At the beginning of the decade, a rapid succession of important court cases — Cruzan, Brophy, Wanglie, Baby K — propelled the debate over medical futility to national attention. The cases, and the human tragedies behind them, fueled arguments as to whether or not medical futility provides ethically coherent ground on which to limit life-prolonging treatments. In the years that have followed, ethicists, policymakers and clinicians continue to disagree over a proper definition for medical futility, and its appropriate application in clinical practice. This new volume, by two prominent scholars in the futility debate, summarizes five years of their work and presents their pro-futility stand without apology as “an extended argument rather than . . . a bland on-the-one-hand-on-the-other-hand tome.” Each chapter offers readers a forceful, consistent, comprehensive argument supporting their perspective, retelling infamous examples of medicine gone awry while appealing to physicians “to restore a vision of medicine’s proper ends and reform medical practice.”

Wrong Medicine will be welcomed by caregivers in modern-day America, where aggressive life-prolonging treatments too commonly appear to offer no medical benefit to patients. From the technology-driven ICU’s of quaternary medical meccas to the halls of rural nursing homes, doctors nevertheless continue to provide those very treatments. Physicians fear that futility judgments will be disputed by families, or even worse, challenged in litigation, railed in the media and condemned by patient advocacy groups as a return to the “silent world” of medical paternalism. In a confusing world of intensive care, medical miracles and near-misses, patients’ families also express dissatisfaction at inhumane end-of-life treatment, yet they fear giving up too soon. Those who wonder how the “technological imperative” has come to dominate medicine’s rich caring tradition will be drawn toward Schneiderman and Jecker’s work. Grounding their argument in medicine’s historical, ethical and professional foundation, they forcefully assert that the goals of medicine, which society has empowered the medical community to define, obliges physicians to refrain from futile treatments.

Our ability to define explicit, ethically valid standards for medical futility has been a major sticking point in the futility debate. The authors’ two-pronged definition incorporates quantitative (probability of success) and qualitative (quality of life) elements, and intuitively appeals to practitioners’ own concerns — what chance of success is too small to be considered useful? In what health states have patients lost their “personhood,” making further attempts to preserve life unwarranted? A second hurdle the authors face is persuading physicians that their definition provides the necessary and sufficient conditions to oblige professional practice. In ten short chapters, the authors attempt to do just this, taking readers through the futility minefield as they stake their claim on medicine’s proper goals. They discuss reasons doctors provide futile care and patients ask for it; present the ethical, social and professional imperatives for physicians not to offer futile care; counter the frequently voiced ethical arguments against their position; and outline how patients and physicians may address the care needs of dying patients without resorting to futile treatments. The authors do not offer their standpoint as value-free, but argue that reaffirming medicine’s valued goals will preserve physicians’ professional integrity and uphold the public trust.

Nearly all physicians, even those who oppose futility policies, will agree that there are limits to physicians’ professional obligations to provide requested treatment. Much of the current debate surrounds how and where those limits may ethically be set, and how they will be executed. It is this territory which the authors tread unabashed, and on which they systematically rebut most of their critics’ counterarguments. In an especially well-written chapter, they respond to critics’ objection that futility policies represent thinly veiled attempts to ration treatments in favor of patients considered most deserving. Articulately presenting the differences between futility (a patient-centered determination of no benefit) and rationing (a means of distributing resources that do offer benefits), they assure the reader that futility policies need not engender rationing decisions. In other chapters, they assert that explicit standards will reduce the likelihood that futility judgments will be applied arbitrarily, a practice that current research suggests is disturbingly common. Yet at certain points in their argument, readers may wonder if the authors themselves are sliding down the same “slippery slope” which they cautiously defend their position against. For example, in decrying the annual costs of misusing dialysis in “patients with conditions never envisioned by the original proponents: patients with severe diabetes, heart disease, liver disease and even those in permanent vegetative state. . . .,” one questions whether the authors have strayed from the strict futility focus they advocate.

If the debate over medical futility were merely concerned with identifying limits to the goals of medicine, the authors’ work would represent a cornerstone for discussions of professional futility standards — professional goals oblige physicians not to offer these nonbeneficial treatments to patients and families, case closed. Yet our medical tradition measures quality of care not only in terms of treatment outcomes, but also by the process through which those outcomes are achieved. The authors may not have intended to incorporate quality-of-care process elements into their proposal. Nevertheless, taking the authors’ “ethic of care” one step further, to address the process of carrying out futility decisions, would provide even greater comfort and respect for dying patients’ and their families. For example, given that physicians still control medicine’s decision-making power structure, will futility policies become the ultimate “trump card,” allowing physicians to avoid difficult family discussions during a patient’s progressively downhill course? Will families have equal access to information regarding benefits and burdens of continued treatment, to allow them to invoke futility against physician objections? What options will families have in the face of unilateral futility determinations? A futility policy that incorporates an ethic of caring will encourage and require physicians to assist patients in clarifying their values and preferences; will help providers identify situations at high-risk of futility, in order to facilitate shared decision-making; will provide mechanisms for families to appeal futility determinations; and will provide quality assurance through case-finding of inappropriately managed situations. Policies that focus only on health-state outcomes risk reversing hard-fought gains in physician-patient communication, and foreshadow a return to medical paternalism. Just as in the U.S. legal system, where the commitment to due process occasionally results in bad outcomes, futility policies must rest on a foundation of compassion, communication and due process.

By providing a comprehensive summary of these respected authors’ scholarly work, Wrong Medicine will likely help to shape the ongoing futility debate. Whether or not the dialogue ever bears the fruit of definitive futility standards, other forces may well carve the way for institutional policies. The looming presence of managed care in the medical marketplace will pressure institutions to develop policies eliminating inappropriate resource use. An expanding pool of retrospective studies, suggesting situations in which life- prolonging treatments offer little chance to benefit patients, will likely lead to prospective studies examining these same outcomes. To balance these forces, procedural safeguards provided by hospital ethics committees can ensure that futility determinations are not issued arbitrarily. Hopefully, these developments will lead to policies that support the ethic of care in treating hopelessly ill patients, within a framework ensuring quality of care both in treatment outcomes and decision-making processes.