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When Doctors Say No. The Battleground of Medical Futility
  1. John Saunders
  1. Department of Medicine, Nevill Hall Hospital, Abergavenny, Centre for Philosophy and Health Care, University of Wales, Swansea

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    Susan B Rubin, Bloomington, Indiana, Indiana University Press, 1998, 191 pages, US$24.95.

    This book is a polemical monograph. It aims to demonstrate that “physicians would not be justified in refusing unilaterally to offer, provide, or continue treatment based on their opinion that the treatment in question would be futile”.

    Expressed in these terms, the central thesis of the book may sound unrealistic or even absurd to many busy practising doctors. Is this then just another piece of doctor bashing by an armchair philosopher? Even the title sounds ominous.

    In fact Rubin's thesis is more complex. For, as usual in futility debates, it all depends on what you mean by futility. After an introductory first chapter that sets the scene with a description of some publicly prominent cases and professional statements, she sketches out what futility is usually taken to mean and what criteria might be applied in deciding when treatments are futile. From here it is a short and familiar step to discussing futility in terms of the value of the outcome (evaluative futility) and futility in terms of whether treatment even offers the (reasonable) prospect of an outcome (physiologic futility). In practice it may be easy to muddle these two together but the basic distinction has a certain commonsense appeal. Patients waste valuable resources and doctors prostitute professional integrity by offering treatments that have no prospect of working.Therefore, physiologic futility implies that doctors say “no” and patients don't get asked—just told. Chapter four, pretentiously entitled The power of positivist thinking, is the central and most important chapter of this book. It is here that Rubin argues that the predictive claim of physiologic futility “always includes an evaluative component”. This conclusion is reached by caricaturing factual statements as “positivist” (the “autonomy of knowledge credo”), in contrast with a “social constructionist model”, while conceding that this theory and orientation is “not perfect”. We are not told how imperfect.

    The final chapter then argues that, despite all this, the author has “not argued against a physician's right ever to refuse, offer, provide or continue treatment desired by patients. Nor have I argued against society's role in setting limits”. The answer lies in society's involvement in setting the values within which medicine works. Treatment can be refused if there is an “overwhelming consensus” so that the doctor's refusal is socially sanctioned. The book ends with a useful 23-page bibliography, almost entirely American. Perhaps this is a largely American problem: the battleground of medical futility isn't where most professionals or patients are preparing for their biggest fights in Europe.

    The weakness of the book is its failure to convince the reader that the central thesis really makes any difference. For whether treatment is to be stopped because of an “overwhelming consensus” that it is useless or because it is “futile” will strike most doctors at the bedside as an irrelevant word game. It will presumably still involve the doctors' collective or individual values insofar as these determine the acceptance of overwhelming consensus. Medicine is a moral enterprise and the book would have been better balanced if that had been explored in more detail. Instead there is: the impression of a crude epistemology that contrasts positivism with “social constructivism”, as if that is all that philosophy can offer; inelegant English; intrusive use of the first person, and a failure by the author to answer the objections to her thesis already in print, included in the bibliography, and, indeed, reviewed previously in this journal. Rubin has offered an interesting read but not a balanced one.

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