Council of Europe Seeks Input on Medical Futility Guidelines

The Council of Europe Committee on Bioethics has released for public consultation its "Draft Guide Concerning the Decision-making Process Regarding Medical Treatment in End-of-Life Situations."  The following sections are particularly relevant to medical futility.

27. The implementation or continuation of any treatment requires a medical indication.
However, other aspects must be taken into account when assessing whether a form of 
treatment is appropriate in view of the particular situation of the patient concerned. The 
issues that need to be addressed are as follows:
- the benefits, risks and drawbacks of medical treatment depending on the anticipated effects on the patient’s health;
- their appraisal in view of the expectations of the person concerned. This results 
in an assessment of the “overall benefit”, which takes account of the benefit in terms not only of the results of the treatment of the illness or the symptoms but 
also of the patient’s quality of life, psychological and spiritual well-being, etc. 

28. In some cases, this appraisal leads to the conclusion that the treatment is disproportionate when the risks and/or the scale of the constraints and the resources required to implement it are compared with the anticipated benefits. In this case, the doctor is justified in not implementing it or withdrawing it. In English-speaking countries in particular, the treatment concerned in such cases is described as “futile”. 

29. There is no obvious means that would apply to all individual situations, of measuring 
whether treatment is disproportionate. Even though there are medical criteria (from 
evidence-based medicine) to evaluate risks and benefits, which make it possible to 
assess whether treatment is proportionate, the suitability of treatment will always be 
assessed in the light of the patient’s situation as a whole. The answer to this question 
derives from the relationship of trust between doctors, carers and patients. In many 
cases, the disproportionate nature of treatment will tend to be defined according to the 
development of the illness and the patient’s reaction to the treatment, which will 
determine whether the medical indication needs to be called into question. In other 
circumstances, it is in the course of the discussion between doctors, carers and patients 
about the purpose and the expected benefits and potential risks of treatment that a 
possible disproportionality may emerge.

30. When, in a given situation, the treatment that is being contemplated or implemented 
will not yield or no longer yields any benefits, or is regarded as being clearly 
disproportionate, beginning or continuing to implement it can be described as 
“therapeutic obstinacy” (or unreasonable obstinacy). Doctors faced with such situations 
have a duty not to implement treatment or to withdraw it.

31. In end-of-life situations, assessing “overall benefit” has a key part to play in 
determining the suitability of treatment whose purpose may change (shifting from a 
curative to a palliative purpose for example). The prolonging of life must not in itself be 
the sole aim of medical practice, which should attempt just as much to relieve suffering. 
The difficulty of any medical decision at the end of life is that of ensuring that the 
patient’s dignity is respected and that the balance is struck between the protection of life 
and the person’s right to be relieved of suffering if possible