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Applying futility in psychiatry: a concept whose time has come
  1. Sarah Levitt1,2,
  2. Daniel Z Buchman3,4,5,6,7
  1. 1Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
  2. 2Department of Psychiatry, University Health Network, Toronto, Ontario, Canada
  3. 3Department of Bioethics, University Health Network, Toronto, Ontario, Canada
  4. 4Joint Centre for Bioethics, University of Toronto, Toronto, Ontario, Canada
  5. 5Centre for Addiction and Mental Health, Toronto, Ontario, Canada
  6. 6Krembil Research Institute, Unviersity Health Network, Toronto, Ontario, Canada
  7. 7Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
  1. Correspondence to Dr Sarah Levitt, Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, ON M6G 1A5, Canada; sarah.levitt{at}


Since its introduction in the 1980s, futility as a concept has held contested meaning and applications throughout medicine. There has been little discussion within the psychiatric literature about the use of futility in the care of individuals experiencing severe and persistent mental illness (SPMI), despite some tacit acceptance that futility may apply in certain cases of psychiatric illness. In this paper, we explore the literature surrounding futility and argue that its connotation within medicine is to describe situations where patients (or their substitute decision-makers) believe that interventions will almost certainly provide no meaningful benefit. We then provide two arguments in support of the use of futility within the care of individuals experiencing SPMI: that some SPMI can be considered a terminal illness, and that the risk-benefit ratio is a dynamic entity such that futility can help describe what Gillett calls the ‘risk of unacceptable badness’ when it comes to considering how an intervention might impact a patient’s quality of life. We posit that capacity should not pose an obstacle to declaring futility when caring for individuals experiencing SPMI and explain how futility is not antithetical to recovery in mental health. Finally, we describe how using futility within psychiatric practice can allow for a reorientation of care by signalling the need to shift to a palliative approach.

  • Palliative Care
  • Psychiatry
  • Quality/Value of Life/Personhood

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  • Contributors Both authors contributed equally to the development of the ideas in this paper. SL wrote the initial draft of the paper and was responsible for revising it. DZB provided substantial feedback towards developing the initial submission, as well as support for the revisions.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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