For personal use. Only reproduce with permission from The Lancet Publishing Group. THE LANCET Oncology Vol 3 October 2002 http://oncology.thelancet.com 638 The concept of futility has often been invoked to justify abstention from treatment and decisions such as ‘do not attempt resuscitation’ (DNAR). In this capacity, futility has played an important part in the development of several sets of official clinical guidelines. In this paper, we examine the nature of futility and question whether it is a sufficiently robust concept to meet the ethical and clinical demands placed upon it. Although the concept of futility promises simplicity, it cannot stand alone as a satisfactory frame- work for clinical decision-making. Practitioners and policy makers should be cautious about their use of the concept. Lancet Oncol 2002; 3: 638–42 Decision-making about cardiopulmonary resuscitation (CPR) is at the centre of many complex converging debates in medical care. First, how can we best balance the therapeutic advances, which are available increasingly late in disease progression, while maintaining a focus on quality of life, and on death as a natural process? Second, how should we balance respect for patient autonomy in the current healthcare climate, and the need to ensure clinical effectiveness and the efficient use of limited resources? And third, where do guidelines leave doctors, morally and legally, in terms of clinical discretion? In this article, we aim to provide an overview of current thinking on medical futility, with particular regard to decisions about CPR in UK-based patients with cancer. We hope to show that the concept of futility is just one of a number of ethical considerations in resuscitation decision- making, rather than a panacea which renders the other aspects irrelevant (figure 1). However, by focusing on futility we have not attempted to cover all the other ethical dimensions of the resuscitation debate comprehensively. Cardiopulmonary resuscitation CPR was first developed in the 1960s to treat cardiac arrest secondary to reversible medical conditions (figure 2). The early success of this technique, coupled with its ease of use, led to the application of CPR to patients who were critically ill; however, success in this population was more variable. Patients given poor prognoses before they experienced cardiac arrest fared particularly badly, 1 leading to concerns that CPR was inappropriate and potentially damaging for this group. Institutional policies about use of CPR were established in the USA during the 1970s 2 and in the UK during the 1990s. 3 Such guidelines, along with others concerning end- of-life decision-making, gave the concept of futility an important role in clinical decision-making. 4,5,6 Recently, however, there has been a tendency to shy away from using the word ‘futility’ because, although health professionals are familiar with the concept of not providing ‘futile’ treatment, defining what constitutes ‘futility’ is more difficult. 7 In the past few years, there has been debate among biomedical ethicists about the usefulness (or otherwise) of the concept of futility. Such debate has been poorly covered in the oncological literature—less than 1% of publications about futility have been published in cancer journals. 8 What is futility? A review by Schneiderman and collegues 9 stated that “a futile action is one that cannot achieve the goals of the action, no matter how often repeated”. The article also offers an illustration of futility by recounting the Greek myth of the daughters of Danaus who were condemned to cool themselves from the fires of hell by drawing water with leaky sieves. Indeed, ‘futility’ derives from the Latin word ‘futilis’ meaning leaky. Personal view Futility and clinical decision-making SK is Consultant in Palliative Medicine at the Leeds General Infirmary and Cookridge Hospitals, Leeds, Yorkshire, UK. SW is a lecturer in Philosophy at Keele University, Staffordshire, UK. Correspondence: Suzanne Kite, Palliative Care Team, Old Nurses’ Home, Leeds General Infirmary, Great George Street, Leeds, Yorkshire LS1 3EX, UK. Tel: +44 113 392 2928. Fax: +44 113 392 2177. Email: suzanne.kite@leedsth.nhs.uk Beyond futility: to what extent is the concept of futility useful in clinical decision-making about CPR? Suzanne Kite and Stephen Wilkinson Figure 1. A futile action can never achieve its goals.