We appreciate the thoughtful comments of the readers. Several, however, seem to misunderstand our position. We completely agree that "physiologic futility" is not value free. We also completely agree that "futility policies" that are based on the concept of physiologic futility will be useful only in very few cases.

Our central point is that any concept of futility implies an objectivity and neutrality toward values that is misleading. Although the notion of "physiologic futility" perhaps comes closest to achieving these features, we recognize that it is also inherently flawed.

We certainly agree with the readers that many of the treatments currently provided to patients are inappropriate and should not be used. We disagree, however, on the ways in which these refusals to treat should be justified. As several of the readers observe, after we acknowledge that these decisions to refuse therapy always involve competing values, it becomes clear that these conflicts must be resolved in a way that addresses these diverse values. This approach requires societal involvement and a dialogue between the medical profession and the community. As a result of this process, the questions are placed within a different framework. Instead of asking whether a treatment "works" (the futility question), we more appropriately ask whether providing a treatment is fair and reasonable under the particular circumstances. The concept of futility does more to muddle and confuse these issues than it does to resolve them.