In this cluster, we define a group of concepts relating to ‘Appropriate/Inappropriate’, including ‘Necessary’, ‘Unnecessary’, ‘Medical necessity’ and ‘Futile/Medical futility’.


A procedure is termed appropriate if its benefits sufficiently outweigh its risks to make it worth performing, and it does at least as well as the next best available procedure. A procedure is termed inappropriate if the risks outweigh the benefits.

Source: Kahan JP, Bernstein SJ, Leape LL et al (1994) Measuring the necessity of medical procedures. Medical Care 1994; 32: 352-365.

An appropriate service is one that is expected to do more good than harm for a patient with a given indication or set of indications. An inappropriate service is one that is not expected to benefit the patient or, in the more extreme case, may harm the patient. An equivocal service is neither clearly appropriate nor clearly inappropriate. The appropriateness of the setting in which care is provided is related to cost-effectiveness. This type of appropriateness is determined by whether the patient’s clinical characteristics, and the services required for his or her care, match the setting in which the care is provided. Setting is a proxy measure of the resources used to provide care. Just as effective care can be provided in a way that is not cost-effective, appropriate services can be provided in inappropriate settings. When appropriateness of setting is considered, it is assumed that the services are appropriate and are provided in a technically correct way.

Source: Lavis JN, Anderson GM (1996) Canadian Medical Association Journal 1996; 154(3): 321-328.

Two examples of the term in use:

In many places, relatively junior staff are responsible for patients’ initial assessment, leading to avoidable delays in reaching a diagnosis or developing a management plan and, in some cases, to lengthy detours before patients eventually reach the service that is appropriate for them.

Vaughan L, Edwards N, Imison C, Collins B (2018) Rethinking acute medical care in smaller hospitals. Research report October 2018. Page 32. The Nuffield Trust.

Many health determinants reside outside the health care system, but those that reside within should be distributed equitably and should conform to high-quality standards. Society, through the government, should guarantee equal access to appropriate preventive measures and high-quality treatments to the extent possible.

Ruger JP (2008) Ethics in American Health 2: An Ethical Framework for Health System Reform. American Journal of Public Health 2008; 98(10): 1756-1763. doi: 10.2105/AJPH.2007.121350


We define a procedure as necessary – or crucial – if all four of the following criteria are met:

  • The procedure must be appropriate, as defined … .
  • It would be improper care not to recommend this service.
  • There is a reasonable chance that the procedure will benefit the patient. Procedures with a low likelihood of benefit but few risks are not considered necessary.
  • The benefit to the patient is not small. Procedures that provide only minor benefits are not necessary.

 Source: Kahan JP, Bernstein SJ, Leape LL et al (1994) Measuring the necessity of medical procedures. Medical Care 1994; 32: 352-365.

Example of the term in use:

… we found that the specialty of a patient’s “regular source of care” is related to whether the patient undergoes clinically necessary coronary angiography. Patients of cardiologists were more likely to obtain the needed care.

Borowsky SJ, Kravitz RL, Laouri M, Leake B, Patridge J, Kaushik V et al (1995) Effect of physician specialty on use of necessary coronary angiography. Journal of the American College of Cardiology 1995; 26; 1484-1489.


“Unnecessary” means that a particular patient is very unlikely to benefit from the treatment because they don’t have the disease or symptom it’s intended to diagnose or treat, or because the possible harms of treatment outweigh the possible benefits.

Source: Lown Institute [Not dated; accessed 8 January 2019] Overuse 101. What is overuse?

Example of the term in use:

Prescribing unnecessary medical tests, procedures, hospitalizations and surgeries has become an epidemic worldwide. The rates of caesarian sections, for instance, vary widely. While globally the C section rate in public hospitals is 10 percent, it reaches an alarming 98 percent in Brazil’s private hospitals, and 40 percent in private hospitals worldwide.

The World Bank. Is that surgery really necessary? Ensuring the Medical Necessity of Care. July 31, 2014.

Medical necessity

The following definition is typical of the approach taken in defining medical necessity in 1995 Blue Cross plans: “Services or supplies which are required for treatment of illness, injury, diseased condition, or impairment and are consistent with the patient’s diagnosis or symptoms; appropriate treatment according to generally accepted standards of medical practice; not provided only as a convenience to the patient or provider; not investigational or unproven; not excessive in scope, duration or intensity; provided at the most appropriate level of service that is safe.”

Source: Bergthold LA (1995) Medical Necessity: Do We Need It? Health Affairs 1995; 14(4): 180-190.

Example of the term in use:

We refer to a surgery as cosmetic eyelid surgery when the surgical procedure of removing excess skin from the upper eyelids along with any excess muscle or fat as required is not a medical necessity and is performed solely to improve the appearance of the eyes and make the patient look more beautiful and younger.

Oliver J (2017) Functional eyelid surgery. Clinica. April 19th, 2017.

Futile/Medical futility

“Medical futility” refers to interventions that are unlikely to produce any significant benefit for the patient. Two kinds of medical futility are often distinguished:

  1. Quantitative futility, where the likelihood that an intervention will benefit the patient is exceedingly poor, and
  2. Qualitative futility, where the quality of benefit an intervention will produce is exceedingly poor.

Both quantitative and qualitative futility refer to the prospect that a specific treatment will benefit (not simply have a physiological effect) on the patient.

Futility does not apply to treatments globally, to a patient, or to a general medical situation. Instead, it refers to a particular intervention at a particular time, for a specific patient. For example, rather than stating, “It is futile to continue to treat this patient,” one would state, “CPR would be medically futile for this patient.”

Source: Jecker NS (2014) Ethics in Medicine. University of Washington School of Medicine. Last date modified: March 14, 2014.

Example of the term in use:

In the course of caring for a critically ill patient it may become apparent that further intervention will only prolong the final stages of the dying process. At this point, further intervention is often described as futile.

Council On Ethical And Judicial Affairs, American Medical Association (1999) Medical futility in end-of-life care. Report of the Council on Ethical and Judicial Affairs. Journal of the American Medical Association 1999; 281: 937-941.

The debate on medical futility can lead to a fresh revisiting of the doctor-patient relationship and with it a restoration of common sense and reality to society’s perception of the powers of medicine.

Sneidermann LJ, Jecker NS (1995) Wrong Medicine. Doctors, Patients and Futile Treatment. Page 171. Johns Hopkins University Press.