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Medical Ethics |

Medical FutilityMedical Futility: A New Look at an Old Problem: A New Look at an Old Problem

Cheryl J. Misak, DPhil; Douglas B. White, MD; Robert D. Truog, MD
Author and Funding Information

From the Department of Philosophy (Dr Misak), University of Toronto, Toronto, ON, Canada; Program on Ethics and Decision Making in Critical Illness (Dr White), Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA; the Division of Critical Care Medicine (Dr Truog), Department of Anesthesia, Perioperative and Pain Medicine, Boston Children’s Hospital, Boston, MA; and the Center for Bioethics (Dr Truog), Harvard Medical School, Boston, MA.

CORRESPONDENCE TO: Robert D. Truog, MD, Boston Children’s Hospital / Bader 621, 300 Longwood Ave, Boston, MA 02115; e-mail: robert.truog@childrens.harvard.edu


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


Chest. 2014;146(6):1667-1672. doi:10.1378/chest.14-0513
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Efforts to answer the question of whether or when physicians may unilaterally refuse to provide treatments they deem medically futile, but that are nonetheless demanded by patients or their surrogates, have been characterized as intractable failures. We propose a new look at this old problem and suggest reframing the debate in terms of the implicit social contract, in healthy democracies, between the medical profession and the society it serves. This ever-evolving contract is predicated upon providing patients with beneficial and desired medical care within the constraints of scarce resources and the characteristics of our health-care system. The contract ranges over a continuum of decisions, from those that do not need an explicit negotiated agreement with the patient or surrogate, to those that do. Between these two poles lies a contentious gray area, where the rights and obligations of patients and physicians are being shaped continuously by the many forces that are at play in a democratic society, including professional guidelines, social advocacy, legislation, and litigation. We provide examples of how this gray area has been and is negotiated around rights to refuse and demand a variety of life-sustaining treatments, and anticipate conflicts likely to arise in the future. Reframing the futility debate in this way reveals that the issue is not a story of intractable failure, but rather, a successful narrative about how democracies balance the legitimate perspectives of patients and physicians against a backdrop of societal constraints and values.


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