Medical futility is a controversial topic. Many bioethicists claim it is wrong to use the term "futility," that this merely avoids making proper medical decisions. Others insist that some treatments are futile and so the issue must be squarely faced.

Intruding value issues lie at the heart of controversy. It may seem that medical futility is a simple matter of fact: a treatment either works or it doesn't. But "futile" is defined in terms of "benefit," and "effectiveness." Use of these labels involves a subjective call.

Who is to decide that a treatment is futile? This is the issue at the center of the futility debate.

Suppose that in the opinion of an oncologist no known treatment will work for a patient. For this oncologist, further treatment is judged futile since the usual goals of treatment are not possible to accomplish. Here "futile" is meant to indicate that there is no chance that treatment will work; it will provide no medical benefit. This is called physiologic or strict futility.

Of course, to say that a treatment will provide no medical benefit is extreme, at least in most cases. "No chance" more often really means, "little chance of working."

Quantitative futility is the term used when there is reason to believe that the chance of success can be stated numerically, such as 1 in 1000, or 1 in 50.

If the judgment of futility is made on quantitative grounds, controversy comes more clearly into view because values are at work here. Who gets to say what chance of success is enough of a chance to validate treatment?

In quantitative cases, values enter, even if only implicitly. The issue gets more controversial when we deal with another sense of futility called qualitative futility.

Some treatments clearly work. Technology can be used to keep someone alive in a persistent vegetative state (PVS), often prolonging life for many years. But this raises the question: is such a life worth continuing? Treatments are called qualitatively futile when they work yet leave a patient with an unacceptable quality of life. However, judgments about what is acceptable and unacceptable vary from person to person. A physician might think of a result as unacceptable that a patient or a patient's family would consider worthwhile.