All elements of the base MFM and its valuation should be open to examination. Clearly this requires discourse. Although not absolute,26
the power to value the MFM has moved more and more towards the patient. This is because the objective of the doctor–patient relationship is to promote the patient's welfare, and respect for patient autonomy is a powerful and effective way to achieve this goal. This accords with general medical professional values.27
As between doctor and patient in English law, only if both valuations agree that there is likely to be net benefit gain can the defined intervention be delivered.22,26,28,29
This power to value can be usurped by the doctor in two ways. Firstly, this can arise if the doctors exercise their power over the assessment of linking probabilities to adjust down the probability of reaching a particular positive outcome and adjust up the probability of reaching a particular negative outcome. Such recalculations have the effect of moving the power of decision towards the doctor. If the doctor makes the judgement that the material linking probability is not alterable by a defined intervention, then even if the patients make their valuation of the relevant material outcome state infinite the doctor can refuse treatment on the grounds of goal futility. This translation of value futility to goal futility amounts to a shift in power over determining the choice of treatment.
The second way in which the power to value can be usurped is by the doctor deploying personal values under the guise of general professional values. Although personal values may give grounds for conscientious objection, I would submit that they should not be deployed in valuation of the MFM for the purposes of determining the likely net gain in benefit. The problem here is that it is difficult to detect such covert deployment of personal values and that general professional values are often less than clear and explicit when applied to particular medical situations.
A conflict could also arise where there is a dispute over the choice of the defined goal of treatment. This may arise where, for example, a doctor has usurped the power to value the MFM. In this case, a patient striving to regain power over the final decision may seek to redefine the defined goal of treatment. For example, in Spritz's case mentioned earlier, if the doctor had not agreed to the defined goal of treatment, such a conflict could have arisen. Interestingly, we can see here how the concept of physiological futility remains vulnerable to the charge of being value loaded precisely because it claims control over the definition of the defined goal of treatment, where this can be disputed.6,30
Other options are available to the patient. One is to place infinite value on the fact of intervention alone. This effectively translates the defined goal of treatment from the achievement of a particular outcome state into mere delivery of the defined intervention. This effectively removes the linking probabilities from the equation and disempowers the doctor. This is the “it will make me feel much better just knowing you will try” argument. Another option is to try and re‐evaluate the linking probabilities. This can be via a second medical opinion or through personal research. This approach is particularly effective when the degree of uncertainty surrounding the linking probabilities is great.
This analysis shows a fine balance of power at the heart of the doctor–patient relationship in relation to questions of futility. If we regard medicine as a mutually cooperative exercise with the aim of objectively benefiting patients, then this may not be a bad thing. Given this fine balance, conflicts will almost inevitably arise on occasion.1
Methods of conflict resolution lie beyond the scope of this paper,31
but the point here is that use of the MFM allows a clearer analysis of the actual situation and may allow a route through the minefield to be identified. The requirement to agree on the defined goal of treatment before making a declaration of futility should force doctors to deal with this heretofore hidden issue of value. If accepted into clinical practice, this should reduce both the giving of unnecessary treatments and the risk of substantive conflicts arising.
A role for third‐party ethical input at this level32
exists, and perhaps a method should be developed to generate valuation sets that are more useful to practising clinicians (eg, case‐based reasoning). The benefit for doctors is that such third‐party input can assure appropriate deployment of values, improve transparency of decision making and buttress the public perception of physician integrity.