Waisel and Truog [1] give examples of four hospitals' CPR-not-indicated policies and then provide three proposals for discrete conceptual views of such policies. Although I appreciated the clear and thought-provoking review of issues related to futility, I question their definition of physiologic futility, which states that "CPR is futile only if it is impossible to do cardiac massage and ventilation." It is possible to envision instances in which it is physically possible to do cardiac massage and ventilation but not possible to achieve the proximal physiologic objectives of CPR. Physiologic futility may be more closely related to the impossibility of achieving the goals of CPR, such as effective cardiac muscle contraction that produces circulation adequate to supply vital organs and pulmonary gas exchange to remove waste CO₂ while supplying sufficient oxygen to vital organs. Is not CPR futile in patients in whom these objectives cannot be expected to be met but in whom cardiac massage and ventilation are physically possible?

Another question relates to the statement that "economic factors should be considered only if ... a reasonable guarantee exists that the money saved with this policy benefits other medical causes." This statement probably represents a value judgment, common among physicians, that may not be shared by some or even most members of society. Little doubt exists that medical care and health are valued highly in our society; however, other things are also highly valued, including education, national defense, and safety from crime. Depending on current conditions, society's concept of a desirable proportional allocation of scarce resources among highly valued causes may shift. In some circumstances, might not medical resources conserved by any "rationing" of CPR actually be best used to "benefit other causes"?