Introduction to the Special Issue

In the summer of 2017, much of the world was riveted by the case of Charlie Gard, a baby in London whose parents wanted an experimental treatment and whose doctors thought that further treatment would be futile. The case worked its way through the British courts and, eventually, was even heard by the European Court of Human Rights. Pope Francis and President Trump weighed in. If nothing else, the case revealed how controversial the issues around medical futility and shared decision-making still are.

Many ethical issues resolve over time. Discussions about disagreements lead to discovery of common ground. That doesn’t seem to be the case with the issue of medical futility and, particularly, with the appropriateness of unilateral decisions by doctors to withdraw life support over the objections of patients or family members. Thirty years of debate and discussion, thousands of articles, and numerous court cases seem to have sharpened, rather than softened, disagreements. States have different laws regarding these issues. Some permit unilateral treatment withdrawal. Others strengthen the power of patients and families to resist such unilateral choices. Hospitals have policies, but the policies differ.

Recently, several critical care societies tried to hammer out a consensus on these matters (Bosslet et al. 2015). Not everyone agreed with their conclusions. Larry Schneiderman and colleagues sent us a paper in which they took issue with some aspects of the professional societies’ consensus statement. In this issue, we are publishing that paper. But we wanted to put it into a larger context. So we invited scholars to respond to the Schneiderman paper. The scholars who answered the call were people who had previously written about futility, unilateral DNR orders, or other aspects of this debate. Some were on the task force that wrote the paper for the critical care societies. In this issue, we present the Schneiderman response to the Multiorganization Policy Statement, Bosslet and colleagues’ reply, and 20 additional commentaries.

It is clear from these papers that many people have strong feelings and deeply held moral convictions about futility. The commentaries vary in tone, length, and focus. Taken together, they constitute a powerful discussion about what matters in the debates taking place among doctors, nurses, patients, and family members in hospitals, courtrooms, legislatures, and Twitter chats around the world.

We hope that these thoughtful analyses of the futility controversy will be useful for practitioners, policymakers, patients, and families as they all struggle to do the right thing when medical treatment is unlikely to benefit a critically ill patient.