Medical futility: legal and ethical aspects

I welcome the long-overdue recognition of medical futility represented by the contributions of Koch, et al., Miles, and Dew [in this issue of Law, Medicine and Health Care], although I would be more comfortable with using the more global (and optimistic) term of "beneficence." However labeled, the notion that medical treatment decisions are primarily that -- medical decisions -- is a far more appropriate starting point in both law and ethics than the customary departure point of patient autonomy. This is particularly true in cases in which the patient is not competent, and prior expressions of intent are remote, vague, or otherwise unreliable. Despite such flaws, prior statements have been invested with a talismanic quality, permitting avoidance of the genuine moral issues of duty and benefit that are presented by every severely ill and incompetent patient.