Why the words we use matter
By Howard Brody
“Family vows to fight futile-care law,” said the headline in the May 9 Houston Chronicle. This seems like an innocent and neutral statement. Let me explain why it might be profoundly misleading.
The article went on to say that the family of a woman who recently died, for whom the hospital earlier had tried to stop various measures its medical staff regarded as futile, was determined to battle the Texas statute that allows physicians and hospitals to invoke the “futility” doctrine.
The proper role of “futility” in end-of-life medical care is controversial. Some argue that the Texas law takes away the rights of patients and their families, threatening the vulnerable in an era when cost-cutting, not treatment, seems to be the rule. Others hold that physicians are professionals, not vending machines that dispense treatment at the buyer’s whim. Professionals should have the prerogative not to perform interventions that, based on their best scientific judgment, won’t improve the patient’s condition.
Rather than trying here to resolve this thorny debate, I want to show that it matters which words we use to describe the question. Certain language seems neutral but has the effect of handing the victory to one side before the discussion is fully joined.
Those who most strongly oppose the “futility” concept, such as attorney Wesley J. Smith in his book, Culture of Death, refer to the position underlying the Texas law as “futile care theory.” It is also common to hear mention of “futile treatment.”
The problem with these innocent-sounding phrases is that they immediately introduce an apparent contradiction. What, for instance, does a hospice program do when a patient is clearly dying and no “cure” of the disease is possible? The hospice team provides care. They know that the patient will die no matter what they do.
But they would bristle at the idea that what they are doing is somehow futile.
Similarly, we call something a medical “treatment” because it has the presumed potential to treat something. So care and treatment, by definition, sound like things that work. If they do not cure the disease, it simply shows that the right sort of medicine can provide a lot of benefit, even in cases that are incurable.
So calling anything “futile care” or “futile treatment” sounds like an oxymoron. It’s like calling something “useless help.”
When hearing something called by a name that makes it sound self-contradictory from the get-go, what does a sensible person conclude?
Most likely that the idea doesn’t hold water. So when we use terms like “futile care” and “futile treatment,” we effectively hand the victory in the debate to those who oppose the concept of medical futility.
Consider, on the other hand, the question of whether a patient with end-stage heart, kidney, and lung disease who is virtually certain to die within two or three days no matter what is done, would get any real benefit from being sustained on a ventilator in an intensive care unit, or being hooked to a kidney machine. If the physician said that these methods “would not work” for this patient in this circumstance, we’d understand exactly what she was saying.
Whenever I write about the debate over medical futility, I try to always use the term, “futile interventions.” While it may sound unnecessarily complicated, it maintains a level playing field and allows a fair discussion to go forward.
So by all means let’s debate the Texas law. But let’s not use terminology that dismisses the debate before it starts.
Howard Brody, M.D., Ph.D., is director of UTMB's Institute for the Medical Humanities.