With the passage by virtually every state legislature of healthcare proxy laws, the medical profession increasingly can expect to rely on the participation of surrogates in making decisions on behalf of incompetent patients. Several concerns about the legitimacy of proxy decision making have been discussed in the ethical and general medical literature: the lack of concordance between the views of patients and their surrogates have been documented on multiple occasions, and cases of abuse by proxies or potential conflict of interest (...) have been reported. Another dilemma that deserves discussion arises when proxies demand withdrawal of treatment that physicians and nurses regard as essential to the wellbeing of the patient. The following case highlights this dilemma. (shrink)

There are in two assumptions inherent in this issue's theme, both inimical to the traditional goals of medicine and to the standards of care it proposed. First, the idea that treatment must be limited for some (but not others) on the basis of cost was born in the early literature of bioethics. Second, that there is a quantifiable and diagnostically predictable period at the “end-of-life” where treatment is “futile,” and therefore not worth supporting in a context of scarcity grew out (...) of bioethics's construction of allocative protocols in the 1990s. This paper traces the history of these ideas as constructs grounded in neither natural scarcity nor in firm diagnostic categories. Their relation to issues of care is therefore suspect. (shrink)

Early announcements of this special journal issue solicited authors interested in contributing articles on the subject of “costs at the end of life.” Those who replied were then informed the title was being changed, on the basis of early subscriber interest, in “rational end-of-life treatment.” Because that seemed a still inadequate reflection of the authorial concerns of responding potential contributors, the editors again changed the title, two months later, to “Making Treatments More Rational and Compassionate for the Chronically Critically Ill.” (...) At that point the editors gave up and decided this issue’s final title would be determined only after the papers were submitted and reviewed. (shrink)

Samuel Golubchuk was unwittingly at the center of a medical controversy with important ethical ramifications. Mr. Golubchuk, an 84-year-old patient whose precise neurological level of function was open to debate, was being artificially ventilated and fed by a gastrostomy tube prior to his death. According to all reports he was neither brain dead nor in a vegetative state. The physicians directly responsible for his care had requested that they be allowed to remove the patient from life support against the wishes (...) of the patient's family. Concurrently the Manitoba College of Physicians and Surgeons released a statement which states that the final decision to withdraw life support lies with the physician. In our opinion the statement is ethically problematic for a number of reasons. 1. It is an affront to the guiding principles of Western medical ethics: patient autonomy and human freedom. 2. The position of Samuel Golubchuk's physicians and the new statement lack cultural sensitivity towards other traditions. 3. In modern society there exists an erosion of a basic attitude towards the value of life. 4. The ability of physicians to predict life expectancy in terminally ill patients has been shown repeatedly to be quite limited. (shrink)