When Doctors Say No: The Battleground of Medical Futility

In this extensively researched and footnoted dissertation, Rubin, a medical ethicist, argues that medical futility--a concept hard to pin down case by case--cannot be used by physicians as grounds for refusing to provide treatment, and that patients (or their surrogates) have the right to insist on procedures or care a physician deems futile. She clarifies early on, however, that ""[t]his is not a book about the broad problem of the need to set limits in medicine, to ensure the just allocation of our health care resources... or contain or reduce costs."" Instead, Rubin considers what sorts of situations constitute futility from evaluative (where doctors make judgment calls) and physiological perspectives, and proposes a framework for physician-patient discussion concerning patient demands. The book is a fine addition to the world of academic medical ethics, but only lays the groundwork for a more vital discussion, of the ethics of rationing in health care. The economics of providing futile care are only briefly discussed, and the reader needs to have more than a cursory understanding of ethical concepts, as some are defined (autonomy, fidelity) but others are not (nonmaleficence, beneficence). Readers looking for a book on the healthcare industry's impact on futility-based decision-making will not find answers, but will come away armed with some of the tools for further debate. (Nov.)