A War of All Against All? Futility, Value Impositions, and Professional Norms

Defining and applying 'futility' has proven to be a contentious endeavor within bioethics. So contentious that our vocabulary about and conceptualization of futility have shifted to the use of 'potentially inappropriate' or 'non-beneficial' treatment. A longstanding concern has been that futility determinations are in no way objective and are instead a subjective, values-based determination. Recent scholarship has highlighted the relation of the undecided nature of futility to the problem of values imposition. Specifically, Autumn Fiester has argued that futility laws and policies can become an exercise of the 'tyranny of the majority'; the values system(s) of physicians become pitted against the values system(s) of normative minorities. In light of such critiques, I argue that futility determinations are more properly seen as an exercise of a professional objection to non-beneficence. Such a framework is distinct from conscientious objection, which generally centers an individual, as it takes into account the particular moral community(-ies) that shape understandings of futility. That is, I consider whether what is happening in futility determinations, and any subsequent disputes, is best described as a result of the medical profession's values system(s) and the moral significance of such a system. I further consider how specific institutions may legitimately give rise to divergent, localized understandings of futility that may provide a path forward in navigating futility disputes. Overall, I argue for a reframing of futility that seeks to recognize the practice for what it is and allows for a path forward without concealed values impositions.