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Medical Ethics |

Medical FutilityMedical Futility: A New Look at an Old Problem: A New Look at an Old Problem FREE TO VIEW

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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Published online

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.

We are in the midst of a decades-long debate about medical futility, specifically about the question of when physicians can overrule demands by patients and surrogates for treatments the physicians believe to be futile or inappropriate.13 Initial approaches focused on defining futility in terms of medical diagnoses, probability of success, or quality of outcome.4,5 These proved contentious.6 In 1999, the American Medical Association endorsed a procedural approach, in which futility is an “all things considered” type of judgment that must be made on a case-by-case basis, balancing the conflicting values of patients and clinicians.7 Today, many hospitals have procedural policies, and Texas offers civil and criminal immunity to physicians who follow legislated rules.8 Yet there continue to be concerns that these approaches can be unfair, giving too much power and control to physicians and hospitals.9

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.6 We aim to shift the discussion. Rather than seeing the problem of futility as a succession of failed attempts to solve a problem that still awaits its definitive answer, we suggest that the proffered solutions to the problem of futility should be seen, in aggregate, as an example of how complex and difficult matters are best dealt with in a democratic society. The futility debate is an ever-fluid dialogue involving the medical profession and society. Futility policies or laws do not offer permanent or absolute solutions, but rather, they are part of the continual redefining of the boundaries of decision-making authority between physicians and patients, involving a variety of professional, cultural, religious, civic, and legal values and mechanisms. In short, we argue that disputes around medical futility are not problems in search of a clear-cut solution, but rather, dynamic problems that are always being addressed in the ways characteristic of a liberal democracy. This reframing has the significant benefit of seeing futility debates as being responsive to new arguments and articulations of what it is that we value and as gravitating toward better answers to the profound problems that press in on us about the end of life.10,11

Throughout the history of the futility debate, the question has been put in terms of whether or when physicians may act unilaterally, either by choosing not to offer certain treatments, or by explicitly rejecting treatments requested by the patient or surrogate. Our suggestion is that this is an unhelpful and myopic lens through which to view futility. Medical decisions are never made unilaterally, even though at times this may appear to be the case. Medical decisions are made in the context of an implicit and evolving social contract among patients, physicians, and societies at large. Within this implicit contract, we argue, many legitimate medical decisions do not require physicians to explicitly negotiate an agreement with the patient or family, whereas other types of medical decisions do require an explicit negotiation that involves discussion of feasible medical options, risks and benefits, and the values and preferences of the patient. Between these two poles there is a sometimes contentious gray area. By reframing the futility debate as a debate within society, we shift the question away from unilateral decision-making and procedural approaches to one of balancing the legitimate perspectives of patients and physicians against a backdrop of societal constraints and values. In what follows, we present the kinds of cases and vignettes that illustrate them.

In many cases, the connection between the goals of the patient and the appropriate treatment are clear and form part of our background assumptions. The goals of an otherwise healthy postsurgical patient are best served by checking vital signs at regular intervals postoperatively; those of an otherwise healthy child with bacterial meningitis are best served by antibiotics; those of a young man with sudden cardiac arrest are best served by CPR. Similarly, we refrain from treatment when there is no medical or scientific reason to believe that the treatment would be effective or beneficial, as when we withhold CPR from a patient in rigor mortis. Here, clinicians initiate or abstain from treatments without being required to first negotiate with and gain consent from patients or their surrogates. This does not mean that the duties to inform, discuss, and communicate with patients and their families fall by the wayside. It is important not to confuse the need to negotiate with the need to communicate.

In these straightforward unnegotiated cases, the reasons to act, or to refrain from action, are clear. Sometimes there is a rule or a law in place; for example, we might give life-saving treatment to children, under laws prohibiting child neglect, even if their parents refuse. Sometimes, for instance as with emergency treatment, there is a set of widely accepted norms of practice that allow clinicians to initiate treatment without consent. In other cases, clinicians have professional expertise that patients and their surrogates lack, and norms of good practice from which patients want to benefit. And in ICUs, where decisions must often be made on very short notice, care would grind to a halt if moment-to-moment decisions (eg, which pressor or antibiotic to initiate) could not be taken by those charged with caring for patients.

But even when clinicians are making decisions in some sense on their own, it would be a mistake to call them unilateral. Under the implicit terms of the social contract, it has been agreed that physicians should make these judgments. They are made not in isolated arrogance, but with a wealth of input from the clinicians’ experience and knowledge and with appreciation of social laws and norms.

Conversely, many medical decisions should not be made without negotiation; they are in the straightforward negotiated category, in which shared decision-making is appropriate. Consider, for example, the decision for surgery, radiation, or “watchful waiting” for treatment of prostate cancer.12 Although physicians may have strong preferences for a particular approach, individual patients will assign different values to the outcomes and side-effect profiles, and here best practice is that the physician and the patient must reach an agreement about which path to pursue.

The majority of medical decisions fall into one of these two straightforward categories. Patients should recognize that the inefficiencies and impracticalities of requiring a negotiation in the straightforward unnegotiated category are prohibitive, and physicians should recognize the need to negotiate with patients in the straightforward negotiated category. In general, we think that both patients and physicians implicitly endorse this division of labor, reflecting the trust that patients have in the knowledge and experience of physicians, while at the same time expecting of the medical culture (that the medical profession and society have jointly created) that physicians understand the importance of incorporating the preferences and values of patients into decisions of the second type. Without these assumptions, the very practice of medicine would be imperiled.

These two categories, however, do not have impermeable boundaries. Some patients and families will query even straightforward medical decisions, and physicians have biases, conscious and unconscious, that may influence patient choice in negotiated decisions. The order in which options are presented, the way statistics are used, and even the physician’s tone of voice can influence the choices patients make.13 The forces of defensive medicine and fee-for-service reimbursement incentives also can distort decision-making. But distortions exist in all kinds of decision-making and must be taken into account in policy debates. It is nonetheless the case that we can make good sense of our two poles on the continuum of decision-making.

Many decisions fall in the gray zone between these poles. These cases can arise from scientific uncertainty about what course of care will best achieve goals agreed upon by clinicians and patients. Here, clinicians are duty bound to consult their colleagues and the literature, as well as the patient and family. Other disagreements in the gray zone arise because the values of the patient or surrogate are in tension with those of the health-care professionals. These disputes often revolve around the demand for expensive and scarce life support when the medical professionals think that such life support is futile or inappropriate.

In thinking about how to resolve nonstraightforward cases, it is important to see that the very drawing of the boundaries between the straightforward and nonstraightforward categories is a matter for both the medical profession and the public. In well-functioning democratic societies, discussion about the distribution of scarce resources takes place not only within the walls of hospitals and in ethics committees, but in society more broadly.14 Physicians can and must express their views in this public debate, both individually and collectively, through professional organizations and other forms of civic engagement.15,16 Their views often carry considerable weight. However, citizens have the right to challenge these views and may seek to shift the line between the categories through social action, advocacy for legislation, or litigation.17 The lines are not static; they are continually being adjusted as these professional and social influences interact. And, of course, no democracy functions perfectly; the debates may be unduly influenced, for instance, by politicians’ desire for electoral success. These imperfections are also the subject of debate and activism.

Although the medical profession does not have sole authority in deciding where to draw lines, by necessity it must always engage in doing so, using the standards enmeshed in its practice. The fact that the profession has particular standards does not mean that these standards are correct or ethically justified. Historically, there are many examples (see Vignettes and Cases section) where medical judgments have been driven, for instance, by unjustified paternalism. Over time, some of these practices and drawing of the lines have been challenged by patients, families at the bedside, and society, and have been revised to yield yet another version of the implicit social contract. Undoubtedly, further challenges and revisions will be warranted, but our current practices represent the most recent iteration of this social contract and embody our current view about how to balance and respect the various values that define the relationship among patients, physicians, and society.

Although tensions between the perspectives of patients and physicians have dominated earlier debates, societal values are likely to play more of a role in the future. In our multicultural society, we will need to decide together how best to respect those values that may make substantial demands on medical resources. As we move into the world of personalized medicine, the development of ever more sophisticated and expensive treatments will force societies to consider how much of other goods (eg, education, infrastructure, and defense) they are willing to sacrifice for these additional medical benefits.18

But unless and until current standards and best judgments are challenged, from either within or outside the medical profession, current best practice will and must largely determine whether there is a need to arrive at a negotiated agreement around initiating or foregoing particular medical interventions. When these professional standards are challenged, then they may be modified, adjusted, and improved by the professional and societal forces described earlier.

It is important to remember that the views of the medical profession are rarely monolithic when it comes to gray zone cases, and so some degree of variation in practice is likely to be present. A good example is decisions about CPR for patients with advanced and terminal illness. Although many hospitals have policies that permit physicians to write a do-not-resuscitate order without the need to negotiate an agreement with the patient or surrogate, others specifically reject this approach.19,20 The personal moral and religious beliefs of many physicians conflict with the professional codes of the medical organizations to which they belong.21 This lack of consensus is not to be disparaged. It reflects the fact that there are no bright lines here and that the answers to these questions are difficult. Physicians must be mindful about recognizing when the gray zone is being entered and be vigilant and transparent about the complexities and potential biases. It may well be that with respect to many particular matters, the best solution is to put a procedure in place, to ensure, for instance, that like cases are treated alike. With this approach, these procedures and guidelines (American Medical Association statements, specialty society guidelines, and so forth) will be developed, published, challenged, and revised in our ongoing deliberation.

In thinking about how to resolve cases in the gray zone, it is also important that the solutions not jeopardize the functionality and ethical legitimacy of those practices that are not controversial. Some argue, for example, that because no medical decisions are strictly free of values, every decision must involve a negotiated agreement with the patient.22 This view puts at risk entire swaths of uncontentious practice. Neither patients, in general, nor physicians would ever endorse this as a functional solution, nor should they.

The overarching point is that no medical decisions are taken unilaterally or in isolation from a dense network of mostly shared values. Rather than asking when the values of physicians can trump the values of patients, we should be asking how to balance the multitude of values within the context of current societal norms. In addition, we must recognize that this is, and always will be, a work in progress. In the next section, we provide examples that flesh out these ideas in more detail.

The Past: Refusal of Mechanical Ventilation

In the early 1970s, physicians did not seek the negotiated agreement of patients and surrogates in discussions about continuing mechanical ventilation in terminally ill patients. Because removal of the ventilator usually leads directly to the death of the patient, physicians considered it an act of killing that was thereby ethically and legally prohibited.23 Within a changing social context, ascribing greater value to liberty and the rights of patients to refuse unwanted medical treatments, this position was questioned and challenged in many venues, including secular and religious social discourse, legal and political fora, and within the profession itself. By the end of the decade, professional norms had shifted dramatically, with wide consensus that whether to continue mechanical ventilation in terminally ill patients was a decision that required a negotiated agreement with the patient or surrogate.24

Some might interpret this as showing how social and legal reform corrected the unethical behavior of physicians in the early 1970s. But a better understanding is that these physicians were guided by their best judgment about what kinds of decisions demanded a negotiated agreement. These physicians were behaving ethically by the standards of the time, and when these standards were questioned and challenged, motivated by a shift in underlying cultural and social priorities, we saw an evolving dialogue between medicine and society, which led to a change in a common standard and practice.

The Present: Demands for Mechanical Ventilation

Today, the tables have turned. Now the question is whether physicians always need to negotiate decisions to initiate or continue mechanical ventilation when requested or demanded by the patient or family. As noted earlier, some hospitals have policies that allow them to decide not to resuscitate or initiate ventilator support when they believe such treatments to be futile or inappropriate.1 Yet other hospitals will not refuse mechanical ventilation. In a number of cases, physicians have been required by the courts to initiate or provide mechanical ventilation against their judgment.25 Multiple jurisdictions are engaged in this debate, showing various degrees of deference to physician authority.1

Demands for mechanical ventilation and other life-sustaining treatments have been in the gray zone for at least the past 2 decades, with no clarity in sight. They have ignited lively debates in the media and academia, have appeared frequently in the courts, and are the subject of legislative experimentation in the United States.1,17 Although these conflicts are sometimes described as intractable, in our view this is precisely the path that must be taken toward resolving the disputes, while recognizing that the time frame for reaching resolution is turning out to be quite a bit longer that any of us would wish. In the meantime, tools need to continue to be developed for the bedside, for physicians, and for other health-care professionals to address and comfort the patient and family who, for instance, would like a treatment that some would consider futile.

The Future: Demands for Extracorporeal Life Support

When patients with severe forms of respiratory failure can no longer be supported with mechanical ventilation, they can sometimes be kept alive with extracorporeal life support (ECLS). ECLS refers to a variety of techniques that involve surgical placement of cannulae or devices to artificially sustain cardiac and/or pulmonary function. ECLS is a powerful tool for keeping patients alive, and indeed it is very difficult for a patient on ECLS to “die” unless the support is actively removed.

Currently, physicians offer ECLS to only a select group of patients in the ICU, such as those who have reversible forms of cardiac or pulmonary failure or as a bridge to transplant in otherwise suitable candidates. Physicians consider the decision to offer the treatment to fall into the straightforward unnegotiated category. Although they may debate behind closed doors whether a particular patient is a candidate for ECLS, these matters are currently considered to be entirely within the purview of medical expertise. Once a decision has been made to offer ECLS, then the decision as to whether to proceed is certainly one that is negotiated with the patient or surrogate, but unlike mechanical ventilation, virtually no intensive care physicians believe that patients or surrogates have a right to demand this therapy.26

Looking ahead, one might wonder whether this practice will be challenged. Both mechanical ventilation and ECLS are technologies that support failing organs. ECLS is more demanding than mechanical ventilation in terms of expense, expertise, and human resources, but fundamentally they are both tools for keeping patients alive. As patients and surrogates become more familiar with ECLS, will they demand it in situations in which physicians believe its use would be futile or inappropriate? Will physicians succeed in deflecting what they judge to be unreasonable demands? Will the media begin to cover this controversy, will the courts become involved, will professional societies take a public position on the issue, will laws be passed? Any or all of these have the potential to reshape the boundaries of the implied social contract that currently prevails.

Choosing Between Patients: Triage Decisions in the ICU

Intensivists often must decide to move patients out of the ICU, even when the patient would likely benefit from continued ICU care, to make room for another patient in need of a bed.27 In these circumstances, the intensivist is trying to maximize the overall value of the limited ICU resources. Indeed, a change in culture that required negotiations of these decisions would paralyze most hospitals, making it impossible to schedule surgeries and have enough ICU beds for the critically ill.

Triage decisions currently fall squarely into the straightforward unnegotiated category, so much so that they are rarely even disclosed to the patient or surrogate.28,29 Given the trends toward greater transparency with patients and families, this norm may come under scrutiny, both from within the profession and in society more generally. As in the case of refusal of mechanical ventilation, will we come to see our current practices as incompatible with the rights of patients and the responsibilities of physicians, or will the necessities of maximizing resources trump other considerations?

Unilateral decision-making by clinicians is not what is at issue in debates about futility, because unilateral decision-making is vanishingly rare. Every decision involves the clinicians in a deliberative model of decision-making, in which values, interests, and expertise are all in play. What is at issue in debates about futility is whether our current implicit social contract allows a certain decision to be taken in an unnegotiated way in which clinicians move straight to a decision, whether it requires negotiation, or whether it is falls into a gray, potentially contentious domain. A certain category of decisions will be entrusted to clinicians, knowing that they will base those decisions on evidence and on goals shared by health-care professionals, patients, and surrogates. Again, this does not reduce the need for clinicians to communicate with their patients and their families in these and all circumstances.

The analysis of decision-making presented here has the virtues of accurately reflecting practice; of not setting up unattainable utopias; and of encouraging deliberation, genuine, shared decision-making and the discussion of hard questions in medical education and in public debate. It also has the virtue of not pretending that the judgment of clinicians is excisable. Society educates and trains clinicians and expects them to use that informed judgment. The view offered here, we submit, takes us a step closer than the procedural view to an ethically robust, fair, and practical strategy to manage hard cases in decent, evolving, and democratic societies.

Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Pope TM. Legal briefing: futile or non-beneficial treatment. J Clin Ethics. 2011;22(3):277-296. [PubMed]
 
Luce JM. A history of resolving conflicts over end-of-life care in intensive care units in the United States. Crit Care Med. 2010;38(8):1623-1629. [CrossRef] [PubMed]
 
Burns JP, Truog RD. Futility: a concept in evolution. Chest. 2007;132(6):1987-1993. [CrossRef] [PubMed]
 
Murphy DJ, Finucane TE. New do-not-resuscitate policies. A first step in cost control. Arch Intern Med. 1993;153(14):1641-1648. [CrossRef] [PubMed]
 
Schneiderman LJ, Jecker NS, Jonsen AR. Medical futility: its meaning and ethical implications. Ann Intern Med. 1990;112(12):949-954. [CrossRef] [PubMed]
 
Helft PR, Siegler M, Lantos J. The rise and fall of the futility movement. N Engl J Med. 2000;343(4):293-296. [CrossRef] [PubMed]
 
Medical futility in end-of-life care: report of the Council on Ethical and Judicial Affairs. JAMA. 1999;281(10):937-941. [CrossRef] [PubMed]
 
Tex HS. Code Ann. §166.046: Texas Statutes - Section 166.046: Procedure if not effectuating a directive or treatment decision. 1999.
 
Truog RD. Tackling medical futility in Texas. N Engl J Med. 2007;357(1):1-3. [CrossRef] [PubMed]
 
Misak CJ. Truth, Politics, Morality: Pragmatism and Deliberation. London, England: Routledge; 2000.
 
Wynia MK, Kishore SP, Belar CD. A unified code of ethics for health professionals: insights from an IOM workshop. JAMA. 2014;311(8):799-800. [CrossRef] [PubMed]
 
Slomski A. Expert panel advocates surveillance for men with low-risk prostate cancer. JAMA. 2012;307(2):133. [CrossRef] [PubMed]
 
Epstein RM, Peters E. Beyond information: exploring patients’ preferences. JAMA. 2009;302(2):195-197. [CrossRef] [PubMed]
 
Brock D. Health care resource prioritization and rationing: why is it so difficult. Soc Res (New York). 2007;74(1):125-148.
 
American Thoracic Society. Withholding and withdrawing life-sustaining therapy. Ann Intern Med. 1991;115(6):478-485. [CrossRef] [PubMed]
 
Consensus statement of the Society of Critical Care Medicine’s Ethics Committee regarding futile and other possibly inadvisable treatments. Crit Care Med. 1997;25(5):887-891. [CrossRef] [PubMed]
 
White DB, Pope TM. The courts, futility, and the ends of medicine. JAMA. 2012;307(2):151-152. [CrossRef] [PubMed]
 
Meltzer DO, Detsky AS. The real meaning of rationing. JAMA. 2010;304(20):2292-2293. [CrossRef] [PubMed]
 
Curtis JR, Burt RA. Point: the ethics of unilateral “do not resuscitate” orders: the role of “informed assent.” Chest. 2007;132(3):748-751. [CrossRef] [PubMed]
 
Manthous CA. Counterpoint: is it ethical to order “do not resuscitate” without patient consent? Chest. 2007;132(3):751-754. [CrossRef] [PubMed]
 
Antiel RM, Curlin FA, Hook CC, Tilburt JC. The impact of medical school oaths and other professional codes of ethics: results of a national physician survey. Arch Intern Med. 2011;171(5):469-471. [CrossRef] [PubMed]
 
Veatch RM. Why physicians cannot determine if care is futile. J Am Geriatr Soc. 1994;42(8):871-874. [PubMed]
 
In the Matter of Karen Ann Quinlan, an alleged incompetent. 355 A.2d 647; or 70 NJ 10. March 31, 1976. 1976.
 
Meisel A, Cerminara K. The Right to Die: The Law of End-of-Life Decision-Making.3rd ed. New York, NY: Aspen Publishers; 2004.
 
Miles SH. Informed demand for “non-beneficial” medical treatment. N Engl J Med. 1991;325(7):512-515. [CrossRef] [PubMed]
 
Crow S, Fischer AC, Schears RM. Extracorporeal life support: utilization, cost, controversy, and ethics of trying to save lives. Semin Cardiothorac Vasc Anesth. 2009;13(3):183-191. [CrossRef] [PubMed]
 
Truog RD, Brock DW, Cook DJ, et al; Task Force on Values, Ethics, and Rationing in Critical Care (VERICC). Rationing in the intensive care unit. Crit Care Med. 2006;34(4):958-963. [CrossRef] [PubMed]
 
Young MJ, Brown SE, Truog RD, Halpern SD. Rationing in the intensive care unit: to disclose or disguise? Crit Care Med. 2012;40(1):261-266. [CrossRef] [PubMed]
 
Danis M. Thorny questions on the way to disclosing rationing. Crit Care Med. 2012;40(1):347-348. [CrossRef] [PubMed]
 

Figures

Tables

References

Pope TM. Legal briefing: futile or non-beneficial treatment. J Clin Ethics. 2011;22(3):277-296. [PubMed]
 
Luce JM. A history of resolving conflicts over end-of-life care in intensive care units in the United States. Crit Care Med. 2010;38(8):1623-1629. [CrossRef] [PubMed]
 
Burns JP, Truog RD. Futility: a concept in evolution. Chest. 2007;132(6):1987-1993. [CrossRef] [PubMed]
 
Murphy DJ, Finucane TE. New do-not-resuscitate policies. A first step in cost control. Arch Intern Med. 1993;153(14):1641-1648. [CrossRef] [PubMed]
 
Schneiderman LJ, Jecker NS, Jonsen AR. Medical futility: its meaning and ethical implications. Ann Intern Med. 1990;112(12):949-954. [CrossRef] [PubMed]
 
Helft PR, Siegler M, Lantos J. The rise and fall of the futility movement. N Engl J Med. 2000;343(4):293-296. [CrossRef] [PubMed]
 
Medical futility in end-of-life care: report of the Council on Ethical and Judicial Affairs. JAMA. 1999;281(10):937-941. [CrossRef] [PubMed]
 
Tex HS. Code Ann. §166.046: Texas Statutes - Section 166.046: Procedure if not effectuating a directive or treatment decision. 1999.
 
Truog RD. Tackling medical futility in Texas. N Engl J Med. 2007;357(1):1-3. [CrossRef] [PubMed]
 
Misak CJ. Truth, Politics, Morality: Pragmatism and Deliberation. London, England: Routledge; 2000.
 
Wynia MK, Kishore SP, Belar CD. A unified code of ethics for health professionals: insights from an IOM workshop. JAMA. 2014;311(8):799-800. [CrossRef] [PubMed]
 
Slomski A. Expert panel advocates surveillance for men with low-risk prostate cancer. JAMA. 2012;307(2):133. [CrossRef] [PubMed]
 
Epstein RM, Peters E. Beyond information: exploring patients’ preferences. JAMA. 2009;302(2):195-197. [CrossRef] [PubMed]
 
Brock D. Health care resource prioritization and rationing: why is it so difficult. Soc Res (New York). 2007;74(1):125-148.
 
American Thoracic Society. Withholding and withdrawing life-sustaining therapy. Ann Intern Med. 1991;115(6):478-485. [CrossRef] [PubMed]
 
Consensus statement of the Society of Critical Care Medicine’s Ethics Committee regarding futile and other possibly inadvisable treatments. Crit Care Med. 1997;25(5):887-891. [CrossRef] [PubMed]
 
White DB, Pope TM. The courts, futility, and the ends of medicine. JAMA. 2012;307(2):151-152. [CrossRef] [PubMed]
 
Meltzer DO, Detsky AS. The real meaning of rationing. JAMA. 2010;304(20):2292-2293. [CrossRef] [PubMed]
 
Curtis JR, Burt RA. Point: the ethics of unilateral “do not resuscitate” orders: the role of “informed assent.” Chest. 2007;132(3):748-751. [CrossRef] [PubMed]
 
Manthous CA. Counterpoint: is it ethical to order “do not resuscitate” without patient consent? Chest. 2007;132(3):751-754. [CrossRef] [PubMed]
 
Antiel RM, Curlin FA, Hook CC, Tilburt JC. The impact of medical school oaths and other professional codes of ethics: results of a national physician survey. Arch Intern Med. 2011;171(5):469-471. [CrossRef] [PubMed]
 
Veatch RM. Why physicians cannot determine if care is futile. J Am Geriatr Soc. 1994;42(8):871-874. [PubMed]
 
In the Matter of Karen Ann Quinlan, an alleged incompetent. 355 A.2d 647; or 70 NJ 10. March 31, 1976. 1976.
 
Meisel A, Cerminara K. The Right to Die: The Law of End-of-Life Decision-Making.3rd ed. New York, NY: Aspen Publishers; 2004.
 
Miles SH. Informed demand for “non-beneficial” medical treatment. N Engl J Med. 1991;325(7):512-515. [CrossRef] [PubMed]
 
Crow S, Fischer AC, Schears RM. Extracorporeal life support: utilization, cost, controversy, and ethics of trying to save lives. Semin Cardiothorac Vasc Anesth. 2009;13(3):183-191. [CrossRef] [PubMed]
 
Truog RD, Brock DW, Cook DJ, et al; Task Force on Values, Ethics, and Rationing in Critical Care (VERICC). Rationing in the intensive care unit. Crit Care Med. 2006;34(4):958-963. [CrossRef] [PubMed]
 
Young MJ, Brown SE, Truog RD, Halpern SD. Rationing in the intensive care unit: to disclose or disguise? Crit Care Med. 2012;40(1):261-266. [CrossRef] [PubMed]
 
Danis M. Thorny questions on the way to disclosing rationing. Crit Care Med. 2012;40(1):347-348. [CrossRef] [PubMed]
 
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