Third Year Medicine Clerkship
Medical Ethics Syllabus Chapter
CASE #1
A 91 year old woman was brought to the emergency
room because of syncope. She lost consciousness at the
adult home where she resides. In the ER, she was noted
to be minimally responsive, and had a heart rate of 30
bpm; her BP was barely palpable. She was treated with IV
atropine and isoproterenol. Her heart rate and BP
stabilized, and she became more alert. Cardiology
consultant recommended placement of a permanent
pacemaker. The patient was advised of this, and did not
voice any objection to a pacemaker. Her mental status
and level of consciousness at the time was noted as: "
awake, lethargic, quiet; somewhat confused".
A short time later, the patient's son arrived. He
was noted by the nurses to be "belligerent, with a
hostile attitude". He announced that he was the
patient's only relative, and that furthermore, he was her
"proxy". He presented a copy of her Health Care Proxy
(naming him as health care agent), and demanded that she
NOT have a pacemaker. He stated that his mother was
"obviously incompetent", and that he should be making her
medical decisions.
QUESTIONS:
1. What is the usual process for making medical
decisions? Which parties are ordinarily involved in
the decision making process, and what roles do each
of them play? How does that model apply to this
case?
2. Is this patient capable of making medical decisions?
Who should determine whether or not a patient is
capable? How does one go about making that
determination? If the patient is not capable, how
are decisions made?
3. What is the difference between competence and
decision making capacity? What are the implications
and consequences of this difference?
REFERENCES:
Appelbaum PS, Grisso T. Assessing Patients' Capacities to
Consent to Treatment. N Engl J Med 1988; 319:1635-8.
Hansen-Flaschen JH. In the Best Interests of Helga
Wanglie (Editorial). Hospital Practice 1992; Feb. 28. pp.
8-12.
Seckler AB, Meier DE, Mulvihill M, Paris BE. Substituted
judgment: how accurate are proxy predictions? Ann Int Med
1991; 115(2):92-8.
President's Commission for the Study of Ethical Problems
in Medicine and Biomedical and Behavioral Research
(1983). Deciding to forego life-sustaining treatment:
ethical, medical, and legal issues in treatment
decisions. Washington, D.C.: U.S. Government Printing
Office.
President's Commission for the Study of Ethical Problems
in Medicine and Biomedical and Behavioral Research
(1982): Making Health Care Decisions: the ethical and
legal implications of informed consent in the patient-
practitioner relationship, Washington, D.C., U.S.
Government Printing office, vol. 1: report.
The New York State Task Force on Life and the Law (1987):
Life Sustaining Treatment: making decisions and
appointing a health care agent.
The New York State Task Force on Life and the Law (1992):
When Others Must Choose: deciding for patients without
capacity.
CASE #2
A 62 year old woman was admitted in status
epilepticus. Her respiratory status was compromised and
she required intubation and ventilation. She had a past
history which was positive for Hodgkins Disease (6 year
ago; presently in remission), and lung cancer which was
fully resected 1 year ago.
She was weaned from the ventilator over the next few
days, and began to slowly improve. Her mental status was
noted to fluctuate widely. Whe was largely incoherent,
with occasional "lucid intervals." During one of those
intervals she was asked about life-sustaining treatments,
and reportedly told the housestaff to "do everything".
Much of the time however, she was described by the
housestaff as, "incompetent to make decisions."
After 3 days, the patient's respiratory status again
deteriorated, and the physicians contemplated re-
intubation. By this time, the patient's daughter arrived
from out of town, and brought in a copy of the patient's
"Living Will" (signed by the patient 10 years ago). She
also had a "Power of Attorney" (prepared one year ago)
naming that daughter as "Attorney in Fact". She demanded
that her mother NOT be re-intubated.
QUESTIONS:
1. What means do competent adults have to influence the
future medical care that is provided to them after
they have lost the capacity to make decisions? What
is the difference between an "Instructional
Directive" and a "Proxy Directive"?
2. What is the legal status of Living Wills in New York
State? What about other advance directives?
3. What decision making powers are delegated in a Power
of Attorney?
...a Durable Power of Attorney?
...a Durable Power of Attorney for Health Care?
...a Health Care Proxy?
4. How do you interpret a patient's request to: "do
everything", if they do not elaborate? Since
consent to treatment must be informed, what kinds of
discussions could clarify such a blanket request?
5. How do you resolve the apparent conflict between a
patient who wants "everything", and a relative who
wants to limit treatment? Does it make any
difference
...that the patient was vague in her statement?
...that she was intermittantly confused, and
possibly "incompetent"?
...that the relative has some legal
authorization to make (at least some type of)
decisions for the patient?
...that the authorization does not specifically
refer to health care decisions?
6. Some patients and families are concerned about
getting "stuck" on a ventilator for indefinite
periods of time. Do you share this concern? Is the
only way to avoid this outcome to forego intubation
in the first place?
7. Is there any ethical or philosophical difference
between a.) withholding life sustaining treatment,
and b.) starting it but withdrawing it later?
...any legal difference? ...any psychological
difference?
REFERENCES:
Barnett TJ. Limiting specific interventions in advanced
directives. JAMA 1992; 267(1):51-2.
Emanuel L. Advance directives: what have we learned so
far?. J Clin Eth 1993; 4(1):8-16.
Emanuel EJ, Emanuel LL. Proxy decision making for
incompetent patients. An ethical and empirical analysis.
JAMA 1992; 267(15):2067-71.
Greco PJ, Schulman KA, Lavizzo-Mourey R, Hansen-Flaschen
J. The Patient Self-Determination Act and the Future of
Advance Directives. Ann Int Med 1991; 115:639-643.
La Puma J, Orentlicher D, Moss RJ. Advance directives on
admission; Clinical implications and analysis of the
Patient Self-Determination Act of 1990". JAMA 1991;
266(3):402-5.
Lynn J. Procedures for making medical decisions for
incompetent adults. JAMA 1992;
267(15):2082-4.
CASE #3
A 78 year old man was diagnosed with prostate cancer
4 years ago. It has metastasized to his bones and lungs.
He has developed progressive bone pain as well as lung
congestion and shortness of breath. He presented to the
hospital with fever, and probably urinary tract
infection. He was successfully treated with antibiotics,
but complained of worsening pain.
He was given IV morphine with "minimal relief."
The housestaff documented that he was still in severe
pain at the "maximum dose of morhine". They also
reported that his breathing has become "slow and
shallow", while still remaining in pain.
QUESTIONS:
1. Is it appropriate to give further opioid, with the
knowledge that it will likely suppress his
respirations further? Are we then "responsible for
his death"?
2. How does opioid use for terminal pain (which
hastens death) differ from euthanasia or assisted
suicide?
CASE #3 (Cont.):
The patient was given more morphine with
considerable relief of his pain. His breathing remained
shallow, but adequate. Over the next 24 hours however,
he became more tachypneic and anxious. He cried out that
he was "suffocating".
QUESTIONS (Cont.):
3. What alternatives can you provide for relief of the
patient' symptoms?
4. Advances in knowledge about pain management and
palliative care have actually demonstrated that
concerns about respiratory depression are often
exagerated when treating pain. This is NOT the case
when treating severe dyspnea. While morphine
clearly relieves severe dyspnea, it will frequently
suppress respiratory drive and result in a sooner
death. Is this acceptable?
REFERENCES:
Berry ZS, Lynn J. Hospice medicine. JAMA 1993;
270(2):221-3.
Wanzer SH, Adelstein SJ, Cranford RE, et al. The
physician's responsibility toward hopelessly ill
patients. N Engl J Med 1984; 310:955-959.
Wanzer SH, Federman DD, Adelstein SJ, et al. The
physician's responsibility toward hopelessly ill
patients: a second look. N Engl J Med 1989; 320:844-849.
CASE 4.
A 90 year old female was admitted to a Buffalo area
hospital with abrupt unconsciousness 4 weeks ago.
Neurology diagnosed "massive brainstem stroke". She had
previously lived in a nursing home. Her only close
relative is a son who is named health care agent in a
Health Care Proxy the patient prepared last year. At
present (4 weeks following admission), she remains
unresponsive, and the neurologists offer little hope of
further significant improvement. She has received IV
fluids, but the son has objected to any enteral feeds. A
review of the Proxy reveals no statements about feeding
tubes, but the son emphatically states that he and his
mother had discussed this in the past.
QUESTIONS:
1. Are enteral feeding tubes different from other kinds
of medical treatment? Does anyone have the
authority to refuse feeding tubes for another
individual? ...for themselves?
2. Are enteral feeds "ordinary" or "extraordinary"
care? Is this distinction helpful in making
decisions about such care? How does one go about
categorizing a particular treatment modality in this
schema?
3. Is there any relevant distinction between the IV and
the proposed enteral feeding tube? Is it ever
appropriate to discontine all nutrition and
hydration? If so, under what circumstances?
REFERENCES:
Sullivan RJ. Accepting Death without Artificial Nutrition
and Hydration. J Gen Intern Med 1993; 8:220-224 (with
editorial:225-226).
Scofield GR. Artificial feeding: the least restrictive
alternative? J Am Ger Soc 1991; 39(12):1217-20.
Meyers RM, Grodin MA. Decisionmaking regarding the
initiation of tube feedings in the severely demented
elderly: a review. J Am Ger Soc 1991; 39(5):526-31.
CASE #5.
A 66 year old man with longstanding COPD was
admitted with pneumonia. He was treated with IV
antibiotics, inhaled bronchodilators, and nasal oxygen.
A DNR consent from his out-patient chart was brought to
the hospital and a DNR order was signed. Over the next
12 hours, he became more dyspneic. Arterial blood gas
analysis demonstrated rising CO2, and falling pO2. The
nurse called the resident on call, who felt the patient
required urgent intubation. The resident then noted the
DNR order in the chart, and asked if the patient was
"DNI" as well. None of the nursing staff or housestaff
were certain. They tried to discuss it with the patient,
who was stuporous by this time. They placed a call to
the attending physician's answering service who said they
would page him and give him the message to return the
call.
QUESTION/DISCUSSION:
How is "DNR" different from "DNI"?
1.) DNR is a precise instruction (defined by NYS law)
directing us NOT to provide a specific therapy (CPR) in
the event of a certain situation (cardio-respiratory
arrest). DNI can mean different things to different
people, in different situations.
2.) The DNR process and algorithm is dictated by the DNR
Law. Although it is based upon societal values and
practices, its details derive from its legal status.
Thus, a relative on the DNR surrogate list might make a
DNR decision simply by weighing burdens and benefits
(best interests standard). In the absence of a Proxy,
all other non-treatment decisions (including non-code
intubation) must be based upon the patient's previously
stated wishes.
The DNR documentation for surrogates is also
dictated by law. Similar looking forms for "DNI" carry
no legal authority (except at the VA, which is not
subject to New York State laws).
3.) The probability of successful CPR is well defined
and can be succinctly presented to a patient or surrogate
in advance of a cardiac arrest occurring. There are a
large number of published reports which demonstrate:
a. CPR usually does not restore heartbeat
(approximately 1/3 of codes in cumulative data).
b. Of those who do survive initially, only 1/3 leave
the hospital alive.
This cumulative data includes diverse groups of
patients: Acute MIs on monitor do much better than this,
and chronically ill patient with cancer or multi-system
disease arresting on a general medical floor, do much
worse. The cumulative data can therefore, be further
refined to apply to the individual patient in a very
specific way. DNR/CPR discussions can therefore be
relatively precise.
In contrast, there are very few patients for whom
such accurate predictions can be made concerning
successfully weaning them from the ventilator following
urgent (but pre-arrest) intubation and ventilation.
Attempting such discussions in advance require a fair
amount of conjecture concerning weanablity. In fact, the
question of weanability is best answered once weaning is
attempted. If there are fears about "getting stuck on
the vent", explicit time limits or a Health Care Proxy
are the best protections, and will permit a relatively
comfortably extubation at a later time. Remember,
withholding and withdrawing are (generally) morally and
legally equivalent; if you feel you might not be
justified in extubating a vent-dependent patient, you
probably would not have been justified in withholding
intubation and ventilation.
4.) CPR is a discrete, relatively brief treatment, for a
condition (cardiac arrest) which usually occurs with
little or no warning. Renal, cardiac, and CNS injury
often result from the cardiovascular collapse of a full
arrest. The treatment is completed when it either
successfully restores heartbeat, or it is deemed a failed
attempt. In either case, it rarely lasts longer than an
hour (often much less). Furthermore, once it is "successful",
there is no way to reverse the decision. Therefore, the only
effective means to forego CPR and avoid its sequelae, is
to decline it in advance of the cardiac arrest.
Intubation and mechanical ventilation however, are
often initiated after a period of respiratory decline
lasting minutes to hours; damage to other organ systems
is rare. Once begun, mechanical ventilation can usually
be maintained for extended periods of time. Therefore,
most patients intubated for respiratory failure can be
stabilized and reevaluated after treatment has been
initiated. Often the uncertainty of clinical situations
make it difficult to predict the patient's response in
advance of this therapeutic trial.
There is tremendous heterogeneity in clinical
situations leading to (non-arrest) intubation/ventilation.
These range from bronchospasm or pneumonia to end-stage
heart failure, COPD or lung cancer. People who are
intubated for milder reversible problems often do quite
well after a few days of support. Those with severe
irreversible disease predictably do poorly and may
never be successfully weaned.
In the absence of severe irreversible disease,
patients who decline (non-arrest) intubation/ventilation
need to understand the probability of a good outcome.
The potential for (undesired) prolonged ventilation still
exists, but this is better managed with a health care proxy
or explicit time limits on a therapeutic trial.
Often there is too much attention being paid to
advance decisions to withhold ventilation in questionable
cases. I'm not referring to lung mets, PVS, and other extreme
examples, but to cases in which there is a suspicion that the
patient may be difficult to wean. In such cases, it seems that
students and housestaff are hung up on "getting the DNI order"
so they will not have to intubate where there is a chance
the patient might not get off later. One of my concerns
is that this really represents a "withhold/withdraw"
bias, in which the student or resident has no hesitation
to withhold ventilation from someone they would never
remove from a ventilator.
Unlike CPR/DNR decisions, there is often no pressing
need to decide about other treatments in advance, since
they can always be discontinued later, following a trial
of therapy. Certainly some people with clearly thought
out wishes and attitudes may elect to forego a variety of
treatments in advance. Those individuals should be
encouraged to discuss and formalize those wishes. Most
people however, who do not have such clear ideas, are
better served by executing a Health Care Proxy, naming
someone they trust to make decisions when they become
incapacitated.
In other cases, a particular complication is so
predictable, and untreatable (such as respiratory failure
with lung mets), that it really ought to be discussed in
advance. This must however, be in the context of a
comprehensive treatment plan. Such conversations should
focus on the overall plan to best benefit the patient
(such as adequate palliative treatment). A patient with
progressive dyspnea from lung cancer, is likely to be
more concerned about what you will do to relieve the
suffocation he fears his dying will bring, than he is
whether you will try to extend his life with a vent.
Patients appreciate frank and open discussions when they
are directed toward the patient's particular needs and
concerns.
REFERENCES:
Blackhall LJ. Must We Always Use CPR? N Engl J Med 1987;
317:1281-1285.
Council on Ethical and Judicial Affairs, American Medical
Association. Guidelines for the Appropriate Use of Do-
Not-Resuscitate Orders. JAMA 1991; 265:1868-1871.
Schonwetter RS, Walker RM, Kramer DR, Robinson BE.
Resuscitation Decision Making in the Elderly: the value
of outcome data. J Gen Intern Med 1993; 8:295-300.
If questions remain concerning DNR/DNI, or if you
believe there is something here which is clearly
different from what you have been told elsewhere, please
let me know. Call any time, or better yet, leave me a
message on E-mail
Jack P. Freer, MD
887-4852 (leave recorded message)
887-4600 (page)
CASE 6.
A 78 year old woman was admitted 5 weeks ago with aphasia and
right hemiparesis. She was initially treated with TPA with little
improvement. Within the first week, she developed worsening neurologic
symptoms and was felt to have suffered a second CVA. During the second
hospital week, she developed atrial fibrillation and hypotension. She
required intubation and mechanical ventilation.
At the present time, she is totally unresponsive to all stimulus
(including deep pain). She has diminished, but not totally absent cranial
nerve reflexes. She has shown no progress in the ensuing weeks, and the
neurologists believe she suffered diffuse cerebral anoxic damage, in
addition to the discrete cerebral infarcts. She remains on the ventilator
for apparent ARDS.
Her husband is her only close relative and has indicated he believes she
will get better and come home with him. He has steadfast refused any
limitation of medical treatment including CPR. There is no Health Care
Proxy and the husband has provided no reports of the patient's prior
wishes.
QUESTIONS:
1. Are there any treatments currently provided (or anticipated) that would
be considered "futile?" Explain the way in which they are futile.
2. If there are any such futile treatments, what are the implications
for decision making? Who is authorized to make futility determinations
and why?
2. Is the patient receiving life-sustaining treatments that are not
(strictly speaking) futile, but are still inadvisable, inappropriate, or
otherwise evidence of faulty decision making? On what grounds?
3. What is the relevance of the husband's inability to recount any patient
wishes or statements? How would it matter if he told of her desire to
have her life prolonged at all costs? How would it matter if he told of
her distaste for life-sustaining treatment?
REFERENCES:
Baker R. The ethics of medical futility. Crit Care Clin 1993; 9(3):575-84.
Caplan AC. Odds and Ends: Trust and the Debate over Medical Futility. Ann
Int Med 1996; 125:688-689.
Fins JJ. Futility in clinical practice: report on a Congress of Clinical
Societies. J Am Ger Soc 1994; 42(8):861-5.
Jecker NS, Pearlman RA. Medical Futility: who decides? Arch Int Med 1992;
152:1140-1144.
Lantos JD, Singer PA, Walker RM et al. The Illusion of Futility in Medical
Practice. Am J Med 1989; 87:81-84.
Schneiderman LJ, Jecker NS, Jonsen AR. Medical Futility: its meaning and
ethical implications. Ann Int Med 1990; 112(12):949-54.
Tomlinson T, Brody H. Futility and the Ethics of Resuscitation. JAMA 1990;
264:1276-1280.
Youngner SJ. Applying futility: saying no is not enough. . J Am Ger Soc
1994; 42(8):887-9.
MEDICAL DECISION MAKING PROCESS
Informed consent/refusal
Decision making standards for incapacitated patients:
--prior decision while competent
--substituted judgment standard
--best interest standard
Surrogate decision making
Medical futility
Decision making capacity vs. competence
Decisions to forego life sustaining treatment
Artificial hydration and nutrition
TEXTBOOK REFERENCES
REVIEW ARTICLES
Baker R. The ethics of medical futility. Crit Care Clin
1993; 9(3):575-84.
Jackson DL, Youngner S. Patient Autonomy and "Death with
Dignity": some clinical caveats. N Engl J Med 1979; 301:
404-408.
Jecker NS, Pearlman RA. Medical Futility: who decides?
Arch Int Med 1992; 152:1140-1144.
Lantos JD, Singer PA, Walker RM et al. The Illusion of
Futility in Medical Practice. Am J Med 1989; 87:81-84.
Miller BL. Autonomy & the Refusal of Lifesaving
Treatment. Hast Cent Rep Aug 1981; 12:22-28.
Schneiderman LJ, Jecker NS, Jonsen AR. Medical Futility:
its meaning and ethical implications. Ann Int Med 1990;
112(12):949-54.
Singer PA, Siegler M. Elective Use of Life-sustaining
Treatments in Internal Medicine. Adv Int Med 1991;
36:57-79.
Tomlinson T, Brody H. Futility and the Ethics of
Resuscitation. JAMA 1990; 264:1276-1280.
Truog RD, Brett AS, Frader J. The Problem with Futility.
N Engl J Med 1992; 326:1560-1564.
The following excerpt is an excellent review of the
subject of surrogate decision making. It is from The New
York State Task Force on Life and the Law (1992): When
Others Must Choose: deciding for patients without
capacity. It is found on pages 54-58 of this report:
Ethical Guideposts for Surrogate Decisions
A broad consensus has emerged over the past decade
supporting two standards for surrogate decision making:
formulating a "substituted judgment" as to what the
patient would have decided, and choosing in accord with
the patient's "best interests." Respect for personal
autonomy undergirds the substituted judgment standard,
while the obligation to promote the patient's well-being
in more objective terms forms the basis of the best
interests standard.
The Substituted Judgment Standard
The substituted judgment standard requires the
surrogate to make decisions about treatment according to
the patient's own values, personal preferences, and
goals: in effect, to decide in the same way as the
patient would if he or she were capable. Many sources of
information help to guide the surrogate's exercise of
substituted judgment, ranging from information about the
patient's treatment preferences in particular
circumstances to more general knowledge about the
patient's moral and religious values. The substituted
judgment standard has generally been favored by courts as
well as commentators for those cases in which it is
applicable. The subjective and personalized perspective
takes the patient's own values and views of well-being
into account, and seeks to promote the patient's
self-determination.
Although the substituted judgment standard is widely
recognized and relied upon, frequent application of the
standard has also served to highlight its limitations.
While some commentators have posed the theoretical
problem of whether one can truly know what a formerly
competent individual, now incompetent, would choose,
criticism more often focuses on claims that the standard
has been applied inappropriately in some cases and that
it simply offers no guidance in others. Even with
previously competent patients, application of the
substituted judgment standard is often somewhat
speculative. Many have criticized courts in several
cases for stretching the limits of substituted judgment
when the basis for deciding what the patient would have
chosen was actually quite limited. This propensity to
justify decisions under an expansive notion of
substituted judgment has led some commentators to caution
that the standard is so elastic that it may lead to poor
decisions.
Attempts to apply the substituted judgment standard
are even more problematic for individuals who have never
been competent, such as Joseph Saikewicz, a 67-year-old
profoundly retarded man who was dying of leukemia. In
the Saikewicz case, the court held that chemotherapy
could be withheld, relying on a finding that Mr.
Saikewicz would have chosen this course of treatment for
himself if he were "competent but taking into account the
present and future incompetency of the individual"
[Superindendent of Belchertown State School v. Saikewicz,
373 Mass. 728, 370 N.E.2d 417 (1977)]. Most commentators
agree that for adults who have never been competent, and
for children who have not yet developed the opportunity
to arrive at and communicate their decisions or personal
values, the substituted judgment standard simply offers
no guidance.
The Best Interests Standard
When little or no evidence of the patient's wishes
is available, the most widely embraced guidepost for
surrogate decisions is the best interests standard.
Unlike a substituted judgment, which focuses on the
patient's known preferences in seeking to infer what the
patient would have wanted, the best interests standard
relies to a greater extent upon objective criteria; it
serves primarily to protect and promote the well-being of
vulnerable patients. The best interests standard is
often understood to reflect a societal consensus, or the
perspective of a "reasonable person," choosing as most
people would choose for themselves.
Many commentators urge that under the best interests
standard, the surrogate should weigh the benefits and
burdens of treatment as objectively as possible. In
assessing the patient's interests, the surrogate should
consider the potential goals of treatment in the context
of the patient's particular circumstances. Possible
benefits that should be weighed include the prolongation
of life, the alleviation of pain and suffering, and the
preservation or restoration of function. Treatment
"burdens" involve the pain, risk, degree of invasiveness
of medical interventions, and the possibility of
needlessly prolonging the dying process. According to
most commentators, the burden or discomfort of the
patient's ongoing condition should also be taken into
account.
Some commentators urge that the best interests of
the patient should be identified by taking the view of a
hypothetical average "reasonable person" in the patient's
circumstances and deciding about treatment as we believe
most people would decide for themselves. Others believe
that we must, to the best of our ability, vicariously
assume the perspective of the particular individual. For
example, these commentators suggest that a life of
profound handicap and mental retardation might be wnrth
living from the perspective of one who has known no other
condition, even if it might not seem worth living to
others.
There is obvious potential for tension and conflict
among the values pivotal to determining best interests.
It may be difficult to decide what constitutes or
contributes to the patient's overall well-being in par-
ticular circumstances. In some situations, treatment may
preserve or prolong the patient's life, but at the cost
of burdening the patient with pain or suffering.
Alternatively, effective doses of pain relief may risk
hastening the patient's death. In other cases, the
treatment itself may not cause the patient discomfort,
but may sustain the patient's life in circumstances that
offer no hope for recovery or possibility for human
interaction or awareness.
A determination of best interests often rests upon
basic understandings about the nature and meaning of
human life. What qualities of human life do we cherish?
How do we affirm our caring and basic human commitments
to one another at life's end? Diverse values, often
shaped by religious and moral beliefs, have been embraced
as central to the best interests standard. Indeed, in
our pluralistic society? we do not share a single vision
of the best possible outcome for patients in many
circumstances; the broad concepts of benefits and burdens
of treatment are identified and weighed differently.
Sanctity of life and quality of life. Some
commentators, often identified as emphasizing "sanctity
of life," believe that continued life is an intrinsic and
personal good and that the limitations or burdens imposed
by illness must always be weighed in that light. In one
formulation of this position: "No matter how burdened it
may be, human life remains inherently a good of the
person. Thus, remaining alive is never rightly regarded
as a burden" [May WE: "Feeding and Hydrating the
Permanently Unconscious and Other Vulnerable Persons,"
Issues in Law and Medicine (1987) 3:205].
According to this viewpoint, an assessment of
benefits and burdens that fails to value continued
biological life as an unambiguous good shifts the ethical
focus of treatment decisions to unacceptable judgments
about the quality of the life preserved. For these
commentators, burdensomeness should be assessed by
focusing on the pain or invasiveness caused by the
treatment itself, not by evaluating the quality of life
that such medical intervention may sustain. Hence, if a
treatment such as antibiotics is minimally invasive and
has limited or no side effects, it should be provided to
sustain a patient's life regardless of the quality of
that life. Proponents of sanctity of life also argue
that quality-of-life judgments threaten to undercut
societal commitments to the preservation of life and the
protection of vulnerable persons.
Other commentators view life as a basic and precious
good, but one that is valued principally as a
precondition for other higher goods, such as experience,
thought, and human interaction. Sustained biological
function is not regarded as a goal in and of itself,
apart from the patient's overall condition and the
benefits or burdens that continued life may offer to the
patient. According to this view, discontinuing
treatment, even if it leads to the patient's death, is
consistent with his or her best interests when the
treatment is hopeless and serves only to sustain
biological existence that is painful or of no benefit to
the patient. As expressed by one commentator, "Medicine
has traditionally refused to make prolognation of life
its goal, not only because the goal was finally
unreachable, but also because it recognized that efforts
in that direction often produced more harm than good - in
pain and discomfort as well as anguish and anxiety" [Kass
LR: "Ethical dilemmas in the Care of the Ill: what is the
patient's good?" JAMA (1980) 244:1947].
BRAIN DEATH AND SEVERE CNS INJURY
Determination of death
Death by whole brain criteria
Neocortical death
Persistent vegetative state
TEXTBOOK REFERENCES
REVIEW ARTICLES
Bernat JL, Culver CM, and Gert B. On the Definition and
Criterion of Death. Ann Int Med 1981; 94:389-384.
Black P McL. Brain Death. N Engl J Med 1978; 299:334-344.
Halevy A, Brody B. Brain Death: reconciling definitions,
criteria, and tests. Ann Int Med 1993; 119(6):519-25.
Olick RS. Brain Death, Religious Freedom, and Public
Policy: New Jersey's landmark legislative initiative.
Kenn Inst Eth J 1991; 1:275-288.
Truog RD, Fackler JC. Rethinking Brain Death. Crit Care
Med 1992; 20(12):1705-13.
Veatch RM. The Impending Collapse of the Whole-Brain
Definition of Death. Hast Cent Rep Jul-Aug 1993;
23(4):18-24.
EMERGENCY/CRITICAL CARE
Do not resuscitate orders
intubation and mechanical ventilation
ventilator withdrawal
Withholding treatment vs. withdrawal of treatment
TEXTBOOK REFERENCES
REVIEW ARTICLES
ACCP/SCCM Consensus Panel. Ethical and Moral Guidelines
for the Initiation, Continuation and Withdrawal of
Intensive Care. Chest 1990; 97:949-958.
Adams J, Wolfson AB. Ethical Issues in Geriatric
Emergency Medicine. Emer Med Clin No Amer 1990; 8(2):
183-92.
American Thoracic Society. Withholding and Withdrawing
Life-sustaining Therapy. Ann Int Med 1991; 115:478-485.
{also appears in: Am Rev Resp Dis 1991; 144:727-732.}
Council on Ethical and Judicial Affairs, American Medical
Association. Guidelines for the Appropriate Use of Do-
Not-Resuscitate Orders. JAMA 1991; 265:1868-1871.
Edwards BS, Ueno WM. Sedation Before Ventilator
Withdrawal. J Clin Eth 1991; 2: 118-122.
Task Force on Ethics of the Society of Critical Care
Medicine. Consensus Report on the Ethics of Foregoing
Life-sustaining Treatments in the Critically Ill. Crit
Care Med 1990; 18:1435-1439.
Wachter RM, Luce JM, Hearst N, Lo B. Decisions about
Resuscitation: Inequities among Patients with Different
Diseases but Similar Prognoses. Ann Int Med 1989;
111:525-532.
LEGAL ISSUES
TEXTBOOK REFERENCES
REVIEW ARTICLES
Greco PJ, Schulman KA, Lavizzo-Mourey R, Hansen-Flaschen
J. The Patient Self-determination Act and the Future of
Advance Directives. Ann Int Med 1991; 115:639-643.
Meisel A. Legal Myths About Terminating Life Support.
Arch Int Med 1991; 151:1497-1502.
Meisel A. The legal consensus about forgoing life-
sustaining treatment: its status and its prospects. Kenn
Inst Eth J 1992; 2:309-345.
Veatch RM. Forgoing Life-Sustaining Treatment: Limits to
the consensus. Kenn Inst Eth J 1993; 3:1-19.
The following guidebooks are available from:
The New York State Health Department
Box 2000
Albany, NY 12220
or
The New York State Task Force on Life and the
Law
5 Penn Plaza, 3rd Floor
New York, NY 10001-1803
New York State Department of Health, The New York State
Task Force on Life and the Law (1991): The Health Care
Proxy Law: a guidebook for health care professionals.
Medical Society of the State of New York, New York State
Department of Health, Hospital Association of New York
State (1992): Do Not Resuscitate Orders: questions and
answers for health care professionals (second edition).