To the editor

I read with interest a position of the Polish Society of Internal Medicine Working Group on Medical Futility at Internal Medicine Units (WG) regarding the avoidance of medically futile therapy in patients dying in a hospital.1 Regulations in this matter are undoubtedly necessary. The content of the position, however, raises several doubts. I will point out only some of them. They are closely related to each other.

Firstly, the authors suggest that the concept of medical futility is similar to the concept of persistent therapy. They replace the term “persistent therapy” with the term “medical futility” but retain the content of the definition of persistent therapy developed by the Polish Working Group (PWG) in 2008.1 Such a substitution does not seem entirely appropriate. The terms have different origins and relate to different ethical and anthropological assumptions.2 The narrowest understanding of medical futility (physiological futility) is an intervention that cannot accomplish its intended physiological goal.3 In contrast, the broadest understanding of medical futility involves qualitative and quantitative criteria. These criteria go beyond strictly medical ones.2 The content of the PWG’s definition of persistent therapy seems to converge with physiological futility only because it was limited to terminally ill patients who suffer excessively and die. For this reason, it was criticized.4 It should be emphasized, however, that a much broader meaning of persistent therapy is contained in the Catechism of the Catholic Church. This definition refers to a greater number of criteria than the PWG’s definition, especially to the subjective preferences of a patient (or their surrogate).4 It is questionable to assume that persistent therapy or medically futile therapy, as described by the members of the WG, only applies to dying patients. In the literature, the term “medical futility” has a wider application in medical practice than in the position published by the WG. It is not ruled out that, under certain conditions, both categories (“medical futility” and “persistent therapy”) may prove helpful in medical practice.4

Secondly, it appears that the authors have modified the content of the PWG’s definition of persistent therapy. Instead of the term “patient’s good,” they use the term “patient’s best interests.”1 Such a substitution does not seem appropriate. The expressions used here are not semantically identical. The patient’s good is closely related to the respect of dignity.5 Dignity points to the inherent and inviolable value of a human being. In practice, this means that human life does not lose its value even if the quality of life is low. Dignity serves as an objective and primary criterion for the moral assessment of actions (including medical interventions) concerning an individual. It can be said that the criterion of dignity protects human life from instrumentalization and utilitarian calculation. In contrast, the “best interest” criterion plays an important role in medical and legal decision-making (eg, in the United Kingdom), especially when the patient is unable to express their own will. It is assumed that the best interest includes “consideration of the person’s past and present wishes and feelings, and their values, beliefs and any other factors they would consider relevant to their decision if they were able to do so […], but also puts weight on all the relevant circumstances […], which might— and, in practice, regularly do—include diagnosis, prognosis, and sanctity of life.”5 None of the factors mentioned has a privileged position. This means that, as a result of balancing various criteria, a medical intervention may, for example, be deemed futile based on a low quality of life.5 It is not clear why the members of the WG introduce the term “best interest” into the PWG’s definition or how they understand it.

Finally, the WG’s position is characterized by a paternalistic approach. The final decision regarding withholding or withdrawing therapy belongs to a physician (medical team). The patient’s family has limited say in this matter. The WG members maintain that “the aim of the meeting is not to obtain permission from the family to implement or withdraw from medical interventions, as from a legal perspective their opinion is irrelevant.”1 It seems that a paternalistic approach is appropriate only when therapy does not allow for accomplishing its intended physiological goal. An expert in assessing such a therapy is a physician. When nonmedical factors are considered in the assessment of futility, however, the patient or their family should also have a right to have their opinions considered.4 The paternalistic standard is not widely accepted when assessing medical futility. Confirmation of this view is provided, for example, by guidelines proposed by various medical associations aimed at resolving disputes between a physician and a patient (family) based on multistep procedures.3 It appears that at least some of the solutions proposed by Bosslet et al3 could be adapted in Poland.