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Medical Ethics |

Medical Futility ProceduresMedical Futility Procedures: What More Do We Need to Know?

Emily Rubin, MD, JD; Andrew Courtwright, MD, PhD
Author and Funding Information

From the Department of Internal Medicine (Dr Rubin), Department of Pediatrics (Dr Rubin), and Institute for Patient Care (Dr Courtwright), Massachusetts General Hospital; and Department of Pulmonary and Critical Care Medicine (Dr Courtwright), Brigham and Women’s Hospital, Boston, MA.

Correspondence to: Andrew Courtwright, MD, PhD, Institute for Patient Care, Massachusetts General Hospital, Founders House, Third Floor, 55 Fruit St, Boston, MA 02114; e-mail: acourtwright@partners.org


Editor’s Note: To view articles included in the core curriculum of the ongoing Medical Ethics series, visit http://journal.publications.chestnet.org/collection.aspx?categoryid=9185.

—Constantine A. Manthous, MD, FCCP, Section Editor, Medical Ethics

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2013;144(5):1707-1711. doi:10.1378/chest.13-1240
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Unilateral medical futility policies, which allow health-care providers to limit or withdraw life-sustaining treatment over patient or surrogate objections, are increasingly designed around a procedural approach. Medical or ethics committees follow a prespecified process, the culmination of which is a justified decision about whether ongoing treatment should be withheld or withdrawn. These procedures have three stages. First, health-care providers must decide to refer patients for consideration of whether ongoing treatment is futile. Second, the committees involved must decide whether ongoing treatment is actually futile. Third, there is a clinical outcome that often is, but not always, patient death. We review the available data on procedure-based futility policies, arguing that there is limited information on their potential harms and how these harms are distributed. We consider the ethical implications of policy-making under informational uncertainty, invoking the precautionary principle—in the absence of clear data, if a policy has significant risk of significant harm, the burden of proof that it is not harmful falls on those recommending the policy—as the guiding moral standard for hospitals and professional organizations considering whether to adopt a procedural approach to medical futility. On the basis of this principle, we argue that any new futility guideline must include a significant commitment to collecting prospective data on its application.


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