Futility: revisiting a concept of shared moral judgment.

When caring for patients with end stage illness there tends to be universal agreement that overly aggressive treatment should be discouraged or limited when death is near and when further intervention would be futile or otherwise inflict undue suffering on the patient (1; 2; 3). The modern ability to delay the natural course of dying, however, has challenged the ability to distinguish at what point in the trajectory of disease it is appropriate, and perhaps morally required, to consider less vigorous disease treatment in favor of symptom oriented and patient focused plans of palliative care (4). This paper reflects on futility, not as an objective criteria of facts and prognosis, but as a concept that promotes patient interest when treatment becomes excessively burdensome. A prudent balancing of medical effectiveness, as determined by the physician, and the burdens and benefits of treatment, as identified by the patient, provides a means by which to seek a clinical judgment within the context of the healing relationship as to whether continued treatment is warranted. From an ethical and theological standpoint it has generally been recognized that respect for human dignity requires certain constraints when treatment is excessively burdensome to the patient (5; 6). The ethical distinction between " ordinary " and " extraordinary " treatments takes into consideration whether ongoing emotional and physical discomfort, risk, cost, or other burdens of treatment are acceptable or excessive to the patient as a dignified, autonomous person. The moral content of this concept takes into consideration the intrinsic value of human life, the values and beliefs of the person living that life, and the proportionate means by which suffering and life coexist within the moral framework of acceptability. Efforts to maximize good clinical outcomes (including patient satisfaction and quality of life considerations) and minimize harm to the patient take into consideration the proportionate harms and goods that will ultimately lead to a better state for that patient. When pain and suffering, financial burden, spiritual burden, or