I thank Hunfeld and Skrobik for their critical contribution [1] to the article recently published in Intensive Care Medicine [2]. I agree with the authors that a precise prognostication of survival in critically ill patients—specifically, at the beginning of treatment—based on ‘prognostic scores’ is hardly possible, and it is determined by several subjective factors. The special ethical responsibility of medical profession prohibits—as the authors state—that decisions on therapy reduction or withdrawal could be based on ‘scores’ or simple prognostic models. Estimation of death calculated by numerals derived from failing organs or other clinical determinations may be unethical. On the other hand, medical action is based on the four principles of autonomy, non-maleficence, beneficence, and justice [3]. Furthermore, the Geneva declaration of the World Medical Association stated: I will respect the autonomy and dignity of my patient.
Hence, the medical indication and the patient’s will build—as twin pillars—the ethical guidelines for physicians. A medical indication can be defined as the reasonable professional judgement that a therapy offer is suitable and useful to reach a specific therapeutic goal with a certain probability [4]. Both these columns are helpful to avoid futile treatment in critically ill patients, where futility is defined as a treatment strategy to prolong the lives of terminally ill patients even when there is no hope for successful treatment of their underlying pathology [5]. In a prospective study on 6916 assessments by 36 critical specialists of 1136 patients, it was found that 11% of patients were perceived as receiving futile treatment [6]. Futility results in overtreatment, as diagnostic and therapeutic measures do not improve the length or quality of life of the patients.
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Since worldwide healthcare systems—and, specifically, intensive care medicine as a high-tech, high-cost paradigm for modern medicine—contribute substantially to anthropogenic greenhouse gas emissions, and the current climate crisis becomes more and more threatening, the avoidance of futile treatment entails not only a challenge for medical ethics, but, in addition, important eco-ethical aspects. I agree with Hunfeld and colleague that the assessment of medical futility is a complex, ambiguous, subjective, situation-specific, value-laden, and goal-dependent concept [6], which needs a careful, respectful, and responsible approximation on the basis of a multiple eyes principle.
In summary, careful and responsible awareness for the validity of medical indications and the patient’s will is substantial. The climate crisis is a concrete threat for humans, and yet, avoidance of harm—be it by promoting planetary health, or by avoidance of overtreatment or futility—will be more in the focus of physicians worldwide.
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Conflicts of interest
The author declares no conflicts of interest.
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