Abstract

On many occasions, care givers are faced with problems in which “drastic” types of treatment seem clearly inappropriate but “lesser” interventions still appear to be advisable, if not indeed mandatory. In the hospital setting, examples are frequent: the demented elderly patient, still very much capable of brief social interactions and still able to enjoy at least limited life, who although clearly not a candidate for coronary bypass surgery is, nevertheless, a patient in whom an intercurrent pneumonia deserves treatment; the severely retarded youngster in whom appendectomy seems clearly warranted but for whom long-term dialysis seems ill-advised. The examples are legion, and their variety defies an easy, stereotypical solution. Why, one may ask, is the treatment of intercurrent pneumonia or operating on an acute appendix “clearly indicated” while coronary bypass and long-term dialysis “clearly” are not? The reactions of care givers in the past have often consisted of attempts to give half-hearted treatment or to treat fully even against their better judgment. The lack of conceptual guidelines that might help sort out such problems has inevitably led either to an inflexible absolutism in which all possible treatment to sustain life or no treatment at all is given or has resulted in a pathetic attempt to act but act minimally with the hope that such actions will be ineffective