Background: The concept medical futility may arise when caring for patients with terminal illness when the patient and/or their surrogate are requesting medical interventions that are felt to have little to no chance of providing clinical benefit. This Fast Fact explores bioethical issues with the term futility and as well as recommendations from the American Medical Association (AMA) on how to approach medical futility concerns. Of note, recent literature has recommended a transition away from futility language to use of the term “non-beneficial treatment” (NBT) though both terms continued to be used (1). 

The challenges in defining futility: While no universally accepted definition of futility exists, in general futility is understood to refer to those interventions that are either unlikely to provide benefit or be otherwise unable to achieve a goal of care. Inherent in any definition of futility is a degree of subjectivity; what do we mean by “unlikely?” A less than a 5% chance of benefit? less than 1% chance? Or true physiologic futility (i.e., using antibiotics to treat a viral infection)? Who gets to decide what constitutes clinical benefit? Is prolonging an inevitable dying process by hours to days “beneficial?” This issue of subjectivity in definitions of futility and NBT is reflected in the large variation in what physicians would or would not consider to be a “futile” intervention (2). 

Types of futility:  

• Quantitative futility refers to the intervention that has a minute chance of benefiting the patient; the most used number is less than 1% chance of success.   
• Qualitative futility describes a clinical situation in which the quality of benefit of an intervention is felt to be exceedingly poor.  One example would be prolonging life via use of an extracorporeal membrane oxygenation circuit for which a terminally ill patient is completely dependent upon and therefore unlikely to ever leave the ICU setting.   
• Physiologic futility is likely the most straightforward and least controversial type of futility.  It describes a clinical intervention that has no physiologic rationale (i.e., use of antibiotics for a viral infection) (3). 

Ethics of futility and NBT: Despite the subjectivity of definitions of futility and NBT, it is broadly held that clinicians are under no obligation to offer treatments they deem to be futile or otherwise non-beneficial. In these instances, the principle of autonomy (a patient’s right to decide what treatments to engage in or refuse) is said to be trumped by non-maleficence and beneficence. As such, limit-setting is appropriate for those patients with a serious illness when a requested treatment (e.g., chemotherapy, surgery, dialysis) is either of no benefit or clinicians feel the intervention would cause more harm than good (2).  

Medical Futility Policies    In order to reduce subjectivity in determinations of medical futility and NBT, the AMA and other national organizations recommend that health care institutions adopt a clear policy that outlines a due process for approaching these disputes. These policies should provide both patient protections and clinician options in cases where initiating or continuing life-prolonging treatments serve no applicable medical benefit. Suggestions from an AMA Council on Ethical and Judicial Affairs on the content of such a medical futility policy include: 

• Earnest attempts should be made in advance to negotiate between patient, proxy, and physician on what constitutes futile care for the patient. 
• Joint decision making between patient or proxy and physician should occur to the maximum extent. 
• Assistance of consultants such as ethics committees should be pursued to negotiate disagreements. 
• If a dispute remains unresolved and the institutional review supports the patient’s position and the physician is unpersuaded, transfer of care to another physician within the institution may be arranged. 
• If the institutional review supports the clinician’s position and the patient remains unpersuaded, transfer to another institution should be sought.  
• If no transfer of care can be arranged, halting futile treatment is ethically acceptable (4). 

Other Suggestions 

• Check with your health care institution regarding the presence of an existing futility policy. 
• Ethics committees and medical organizations (local/state/national) can provide resources to understand medical futility and professional responsibilities in one’s practice area.   
• Avoid using the term ‘futility’ in discussion with patients/families.  Rather, speak in terms of ‘benefits’/’burdens’ of treatment and patient or family-specific goals of care.  
• Involve a palliative care and/or ethics consultant in any situation where ‘futility’ will be invoked as a process step in formulating decisions. 
• See Fast Fact #183 and Fast Fact #184 for more information on conflict resolution strategies. 

References 

1. Lo JJ, Graves N, Chee JH, Hildon ZJ. A systematic review defining non-beneficial and inappropriate end-of-life treatment in patients with non-cancer diagnoses: theoretical development for multi-stakeholder intervention design in acute care settings. BMC Palliat Care. 2022 Nov 9;21(1):195. 
2. Beauchamp TL, Childress JF. Principles of biomedical ethics (8th ed). 2019. Oxford University Press. 
3. Aghabarary M, Dehghan Nayeri N. Medical futility and its challenges: a review study. J Med Ethics Hist Med. 2016 Oct 20; 9:11 
4. American Medical Association.  Opinion 2.037: Medical Futility in End-of-Life Care.  JAMA. 1999; 281: 937-41.  Accessed February 23rd, 2024. 

Version History:  Originally published in April 2005. 2nd Edition in April 2009; 3rd Edition in March 2016 by Sean Marks MD; 4th Edition in February 2024 by Adam Marks MD
Conflicts of Interest: None reported.