Three Definitions of Medical Futility And How to Balance Them

There is an old saying, “Just because we can, doesn’t mean we should.” This is an important adage for the field of medicine and medical ethics.

As modern medicine continues to push forward, it will continue to create scenarios that challenge our presupposed notions of right and wrong. New technologies and advancements in medicine will raise questions regarding the ethical permissibility of continuing to do “everything” versus the risks of holding back. These questions are especially true regarding questions of medical futility.

Three Definitions

Because of technology and medical advancements, it has become increasingly difficult to define medical futility. A working but far from comprehensive definition by Schneiderman, Jecker, and Jonsen states that “a medical act is futile if (based on empirical data) the desired outcome, although possible, is overwhelmingly improbable.” In other words, the desired outcome that a therapy will benefit a patient will not occur, based on the best available evidence (Bernat et al.).

However, this definition does not fully account for the difficulty in determining whether or not a particular intervention is medically futile nor the subtlety that is needed. It is even half-joked that whether or not something is medically futile depends on your definition of futile. Because of this difficulty in defining the word futile, many have opted to use different terms such as Medically Non-Beneficial and Potentially Medically Inappropriate.

 When we consider what is and is not futile, we tend to utilize three separate definitions: Quantitative Futility, Qualitative Futility, and Physiological Futility.

In this blog, we will delve into what each one means, how they relate to each other, how some interventions might meet one definition, why some are failing to meet another, and how a clinician should balance each of these concepts to provide the highest ethically supported recommendations.

Physiological Futility

Physiological futility is likely the easiest situation to recognize and manage because it is the only one that truly meets the definition of futile as socially understood. Physiological futility is when the medical intervention is not capable of producing the desired effects and/or benefits.

An example would be a patient requesting chemotherapy to alleviate their stomach ulcer. All scientific data and medical understanding agree that chemotherapy would not cure a patient’s stomach ulcer; therefore, it would be argued that chemotherapy would be futile in this situation. While physiological futility is the easiest to manage, it is also the most rare. It is not common for patients to request interventions that are truly futile. Even if the patient was requesting, these situations can often be managed with a conversation explaining how the interventions would not be beneficial and why it is not a viable option.

Quantitative Futility

Quantitative futility is a more challenging scenario but also more common than physiological futility. This is when the likelihood that an intervention will benefit the patient is exceedingly poor. The determination is typically based on clinical studies and scoring systems that provide information on an empirical basis for establishing percentage thresholds.

For example, imagine a patient actively dying while receiving full aggressive interventions, such as ventilator support, blood pressure medication, etc. Even through all of this, the patient’s family insists that the patient remain a full code and, if the patient’s heart were to stop, full resuscitation be performed. Beyond the imaginable moral distress this situation can create, it could be argued that resuscitation would be quantitatively futile because the likelihood of it being successful is so low.

Resuscitation cannot be said to be physiologically futile because there is still a chance, be it a small chance, that resuscitation would be successful. The difficulty with these situations is that the intervention is not truly futile. It requires a large amount of clinical judgment and statistical threshold determination, which can be challenged by patients and their families. Medical providers cannot say that it would never work because there is still a small chance that it would.

This ambiguity can create friction between physicians wanting to only offer interventions that are likely to increase benefit while minimizing harm and patients/families looking for any hope of life-prolonging interventions. There is also the difficulty of establishing thresholds. Should the effectiveness be 10%? 5%? 3%? A 10% likelihood of success might sound too low for a physician to comfortably recommend, but to a patient, 10% being the difference between life and death, could mean a lot. Effectiveness thresholds need to be demonstrated and standardized through scientific review and then communicated with compassion to patients and their families.

Qualitative Futility

The final variation of a definition of futility is qualitative futility, which is when the quality of benefit an intervention will produce is exceedingly poor. An intervention can be qualitatively futile when an intervention’s prospective benefits are outweighed by its associated burdens or when it simply cannot provide the patient with a minimum quality of life worth living.

An example would be a patient with a cardiovascular condition that requires a left ventricular assist device (LVAD) to survive. The major difficulty with a qualitative futility determination is that it begs the question: How do you define quality of life? While life with an LVAD might not be quality of life for one patient, it might be for another. That is why it is important in all qualitative futility determinations that it is the patient who determines whether or not an intervention would provide quality of life.

Another scenario could be a patient who refuses to be intubated and given mechanical ventilation because that is not quality of life for them. In that scenario, mechanical ventilation would be seen as qualitatively futile because it cannot achieve quality of life for that patient. It would not be seen as physiologically or quantitatively futile because the intervention has a high likelihood of achieving life. But that life is not quality of life, and thus qualitatively futile. Again, it is important to maintain the standard that in all qualitative futility judgments, quality of life is determined by the patient and not the medical team.

AMA Code of Ethics

Each of these definitions and approaches to medical futility has its own merits and limitations. However, it is not unusual for physicians to interchange concepts of qualitative and quantitative futility.

Interventions are not physiologically or quantitatively futile because they are achieving their desired benefit, that is maintaining the life of the patient. The sense of futility comes from the fact that these interventions are unlikely to achieve a quality of life that the medical providers believe is acceptable. A not uncommon example of this is when a patient’s life continues through medical intervention but in an unresponsive state and without the likelihood of the patient improving.

Always in these situations, it is important to remember that patients should determine their quality of life and thus qualitative futility judgments. The ability to recognize and balance these different definitions is necessary for all assessments of whether or not a medical intervention is medically non-beneficial.

The Code of Ethics for the American Medical Association regarding Medically Ineffective Interventions does a commendable job of taking all three of these definitions into account. It states,

“Physicians should only recommend and provide interventions that are medically appropriate—i.e., scientifically grounded—and that reflect the physician’s considered medical judgment about the risks and likely benefits of available options in light of the patient’s goals for care. Physicians are not required to offer or to provide interventions that, in their best medical judgment, cannot reasonably be expected to yield the intended clinical benefit or achieve agreed-on goals for care. Respecting patient autonomy does not mean that patients should receive specific interventions simply because they (or their surrogates) request them.” (AMA Code of Ethics, Opinion 5.5).

This statement has components of all three definitions of medical futility and organizes them in an effective way. The focus on interventions that are based on science and can achieve agreed-on goals of care establishes that medicine is more than just doing what will work and avoiding what will not. It is a balance of goals of care, expectations, hopes and reality.

Modern medicine continues to push the boundaries of what is possible. But the nature of medicine remains the same. Medicine should do what it can to provide benefits to patients and minimize harm. There can be difficulty in determining what is a benefit and what is a harm, and confusion of their interplay with each other. This is why questions of medical futility exist outside of simply prognosis and diagnosis. It is a connection of care from one to another and a desire to use that connection to improve the lives of others.

By Ryan Pferdehirt, D. Bioethics, HEC-C, Vice President of Ethics Services,

and Marissa Hernandez, Program Specialist, Center for Practical Bioethics

References:

AMA code of ethics

Schneiderman LJ, Jecker NS, Jonsen AR. Medical futility: its meaning and ethical implications. Ann Intern Med 1990;112:949–954.

Bernat JL. Medical futility: definition, determination, and disputes in critical care. Neurocrit Care. 2005;2(2):198-205. doi: 10.1385/NCC:2:2:198. PMID: 16159066.