Paternalistic "Handling" of Medical Futility Cases

In a forthcoming article in HEC Forum, Colleen Gallagher and Ryan Holmes describe how medical futility cases are handled at the University of Texas MD Anderson Cancer Center.  While most of their advice is good and standard fare, I was a little concerned by one suggestion.

The authors note that they rarely use the formal TADA mechanism.  That is fine.  Other Texas facilities similarly report that less formal mechanisms are usually (though not always) sufficient to resolve futility disputes.  What concerns me is one of the authors’ other "suggestions for community physicians."  Gallagher and Ryan write: "do not offer options that are not medically appropriate."  They explain that physicians should offer only "reasonable options."  They should not offer: (a) treatments with "slim chances," (b) "treatments with high risk-to-benefit-ratios, (c) "treatments with "a low likelihood of achieving notable results," or (d) treatments the physician does not "feel comfortable in offering." 

In July, I wrote about "illusory consensus."  I think that concept applies here.  Following Gallagher and Ryan may avoid conflict.  There may be agreement and consensus.  But it is conditioned on deception.  

I agree that providers should not offer false hope.  But preventing or resolving conflict by withholding options and information is very dangerous.  It is especially dangerous because there are few lines (medical or ethical) that clearly separate the medically appropriate options from the medically inappropriate options.  That lack of definition is a constitutive feature of medical futility.  Gallagher and Ryan propose dealing with medical futility situations by pretending that there is literally nothing more that can be done.  This gets too close to constituting a hard paternalistic abandonment of informed consent.