In neonatal intensive care, disputes sometimes arise between families and clinicians over potentially beneficial life-prolonging treatment for a newborn infant. Parents strongly desire the treatment, yet health professionals judge that it would be futile. While professional guidelines support the concept of ‘medical futility’, there is no guidance on how to determine whether or when treatment would be futile.
In this paper, we explore the application of cost-effectiveness thresholds (CET), used elsewhere in public health systems, to the determination of resource-based futility in newborn intensive care. We outline briefly the concept of futility, and of cost-effectiveness assessment. We then draw on CET to explore sequentially a series of clinical questions. When is a patient’s chance of survival too low to provide expensive life-support? How long is too long to provide intensive life-prolonging medical treatment? What level of quality of life is too low for life- saving surgery to be provided?
This paper represents the first attempt to evaluate distributive justice based determination of futility in intensive care. It builds on careful analysis of existing empirical evidence as well as ethical argument. We identify and address major counterarguments to the use of cost-effectiveness in deriving futility thresholds for intensive care.
Conclusions: our analysis identifies key normative questions for resource-based treatment limitation decisions as well as key empirical data necessary to inform such decisions.