Medical Futility: Just Because We Can Do Something...Should We?

John William Waterhouse created a very impactful painting called “The Danaides”. The painting depicts the Greek mythologic story of the daughters of King Danaus being punished in Hades for murdering their husbands on their wedding night. King Danaus was forced to marry his daughters to the sons of his brother, Aegyptus. He then commanded his daughters to kill their husbands. In punishment for their crime, the Danaides (daughters of King Danaus) were condemned in Hades to the endless task of filling a vessel with water that had no bottom. This painting represents the idea of futility because the vessel can never be filled and it is often used in presentations about medical futility.

As a pediatric intensive care physician, I have been in the unfortunate and fortunate position of being part of clinical circumstances that were considered medically futile. The reason that I say that I was in the unfortunate position is because medical futility is not an easy situation to be involved with. The reason that I say that I was in a fortunate position is because I was able to be involved in efforts to help families manage the most difficult and unfathomable experience in their life.

In medicine, there are a number of principles that guide our decision-making when it comes to ethical dilemmas. At a basic level, they include the principles of:

Autonomy: each person (usually referring to patients and their families) has the right to make his or her own decisions, in his or her own way, based on his or her own values

Beneficence: the commitment to doing whatever you judge will best serve the best interests of the person in your care

Nonmaleficence: not doing harm to others

Justice: equity in distribution of community resources (“distributive justice”)

Ideally, we want patients/families to feel like they are able to have a say in their care and make medical decisions that they see are in their best interest. We want to make sure that clinicians are doing the best for their patients and are doing no harm. Finally, we want to make sure that medical care is distributed equally in the community. These are principles that we strive for in medicine. But, we are sometimes found conflicted in certain scenarios which create ethical dilemmas. Medical futility is one such scenario.

As a clinician, I have encounter events where I have reached the limits of what is medically reasonable to treat a medical condition. A child, with a compromised immune system after a bone marrow transplant for leukemia, has had severe dysfunction of the heart, lungs, kidneys, and other organs from a severe infection. The child is being kept alive with machines to support the lungs and the kidneys and medications are being given to support the heart. There is no apparent sign of recovery of the organs and the infection is persisting despite being given medications to fight it. Another child is placed on ECMO (extracorporeal membrane oxygenation), a heart and lung machine, for severe heart failure. While on ECMO, the blood needs to be anticoagulated or thinned, so blood clots do not form in the tubes that take the blood out of the body, into the machine, and back into the body. The child suffers a severely damaging bleed into their brain because of the anticoagulation or thinning of the blood. The blood thinner medication needs to be stopped to save the brain, but it can’t be stopped because the EMCO tubing will clot and not work. The child still needs the machine to survive because the heart has not recovered to be able to work on its own. Finally, a child is declared brain dead after a near drowning event in a pool and is on a mechanical ventilator to support breathing. Brain death is defined as the brain ceasing function, which includes the breathing center in the brain. Without the part of the brain that controls breathing, the child will not breath on their own. Despite a beating heart, a child is considered legally dead if they are declared brain dead. The mechanical ventilator keeps the lungs functioning and pumping oxygen into the body to prevent the other organs from failing, but the brain will not recover. All of these scenarios represent medical futility because the child will not recover to a condition where their body can survive without the support of machines and extreme administrations of medications to keep them alive.

The concept of medical futility is often a difficult concept for families to grasp because their child still appears alive with all of the efforts to support their body. As I mentioned previously, it is an unfathomable position to be in to decide to stop the medical support for a child when their treatment is considered medically futile. It is akin to the decision to “pulling the plug” on life support measures. But, in the end, one has to consider if treatments are actually in the best interest of the child (beneficence) or if they are actually causing harm or suffering by prolonging the inevitable (non-maleficence). When I think of the image created by John William Waterhouse, it is no wonder why the painting is referenced so often in medical futility presentations. It so accurately reflects the model of futility with medical treatments in some situations and really highlights the concept that we often confront in medicine…“Just because we can do something…should we?”

Have you ever been involved in a discussion about medical futility?