be legally risky.
Evidence indicates that negotiation usually resolves these problems without the
need to resort to unilateral action.
