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quality of life. The researchers commented that the degree of predictive error that is generally “acceptable” reflects the value placed upon an individual human life in a particular culture or society. For that reason, they suggested that the APACHE II score should not “necessitate” withdrawing treatment, but rather “focus the attention” of the doctor and the patient’s surrogate on discussing “in a more informed fashion” the nature of the condition. They concluded that treatment should be withdrawn only if “this was in the patient’s best interests.” Because a formula for futility seemed impossible to devise, the authors invoked the principle of beneficence, the “best interests” of the patient.

The decision to stop treating a patient is one of the most agonizing in medicine. Doctors don’t give up on many of the sickest patients for the sake of the few like Omar who will survive catastrophic illness and return to life.

Boris Veysman, a senior emergency care physician at the University of Medicine & Dentistry of New Jersey, wrote in 2010 in the journal Health Affairs of his own changing attitude about the meaning of futility: “In my role as a doctor, I’ve met countless disabled, disfigured, machine-supported people who enjoy living and wish to continue doing so as long as possible. I’ve met intensive care survivors who lead full, productive lives, often with few or no memories of their ordeals and heroic procedures because their sedation was done correctly. . . .

“Life is precious and irreplaceable. Even severe incurable illness can often be temporarily fixed, moderated, or controlled, and most discomfort can be made tolerable or even pleasant with simple drugs. In chess, to resign is to give up the game with pieces and options remaining. My version of DNR is ‘Do Not Resign.’ Don’t give up on me if I can still think, communicate, create, and enjoy life. When taking care of me, take care of yourself as well, to make sure you don’t burn out by the time I need your optimism the most.

“It’s so easy to let someone die, but it takes effort, determination, and stamina to help someone stay and feel alive.”

Ayesha shared this view. “Whatever might be lifesaving,” she told us, “I wanted for Omar. So long as the doctors believed there was even a small chance to save his life, it was worth trying. Everything else was secondary.”

Of course, such care is expensive. Some health care economists and policy planners seek a monetary cutoff that will clearly dictate whether to start or continue costly treatments. But Michael K. Gusmano and Daniel Callahan of the Hastings Center in New York, who have extensively studied the ethics of medical economics, point out in a 2011 Annals of Internal Medicine article, “What may be a good value for money for a sick person may not be good value for other members of society.” So where do you draw the line? Gusmano and Callahan continue, “Formal economic evaluations try to address this issue by adopting explicit standards that specify and place limits on the economic value of health benefits. Yet . . . setting the standard is crucial and problematic.”

The standard that has been most widely proposed is the quality-adjusted life year (QALY). A QALY is a measure of one year of added life adjusted up or down for the quality of life during that year. In the United Kingdom, the National Institute for Health and Clinical Excellence (NICE) relies on the QALY in determining whether a new treatment will be approved for general use. Although NICE does not have an explicit monetary cutoff, it tends to use a cost-per-QALY amount between £20,000 (about $30,000) and £30,000 (about $42,000) in order to approve a new drug or device.

Although one year of life is an objective measure, critics of QALYs have pointed out that the quality of life for any individual during that year is clearly subjective and can’t be assessed accurately by using any currently available method. Paul Dolan, a professor of economics at Imperial College London, contends that the approach NICE uses to formulate QALYs is flawed. Healthy people are