The ethical principle of respect for autonomy has come into its own In American medicine since World War II as equal in importance to the traditional medicomoral principles of nonmaleficence and beneficence. Respect for autonomy provides the ethical underpinning for the patient's right to exercise an informed choice – whether to consent to or to refuse recommended medical treatment. However, an informed choice demands a certain level of competence. Typical criteria for patient competence to accept or to refuse medical treatments (...) Include ability to make a choice and ability to comprehend the nature of the treatment, as well as the risks and benefits of accepting or refusing the treatment. (shrink)

It is not the outpatient setting, per se, that is presenting new challenges and opportunities to ethics consultants and ethics committees. Rather, it is the underlying reason for shifting more and more patient care from the inpatient to the outpatient setting-namely, calculations of cost-effectiveness.

In brief compass, I will touch on three of the central ethical and public policy issues that divide those who are opposed to physician-assisted dying from those who are supportive of this practice. These are: the moral distinction between actively hastening death and passively allowing to die; how to interpret the Hippocratic tradition in medicine with respect to physician-assisted death; and whether physician-assisted suicide can be effectively regulated. I shall summarize the arguments pro and con with respect to each issue, (...) and also indicate my own position. (shrink)

There is good news, and there is bad news. The good news is that in my experience, younger physicians generally are much more concerned about the cost of clinical tests and treatments, and about justly distributing finite medical resources, than were those who practiced medicine in the fee-for-service era. The bad news has at least three components. First, with respect to medically nonbeneficial treatment in the ICU, managed care has not yet given evidence of wanting to put the brakes on (...) unrealistic family demands for aggressive medical interventions. Second, managed care is frustrating many healthcare professionals as well as patients. And third, managed care has no apparent interest in addressing, and may even have contributed to, the problem of medical indigence. Let me develop these propositions more fully. (shrink)

As Part of the Omnibus Budget Reconciliation Act of 1990, the Patient Self Determination Act legislates new responsibilites for healthcare facilities. The authors served as members of the California Consortium on Patient Self-Determination, and the materials produced by this group offer healthcare facilities a valuable guide for implementing the PSDA. The ACt follows a historical trend led by doctrines of informed consent and increasing patient autonomy regarding rights to accept or refuse medical treatment and to execute advance directives. The requirements (...) of the Act will influence healthcare facilities and how they communicate with patients about advance directives. Although the Act seeks to increase awareness of advance directices among all participants in healthcare interactions, it could pose major stumbling blocks to providing sensitive and humane care if certain concerns are nor addressed adequatley. The benefits of the Act could be far reaching and substantial for patients and healthcare facilities alike. (shrink)