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Table of Contents
Think
Assess
Patient: Autonomy
Practitioner: Beneficence & Nonmaleficence
Public Policy: Justice
Conclude
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19. Futile Treatment
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What sense would it make, or what would it benefit a medical practitioner if they discover the origin of diseases but could not cure or alleviate them?
~ Paracelsus
Futile Struggle
The Ethical Dilemma of Providing Futile Treatment in Medicine
Dr. Sarah Johnson was a well-respected oncologist in the small town of Clearwater. She had been practicing for over 20 years and had built a reputation for being a compassionate and knowledgeable practitioner. However, her world was about to be turned upside down.
One day, a patient named John Smith came to her with a request for a treatment that Dr. Johnson knew was futile. John had been diagnosed with advanced stage lung cancer and had already undergone several rounds of chemotherapy and radiation therapy. Unfortunately, his cancer had progressed, and he was looking for other treatment options.
John had heard about a new treatment that had shown some promise in other patients with advanced stage cancer, and he was convinced that this was the treatment he needed. Dr. Johnson knew that the treatment was ineffective and would only cause John more harm than good.
Dr. Johnson explained to John the reasons why the treatment was futile and provided him with evidence-based medical options that could improve his quality of life. However, John was adamant that he wanted the new treatment, and he refused to listen to Dr. Johnson’s advice.
Dr. Johnson was torn between her professional obligations to provide John with the best possible medical care and her ethical obligations not to harm him. She knew that if she provided John with the treatment he wanted, it would violate the principles of beneficence (do good) and nonmaleficence (do no harm).
Dr. Johnson tried to reason with John, but he was unresponsive. She even tried to involve John’s family members in the decision-making process, but they were also convinced that the new treatment was the best option.
Dr. Johnson finally realized that she could not continue to treat John, and she had to refer him to another practitioner. She informed John and his family that she could not provide the treatment he wanted because it was futile and would only cause him more harm than good.
A few days later, Dr. Johnson received a call from the local medical board, informing her that John had filed a complaint against her for not providing him with the treatment he wanted. The medical board launched an investigation, and Dr. Johnson was suspended from practicing medicine until the investigation was completed.
Dr. Johnson was devastated. She had always put her patients’ best interests first and had never been accused of malpractice. She knew that she had done the right thing by not providing John with the futile treatment he wanted, but now her reputation was on the line.
After a thorough investigation, the medical board found that Dr. Johnson had acted in accordance with evidence-based medicine and had upheld the principles of medical ethics. She was cleared of all charges, and her license to practice medicine was reinstated.
The incident had a profound effect on Dr. Johnson. She realized the importance of discussing with patients the reasons for wanting ineffective and futile treatments and correcting any misinformation they may have. She also became an advocate for informed consent and patient autonomy, recognizing that these principles are essential for maintaining the patient-practitioner relationship and ensuring the fair distribution of benefits and burdens within society.
Abstract
The concept of futile treatment refers to treatments that lack evidence of benefiting the patient or achieving desired medical outcomes, as determined by evidence-based medicine. Patient autonomy is a crucial aspect of informed consent decision-making and is based on a shared decision-making process between the patient and practitioner. The practitioner has the responsibility to inform the patient of the diagnosis, prognosis, treatment options, benefits, risks, and answer any questions. The practitioner is expected to provide treatment options that comply with medical standards of care, and futile treatments should not be part of the patient’s decision-making options. If a patient chooses a futile treatment, the practitioner must discuss the reasons for this choice and correct any misinformation. The practitioner has a professional obligation of beneficence (do good) and nonmaleficence (do no harm) to only provide treatment options that will benefit the patient and minimize harm. Society expects practitioners to help patients make rational and informed medical decisions, and futile treatments should never delay proper patient treatment or drain limited medical resources. It is essential for the practitioner to discuss with the patient why they want a futile treatment to correct any misinformation and ensure informed consent.
**
Think
[19:1] Futile treatment is any treatment determined by evidence-based medicine not to benefit the patient or achieve the intended medical outcomes. The medical standards of care are treatment options that are based on evidence-based medicine, objectively determined by measurable peered reviewed data and research, and practiced in the community.
Assess
Patient 1) Autonomy
[19:2] Central to patient autonomy, as expressed with informed consent decision-making, is the patient-practitioner relationship. Informed consent is a shared decision-making process because of the patient’s positive right to be informed by the practitioner of the diagnosis, prognosis, treatment options, benefits, risks, and have questions answered. With this information, the patient can provide informed consent authorizing the practitioner to provide medical treatment or to withdraw treatment already started.
[19:3] It is not the patient who presents treatment options to the practitioner; rather, the practitioner presents treatment options to the patient. All treatment options must comply with medical standards of care. Futile treatments violate such parameters and should not even be part of the patient’s decision-making options.
[19:4] If a patient chooses a futile treatment independently from the practitioner, then the practitioner must discuss why they want the futile treatment. This will allow the practitioner to:
- 1. correct any misinformation regarding the practitioner’s proposed treatment options, and
- 2. provide the opportunity to correct any false beliefs and misinformation that the patient may have regarding the ineffective treatment.
[19:5] This is a necessary corrective exchange because, without correct medical knowledge, the patient is not informed, making it impossible to provide informed consent. Without having correct medical knowledge, the patient, by definition, lacks decisional capacity. It is not that the patient only has decisional capacity if they choose the right course of treatment; instead, it is the requirement to be logically consistent and coherent with the patient’s reasonable goals, values, and priorities and agree to permit treatment consistent with medical standards of care. A patient’s informed consent is the authorization for the practitioner to provide one of the treatment options that the practitioner has proposed for maximizing the patient’s best interests.
Practitioner: 2) Beneficence & 3) Nonmaleficence
[19:6] The practitioner has a professional obligation of beneficence (do good) only to provide treatment options that will benefit the patient. The practitioner also has the obligation of nonmaleficence (do no harm) to minimize the risk of harm to the patient. For the practitioner to provide futile treatment would violate both beneficence (do good) and nonmaleficence (do no harm).
[19:7] There are times when the patient’s goals, values, and priorities may result in the patient wanting to try one or more futile treatments, independent of practitioner care. Not all futile treatments outside of evidence-based medicine are objectionable if the ineffective treatments have minimal risks of harm, even if they have no hope of benefits.
[19:8] It is incumbent upon the practitioner to inquire into non-western medicines, cultural treatments, and complementary approaches the patient has been engaged in as part of a complete medical history and physical (H&P). Some of these ineffective treatments may have a physiological and medical impact on evidence-based medicine, and it is essential to know this information to avoid the risk of adverse reactions. The practitioner is the one who offers evidence-based treatment options for the patient to choose from, based on what will maximize the patient’s best interests using the patient’s reasonable goals, values, and priorities.
[19:9] However, as a matter of medical professionalism, it is never permissible for a practitioner to offer or agree to provide futile treatment that would result in an increased risk of harm to the patient as that would be a violation of the principle of nonmaleficence (do no harm) and a violation of medical standards of care. Offering a patient an ineffective or futile treatment is a violation of medical professionalism.
Public Policy: 4) Justice
[19:10] Justice is defined as the fair distribution of benefits and burdens within society. Society has given the medical profession an enormous amount of resources and trust for helping society to address healthcare disparities. In response, society expects that when futile treatments either harm the patient, prevent or delay the patient from getting the proper medical treatment required, the practitioner has a social obligation to help the patient make rational and informed medical decisions. Futile treatments ought never to delay proper patient treatment or drain societies’ limited medical resources.
Conclude
[19:11] It is important that the practitioner discusses with the patient why they want an ineffective and futile treatment. This will allow the practitioner to correct any misinformation the patient may have regarding the medical standards of care and any misinformation the patient may have regarding the ineffective and futile treatment.
[19:12] In summary, pactitioners play a vital role in helping patients make informed and rational medical decisions. It is essential for practitioners to discuss with patients their reasons for wanting a futile treatment, correct any misinformation, and ensure that informed consent is obtained. By doing so, they uphold the principles of medical professionalism, ensure patient autonomy, and contribute to the fair distribution of benefits and burdens within society.
**
19. Review Questions
1. A practitioner has a professional responsibility to respect a patient’s authority to choose a medical treatment even if the practitioner disagrees.
2. A practitioner must respect the patient’s right to choose a medical treatment that they believe will be best. It would be disrespectful to be so bold as to correct misinformation and false beliefs.
3. If a patient has misinformation and false beliefs that relate to the treatment options, then the patient by definition lacks decisional capacity.
4. The practitioner has the professional obligation of nonmaleficence (do no harm) not to administer futile treatments that only increase the risk of harm.
5. Not all futile treatments outside of evidence-based medicine are objectionable if the ineffective treatments have minimal risks of harm, even if they have no hope of benefits.
6. Some ineffective treatments may have a physiological and medical impact on evidence-based medicine, and it is essential to know this information to avoid the risk of adverse reactions.
**
CORRECT! 🙂
[19:3] It is not the patient who presents treatment options to the practitioner; rather, the practitioner presents treatment options to the patient. All treatment options must comply with medical standards of care. Futile treatments violate such parameters and should not even be part of the patient’s decision-making options.
Wrong 😕
[19:3] It is not the patient who presents treatment options to the practitioner; rather, the practitioner presents treatment options to the patient. All treatment options must comply with medical standards of care. Futile treatments violate such parameters and should not even be part of the patient’s decision-making options.
CORRECT! 🙂
[19:3] It is not the patient who presents treatment options to the practitioner; rather, the practitioner presents treatment options to the patient. All treatment options must comply with medical standards of care. Futile treatments violate such parameters and should not even be part of the patient’s decision-making options.
Wrong 😕
[19:3] It is not the patient who presents treatment options to the practitioner; rather, the practitioner presents treatment options to the patient. All treatment options must comply with medical standards of care. Futile treatments violate such parameters and should not even be part of the patient’s decision-making options.
CORRECT! 🙂
[19:5] This is a necessary corrective exchange because, without correct medical knowledge, the patient is not informed, making it impossible to provide informed consent. Without having correct medical knowledge, the patient, by definition, lacks decisional capacity. It is not that the patient only has decisional capacity if they choose the right course of treatment; instead, it is the requirement to be logically consistent and coherent with the patient’s reasonable goals, values, and priorities and agree to permit treatment consistent with medical standards of care. A patient’s informed consent is the authorization for the practitioner to provide one of the treatment options that the practitioner has proposed for maximizing the patient’s best interests.
Wrong 😕
[19:5] This is a necessary corrective exchange because, without correct medical knowledge, the patient is not informed, making it impossible to provide informed consent. Without having correct medical knowledge, the patient, by definition, lacks decisional capacity. It is not that the patient only has decisional capacity if they choose the right course of treatment; instead, it is the requirement to be logically consistent and coherent with the patient’s reasonable goals, values, and priorities and agree to permit treatment consistent with medical standards of care. A patient’s informed consent is the authorization for the practitioner to provide one of the treatment options that the practitioner has provided for maximizing the patient’s best interests.
CORRECT! 🙂
[19:6] The practitioner has a professional obligation of beneficence (do good) only to provide treatment options that will benefit the patient. The practitioner also has the obligation of nonmaleficence (do no harm) to minimize the risk of harm to the patient. For the practitioner to provide futile treatment would violate both beneficence (do good) and nonmaleficence (do no harm).
Wrong 😕
[19:6] The practitioner has a professional obligation of beneficence (do good) only to provide treatment options that will benefit the patient. The practitioner also has the obligation of nonmaleficence (do no harm) to minimize the risk of harm to the patient. For the practitioner to provide futile treatment would violate both beneficence (do good) and nonmaleficence (do no harm).
CORRECT! 🙂
[19:7] There are times when the patient’s goals, values, and priorities may result in the patient wanting to try one or more futile treatments, independent of practitioner care. Not all futile treatments outside of evidence-based medicine are objectionable if the ineffective treatments have minimal risks of harm, even if they have no hope of benefits.
Wrong 😕
[19:7] There are times when the patient’s goals, values, and priorities may result in the patient wanting to try one or more futile treatments, independent of practitioner care. Not all futile treatments outside of evidence-based medicine are objectionable if the ineffective treatments have minimal risks of harm, even if they have no hope of benefits.
CORRECT! 🙂
[19:8] It is incumbent upon the practitioner to inquire into non-western medicines, cultural treatments, and complementary approaches the patient has been engaged in as part of a complete medical history and physical (H&P). Some of these ineffective treatments may have a physiological and medical impact on evidence-based medicine, and it is essential to know this information to avoid the risk of adverse reactions. The practitioner is the one who offers evidence-based treatment options for the patient to choose from, based on what will maximize the patient’s best interests using the patient’s reasonable goals, values, and priorities.
Wrong 😕
[19:8] It is incumbent upon the practitioner to inquire into non-western medicines, cultural treatments, and complementary approaches the patient has been engaged in as part of a complete medical history and physical (H&P). Some of these ineffective treatments may have a physiological and medical impact on evidence-based medicine, and it is essential to know this information to avoid the risk of adverse reactions. The practitioner is the one who offers evidence-based treatment options for the patient to choose from, based on what will maximize the patient’s best interests using the patient’s reasonable goals, values, and priorities.
19. Clinical Vignettes
1. Ms. Natalia Miller, a 68-year-old astronomer presents to their practitioner with a chronic medical condition that has not responded to previous treatments. The patient expresses interest in a new, experimental treatment they have read about online. Which of the following is the most appropriate response for the practitioner?
2. Mr. Lazarus Wilson, a 73-year-old retiree presents to the clinic with a complex medical condition and several treatment options are presented by the practitioner. The patient is uncertain about which option to choose and expresses confusion about the potential risks and benefits of each option. Which of the following best represents the requirement for informed consent?
3. Ms. Yoko O’Rylee, a 59-year-old environmental engineer has a serious medical condition. The practitioner’s professional obligations include both “beneficence” (do good) and “nonmaleficence” (do no harm). Which of the following best describes those ethical obligations in this situation?
4. Mr. Kurt Chen, a 51-year-old costume designer is diagnosed with a terminal illness and the medical team has exhausted all evidence-based treatments options. The patient's family expresses their wish to try alternative treatments which are not supported by scientific evidence and carry minimal risk of harm. Which of the following statements best describes the ethical considerations in this scenario?
5. Ms. Norah Henderson, a 32-year-old advertising executive presents to the clinic for a routine check-up. The practitioner is conducting a complete medical history and physical examination. Although all of the following are important, which is most the critical factor for the practitioner to consider when determining prescriptions and dosages?
CORRECT! 🙂
Explanation: The most appropriate response for the practitioner is to help the patient understand why the experimental treatment is not a viable option and discuss alternative treatments that are in line with evidence-based medical standards of care [19:1]. While patients may express interest in new, experimental treatments they have read about online, it is the practitioner's responsibility to ensure that the treatment offered is safe, effective, and in line with evidence-based medical standards of care [19:6]. The practitioner should explain to the patient why the experimental treatment may not be a viable option and discuss alternative treatments that have been shown to be effective [19:4]. Providing the patient with information about the experimental treatment and leaving the decision to them may not be the best course of action, as the patient may not have the medical knowledge or expertise to assess the risks and benefits of the treatment [19:2].
Wrong 😕
Explanation: The most appropriate response for the practitioner is to help the patient understand why the experimental treatment is not a viable option and discuss alternative treatments that are in line with evidence-based medical standards of care [19:1]. While patients may express interest in new, experimental treatments they have read about online, it is the practitioner's responsibility to ensure that the treatment offered is safe, effective, and in line with evidence-based medical standards of care [19:6]. The practitioner should explain to the patient why the experimental treatment may not be a viable option and discuss alternative treatments that have been shown to be effective [19:4]. Providing the patient with information about the experimental treatment and leaving the decision to them may not be the best course of action, as the patient may not have the medical knowledge or expertise to assess the risks and benefits of the treatment [19:2].
CORRECT! 🙂
Explanation: Informed consent requires the practitioner to provide the patient with all available information about each treatment option and allow the patient to make an informed decision. Informed consent is a critical component of ethical medical practice and involves the provision of information about the nature, risks, benefits, and alternatives of a proposed treatment [19:2]. This information allows the patient to make an informed decision about their healthcare. Providing all available information empowers the patient to make a decision that is best for them based on their values, beliefs, and preferences [19:5]. It is incorrect to provide the patient with only limited information of only one treatment option as the result is no choice. It is incorrect to not involve the patient in the decision-making process, which is essential for informed consent [19:2]. Pressuring the patient is usually not in the patient's best interest and violates the requirement for informed consent.
Wrong 😕
Explanation: Informed consent requires the practitioner to provide the patient with all available information about each treatment option and allow the patient to make an informed decision. Informed consent is a critical component of ethical medical practice and involves the provision of information about the nature, risks, benefits, and alternatives of a proposed treatment [19:2]. This information allows the patient to make an informed decision about their healthcare. Providing all available information empowers the patient to make a decision that is best for them based on their values, beliefs, and preferences [19:5]. It is incorrect to provide the patient with only limited information of only one treatment option as the result is no choice. It is incorrect to not involve the patient in the decision-making process, which is essential for informed consent [19:2]. Pressuring the patient is usually not in the patient's best interest and violates the requirement for informed consent.
CORRECT! 🙂
Explanation: The ethical obligation is to provide treatments that offer a reasonable chance of benefiting the patient, while minimizing the risk of harm [19:1]. This obligation is rooted in the principles of beneficence and nonmaleficence, which require that practitioners act in the best interest of the patient and avoid harm [19:6]. Providing any treatment option requested by the patient, regardless of its potential benefits or risks would not necessarily be in the patient's best interest and could potentially cause harm [19:3]. Similarly, providing only treatments that are proven to be effective, even if they carry a high risk of harm would not necessarily minimize the risk of harm [19:1]. Finally, providing only futile treatments is not consistent with the principles of beneficence and nonmaleficence, as it would not offer a reasonable chance of benefiting the patient [19:1].
Wrong 😕
Explanation: The ethical obligation is to provide treatments that offer a reasonable chance of benefiting the patient, while minimizing the risk of harm [19:1]. This obligation is rooted in the principles of beneficence and nonmaleficence, which require that practitioners act in the best interest of the patient and avoid harm [19:6]. Providing any treatment option requested by the patient, regardless of its potential benefits or risks would not necessarily be in the patient's best interest and could potentially cause harm [19:3]. Similarly, providing only treatments that are proven to be effective, even if they carry a high risk of harm would not necessarily minimize the risk of harm [19:1]. Finally, providing only futile treatments is not consistent with the principles of beneficence and nonmaleficence, as it would not offer a reasonable chance of benefiting the patient [19:1].
CORRECT! 🙂
Explanation: In this scenario, the patient has been diagnosed with a terminal illness and all evidence-based treatments have been exhausted [19:1]. The patient's family expresses their wish to try alternative treatments that carry minimal risk of harm, but are not supported by scientific evidence. The best statement that describes the ethical considerations in this scenario is that it is ethical to provide treatments that have little hope of benefit as long as they also carry minimal risks of harm [19:7]. This approach aligns with the ethical principle of beneficence, which requires practitioners to take action that promotes the well-being of the patient, and nonmaleficence, which requires practitioners to avoid causing harm to the patient [19:6]. In this situation, the patient and their family have the right to make an informed decision about their treatment options, even if those options are not based on evidence-based medicine [19:2]. It is important for the practitioner to provide the family with clear and accurate information about the potential risks and benefits of the alternative treatments, while also making clear that they are not evidence-based. The ultimate decision should be made by the patient and their family, in collaboration with the practitioner. The other options are incorrect as they do not align with the ethical principles of beneficence and nonmaleficence [19:9].
Wrong 😕
Explanation: In this scenario, the patient has been diagnosed with a terminal illness and all evidence-based treatments have been exhausted [19:1]. The patient's family expresses their wish to try alternative treatments that carry minimal risk of harm, but are not supported by scientific evidence. The best statement that describes the ethical considerations in this scenario is that it is ethical to provide treatments that have little hope of benefit as long as they also carry minimal risks of harm [19:7]. This approach aligns with the ethical principle of beneficence, which requires practitioners to take action that promotes the well-being of the patient, and nonmaleficence, which requires practitioners to avoid causing harm to the patient [19:6]. In this situation, the patient and their family have the right to make an informed decision about their treatment options, even if those options are not based on evidence-based medicine [19:2]. It is important for the practitioner to provide the family with clear and accurate information about the potential risks and benefits of the alternative treatments, while also making clear that they are not evidence-based. The ultimate decision should be made by the patient and their family, in collaboration with the practitioner. The other options are incorrect as they do not align with the ethical principles of beneficence and nonmaleficence [19:9].
CORRECT! 🙂
Explanation: When taking a patient's medical history, it is critical for the practitioner to consider the patient's use of non-western medicines, cultural treatments, and complementary approaches [19:8]. This information is essential to assess the patient's overall health, including any potential interactions with prescribed treatments or drugs, which may affect the efficacy and outcome of the treatment [19:8]. Non-western medicines, cultural treatments, and complementary approaches can include herbal remedies, acupuncture, and meditation, which can affect the patient's well-being and treatment outcomes [19:8]. Additionally, this information can provide insights into the patient's cultural background and beliefs, allowing the practitioner to provide culturally sensitive and appropriate care [19:8]. While the other options can be important factors to consider, they are not as critical as the patient's use of non-western medicines, cultural treatments, and complementary approaches.
Wrong 😕
Explanation: When taking a patient's medical history, it is critical for the practitioner to consider the patient's use of non-western medicines, cultural treatments, and complementary approaches [19:8]. This information is essential to assess the patient's overall health, including any potential interactions with prescribed treatments or drugs, which may affect the efficacy and outcome of the treatment [19:8]. Non-western medicines, cultural treatments, and complementary approaches can include herbal remedies, acupuncture, and meditation, which can affect the patient's well-being and treatment outcomes [19:8]. Additionally, this information can provide insights into the patient's cultural background and beliefs, allowing the practitioner to provide culturally sensitive and appropriate care [19:8]. While the other options can be important factors to consider, they are not as critical as the patient's use of non-western medicines, cultural treatments, and complementary approaches.
**
19. Reflective Vignettes
1. Mr. Michael Brown, a 60-year-old retired accountant, has been hospitalized for an extended period due to complications from cancer treatment. He expresses to the practitioner that he feels frustrated with the slow recovery and wonders if there are any alternative treatments that could help. He mentions that he has been reading about herbal remedies and vitamin supplements online and asks if it would be safe to start a regimen. The practitioner explains that while some supplements may have potential benefits, they may also interact with other medications or exacerbate certain conditions. The differential diagnosis includes drug-herb interactions, malnutrition, and the placebo effect. The practitioner discusses the risks and benefits of the supplements with Mr. Brown and recommends consulting with a qualified healthcare provider before starting any new treatment.
Think
Assess
Patient: Autonomy
Practitioner: Beneficence & Nonmaleficence
Public Policy: Justice
Conclude
**
2. Ms. Maria Rodriguez, a 30-year-old stay-at-home mother, is brought to the emergency room by her family due to severe abdominal pain. The practitioner diagnoses her with acute appendicitis and recommends immediate surgery. However, Ms. Rodriguez expresses that she would like to pursue "prayer" and the "laying on of hands" instead of the accepted medical treatment. The practitioner explains that while the patient has the right to make their own decisions, informed consent requires a clear understanding of the risks and benefits of the chosen treatment. The differential diagnosis includes cultural beliefs, fear of surgery, and lack of knowledge about the condition. The practitioner discusses the potential consequences of delaying or avoiding surgery with Ms. Rodriguez and offers to connect her with a hospital chaplain or spiritual advisor if desired
Think
Assess
Patient: Autonomy
Practitioner: Beneficence & Nonmaleficence
Public Policy: Justice
Conclude
***
