Dr Paulina Taboada
Profesor Centro de Bioetica
Pontificia Universidad Catolica de Chile
Alameda 340 Correo Central 1
Santiago, Chile
An interesting article on alternative medicine and the concept of medical futility appeared in the October 15, 2002 number of the Annals of Internal Medicine (Cf. Adams et. al.: Ethical Considerations of Complementary and Alternative Medical Therapies in Conventional Medical Settings, Ann Intern Med 2002, 137, 8: 660- 664). The authors take a case-based moral reasoning (also known as "casuistry" ethical approach), in which the concrete circumstances play the key role in moral judgments. After analyzing two concrete cases from the perspective of the casuistry approach, they conclude that the increasing use of alternative therapies "provides an opportunity to reexamine the ethical foundations of western medical practice... physicians routinely balance risks and benefits in decision making, but the advent of CAM [Complementary and Alternative Medical] therapies challenges physicians to deal responsibly with paradigms of healing that fall outside the boundaries of conventional medical practice and to make decisions ... in the absence of evidence." (p. 663). Nevertheless, the authors hope that until the body of evidence regarding CAM therapies grows, physicians will learn to "routinely combine the powerful tools of conventional medicine with those CAM therapies shown to be worthy of clinical integration." (p. 664)
A tension between the application of measures that are not based on empirical evidence and the desire to demonstrate the utility of alternative therapies is perceived throughout the article. This tension refers us to the concept of medical utility. Normally, physicians are not willing to implement futile treatments. But to define therapeutic utility/ futility is certainly not an easy task. This concept has been widely explored in bioethical literature over the past years. Schneiderman, for instance, based on a distinction between benefits and effects, proposes a patient's benefit-centered definition of medical futility. But his conception of clinical futility excessively emphasizes the patient's conscious experience of benefit. And medical experience shows that the subjective perception of the benefits of a given therapy is not a necessary condition for defining its objective utility. Hence, a proper understanding of the concept of medical futility should combine both quantitative and qualitative elements.
This distinction between qualitative and quantitative elements in a utility judgment permits one to identify those dimensions of medical futility limited to the evidence-based probability of attaining a given goal from those related to value-judgments. Simplifying a very complex decision-making process, one could say that the statistical component of the utility judgements belongs primarily to the domain of physicians in virtue of their technical expertise, while the value-laden component referring to the desirability of achieving a given goal or to the convenience of taking some risks and burdens associated with a specific medical treatment necessarily involves the patient's judgment.
Thus, with Christensen I would rather introduce a distinction between absolute, statistical and disproportionate futility. Absolute futility refers to those interventions that are completely ineffective in physiological terms. Statistical futility expresses the low probability of a specific measure to achieve a given goal. The expression disproportionate futility qualifies a value-laden decision to abstain from a certain medical intervention - in spite of an eventual statistical probability of achieving an immediate beneficial therapeutic effect - because its application would represent an excessive burden and will actually not substantially modify the patient's prognosis. This relevant distinction underlies the ethical principle of therapeutic proportionality, which states the moral obligation to implement only those medical interventions that fulfill a relation of due proportion between the means to be employed and the pursued end. Medical interventions that do not fulfill this relation can be regarded as morally non-obligatory. But there is also an important distinction between what is morally obligatory and what is morally licit.
Furthermore, the concept of therapeutic utility does not exclusively refer to the goal of restoring health, as to preserve or enhance a patient's comfort and general well-being, and to prevent other diseases or complications of an incurable condition are also desirable goals of medicine, specially in the case of palliative care. This reflection can be applied to the use of alternative therapies as well.
References:
Schneiderman L. Commentary: Bringing Clarity to the Futility Debate: Are the Cases Wrong? Cambridge Quarterly of Healthcare Ethics 1998; 7: 269-278;
Schneiderman L, Faber-Langendoen K, Jecker N. Beyond Futility to an Ethical Care. Am J Med 1994; 96: 110-114
Schneiderman L, Jecker N et al. Medical Futility: Response to Critiques. Ann Intern Med 1996; 125: 669-674
Schneiderman L, Jecker N, Jonsen A. Medical Futility: Its Meaning and Ethical Implications. Ann. Intern. Med. 1990; 112: 949-954
Christensen K. Applying the Concept of Futility at the Bedside. Cambridge Quarterly of Healthcare Ethics 1992; 1: 239-248.
Dr. Paulina Taboada, MD, PhD
Palliative Care and Bioethics