Trauma care is undertaken in order to save the lives and protect the health of patients who have experienced injuries. The ethical obligation to provide trauma care, however, is not unlimited. Sometimes it becomes ethically justified to set limits on the medical or surgical management of trauma, especially on the basis of clinical judgments of futility.
In general terms, futility means that a clinical intervention is reliably expected not to have its usually intended outcome. The clinical applicability of this general notion of futility requires that the outcome be clearly specified. Otherwise, clinical discourse among physicians or with patients and their families is at high risk of gridlock from unnecessary confusion about what is meant by saying that an intervention is “futile.”
Ethical challenges involved in setting limits on clinical management of patients’ diagnoses have been recognized in medical ethics since ancient times. In The Art, for example, the Hippocratic writers define medicine to include refusing to “treat those who are overmastered by their diseases, realizing that in such cases medicine is powerless.”1 More recently, the issue of setting limits has arisen in the context of critical care and how physicians should respond to requests for inappropriate continuation of life-sustaining interventions such as mechanical ventilation, provision of fluids and nutrition, and pharmacologic support of cardiac function. Issues concerning setting limits now arise routinely in the postoperative setting, and futility is sometimes invoked as a justification for setting limits.2 The purpose of this chapter is to identify four major concepts of futility that have been developed in the bioethical and medical literature and to incorporate these concepts with definitions of terminal and irreversible conditions into an algorithm that can be used to set ethically justified limits on the medical and surgical management of trauma patients.
The first three concepts of futility appeal to the ethical principle of beneficence as the basis for the requisite specification. This ethical principle obligates the physician and other healthcare professional to seek the greater balance of clinical goods over clinical harms to the patient. The key component of beneficence for clinical judgments of futility is that for an intervention to be reasonable to offer and perform in patient care, it must hold out the prospect of at least a modicum of potential clinical benefit.3
Tomlinson and Brody introduced the first beneficence-based concept of futility, physiologic or strict futility.4 An intervention is judged to be futile in this first sense when it is reliably expected not to produce its usually intended physiologic outcome. For example, cardiopulmonary resuscitation that continues for such a prolonged period of time that restoration of spontaneous circulation is no longer reasonably expected is properly judged physiologically futile, because there is at this point no reliable expectation, based on outcomes data, to support a clinical judgment that the outcome of resuscitation can be achieved.
Brody and Halevy introduced the second beneficence-based concept ...