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To the Editor: D. Alan Shewmon's work over the last decade has clearly awakened the bioethics community from its dogmatic slumbers. Easy acceptance of the "somatic integration" rationale for equating [...]

Moral problems arise when contemplating the inactivation of total artificial heart technology: however, an ethical obligation to explant the device as part of therapy withdrawal is not one of them. Further, arguments will be presented justifying that inactivation of the device is not morally equivalent to active killing of the patient. When device inactivation is clinically and ethically warranted, this decision should not be unilaterally made by the physician but through thorough discussion with the patient (if possible), the patient's surrogate, and the medical team. Consultation with legal counsel and the hospital ethics committee may also be appropriate.

It seems generally correct that patients (or their valid surrogates) should be able to withdraw consent for the use of the total artificial heart (TAH) just as they presently may withdraw consent for other life-prolonging technologies such as the ventilator, but lingering moral problems remain with such decisions. First, should patients be permitted to demand actual removal of the TAH rather than mere deactivation? Second, forgoing other life-prolonging technologies is normally considered 'indirect' killing and is therefore judged legal (as well as moral to those who accept only indirect killing). As long as the society includes irreversible stoppage of the heart as one of the criteria for death, however, stopping a TAH will be considered direct killing, i.e., murder. To circumvent this inconsistency, society must change its conclusion that stopping other life-prolonging technologies is merely indirect killing, explicitly legalize direct killing by means of stopping a TAH, or revisit the definition of death to eliminate the cardiac standard for death from the definition of death. Assuming that the stopping of the TAH with patient or surrogate consent is acceptable, we must then face the question of whether physicians who believe the TAH is serving no purpose can unilaterally stop the device against the wishes of a patient or surrogate who believes it is still serving a worthwhile purpose. Clinicians should be presumed authoritative in determining the predicted effect of the TAH, but, if the TAH can temporarily prolong life for a patient in a way that is desired by the patient or surrogate, case law, professional society recommendation, and moral analysis all support the conclusion that the TAH must be continued even against the conscientious objection of the physician.

Byline: P. Sjokvist (1), T. Nilstun (2), M. Svantesson (1), L. Berggren (1) Keywords: Key words Decision-making; Ethics medical; Intensive care; Life support; Questionnaire; Public opinion Abstract: Objective: To examine the attitudes of the general public regarding who should decide about the withdrawal of life support and to compare these attitudes with those of intensive care personnel. Design: Nationwide postal questionnaire survey. Setting: Sweden. Participants: One thousand one hundred ninety-six randomly selected persons from the Swedish population register, 339 nurses and 121 physicians from 29 randomly selected intensive care units (ICUs). Measurements and results: Respondents' answers to questions related to two clinical scenarios: one with a conscious and competent patient and one with an unconscious patient. The response rates were 64 % for the general public, 86 % for the nurses and 88 % for the physicians. Concerning the competent patient, 48 % of the public, 31 % of the nurses and 8 % of the physicians were of the opinion that a decision about continued ventilator treatment should be made by the patient alone or together with the family, but without the physician. The vast majority of physicians (87 %) wanted to make the decision themselves, either alone or together with the patient or family. Concerning the incompetent patient, 73 % of the general public and 70 % of the nurses advocated a joint decision made by the family and the physician together. The majority of the physicians (61 %) regarded themselves as the sole decision-maker, a view supported by only 5 % of the public and 20 % of the nurses. Conclusions: While existing Swedish guidelines recommend that the physician should be the sole decision-maker, the general public favour more patient and family influence on the decision to withdraw life support as compared with intensive care physicians. Author Affiliation: (1) Department of Anesthesia and Intensive Care, Orebro Medical Centre Hospital, SE-701 85 Orebro, Sweden, SE (2) Department of Medical Ethics, Lund University, SE-222 22 Lund, Sweden, SE Article note: Received: 7 October 1998 Final revision received: 28 April 1999 Accepted: 3 May 1999

Byline: G. Melltorp (1), T. Nilstun (2) Keywords: Key words Ethical theories; Guidelines; Life-sustaining treatment; Withdrawing; Withholding Abstract: Objectives: First, to present the position on the distinction between withholding and withdrawing life-sustaining treatment as expressed in guidelines and examine its relation to the attitudes of health care professionals. Second, to examine the possible ethical justification of this distinction. Design, setting, and participants: Critical analysis of guidelines on life-sustaining treatment and questionnaire administered to 148 health care professionals -- physicians and nurses at the intensive care unit (ICU), University Hospital MAS, Malmo, Sweden. Results: In contrast to the guidelines, which emphasize that there is no ethical difference between withholding and withdrawing life-sustaining treatment, not less than 50 per cent of the professionals in the ICU were of the opinion that there is an ethical difference. All attempts to justify this difference with reference to an inherent distinction between withholding and withdrawing seem to be controversial. Conclusions: We recommend a change in emphasis in professional guidelines. Such guidelines should avoid the controversial issue about the possible inherent ethical difference between withholding and withdrawing life-sustaining treatment. What should be underlined is that the particular situation and the consequences of withholding as well as withdrawing life-sustaining treatment should always be taken into account. Author Affiliation: (1) Department of Anaesthesiology, University Hospital MAS, S-205 02 Malmo, Sweden FAX: +46 (40) 337 070, SE (2) Department of Medical Ethics, Lund University, St. Grabrodersgatan 16, S-222 22 Lund, Sweden, SE Article note: Received: 1 April 1997 Accepted: 18 October 1997

A study examines the opinions of parents with gravely ill children on whether or not to allow doctors to use life support on the children. After sampling various parents in this situation, eight factors are revealed in their decisions: prolonging of life, pain and suffering, quality of life, loss of self in the child, respect for the best interest of the child, family, faith and nature, and technology.

The existence of new life-sustaining devices and treatments has generated debates on the ethical, moral and legal aspects of their use. The role of bioengineers is especially crucial to this issue as the medical devices they design may be specifically geared only to the wealthy few and may not only prove very expensive but unreliable as well. Furthermore, focus on such devices may unfairly limit efforts towards the development of other devices which the general public can afford.

The case of Baby K serves as an example of the reasons why medical personnel need to develop ethical standards for medical practice and adhere to them vigilantly. Baby K is an anencephalic infant whose mother demanded she be kept on mechanical ventilation, despite the standard practice of not ventilating such children because it would not cure them. Anencephalic infants have no brains. The hospital ventilated the child, and a court battle ensued. Hospital representatives argued that they should not be required to supply medically inappropriate treatment. The courts addressed rules of law and the wording of the Emergency Treatment Act, not medical practice. This resulted in a decision that Baby K must be given ventilation if that is what her mother wants. Because the hospital chose to fight a legal battle rather than adhere to its own rules of medical practice, it, and not the courts or the mother, is to blame.

A war of words is being waged about whether physicians can refuse, unilaterally, to provide life support for patients who are hopelessly or terminally ill. For many years one scenario [...]

Physicians should have no legal obligation to provide treatment that they believe is ineffective or against the best interests of the patient. These treatments are sometimes demanded by patients or their families. In one case, a five-year-old boy fell two stories, was hospitalized and placed on a ventilator. When ventilation was unsuccessful, he was placed on a heart- and lung-bypass machine so his lungs could recuperate. This never happened, and the doctors decided to remove him from the machine. The parents protested and threatened legal action. However, the hospital attorney and an ethics committee backed the physicians' right to discontinue a treatment that was obviously ineffective. The parents ultimately agreed and the boy was removed from the machine. He died immediately. This case illustrates that the physician's decisions should be based on what is best for the patient. However, patients and their families should still be partners in medical decision-making.

The values history form (VHF) allows patients to make decisions on whether to accept the use of life-support systems if they become critically ill. The VHS consists of 50 questions on values, preferences and beliefs regarding medical treatment. The VHF improves physician-patient relations, but it is not a legal document. Patients are advised to supplement the VHF with legal documents such as a living will., An advance directive isn't enough. Patients also need to document their values, beliefs, and preferences. The 78-year-old retired minister, ill with emphysema, arrived at the hospital paralyzed and unconscious from [...]

Bioethical Decisions to End Life examines such well-known questions as artificial nutrition and hydration, direct euthanasia, etc. in the light of 'ordinary' and 'extraordinary' means, of direct and indirect intention, and of the implications of the 'preferential option for the poor.'

In recent years many techniques and approaches to prolonging the lives of patients have been developed. However, there is no assurance in any given case that these strategies actually benefit the patient. An approach to studying the trade-offs between effectiveness, utility and cost has been developed. The model includes a means of defining when a procedure is futile. Aggressive care may be appropriate when it can lead to an enhanced rate of survival over supportive care. To some degree decisions made between supportive and aggressive care come down to a gamble, particularly when the situation becomes more complex than deciding between death and life. Individual feelings come in to play because some patients would prefer death following supportive management to life following a more aggressive approach. In short, some will choose to die rather than to suffer the pain and indignity that can accompany some aggressive interventions. The mathematical model which is developed attempts to define the medical appropriateness of such a medical gamble. The model defines a threshold where the value of supportive care is equal to the value of aggressive care, the 'medical appropriateness' threshold. Values below this point are medically inappropriate. To this value, an economic appropriateness threshold can be added, which views the intervention from the viewpoint of society. As an example, the method is applied to a situation which is deemed to be an incident of inappropriate care - the use of cardiopulmonary resuscitation (CPR) for chronically ill older people. The analysis of this situation demonstrates how the probability of survival with aggressive care falls below the level of medial appropriateness. (Consumer Summary produced by Reliance Medical Information, Inc.)

Recent advances in medical technology that allow people to remain alive longer, often with considerable suffering and cost, have raised new, disturbing questions about doctors' and patients' responsibilities for continuing life. Some of the changes in medical practice and the evolving attitudes about prolonging life are presented. Cardiopulmonary resuscitation allows the 'normal' dying process to be interrupted, but can leave the victim with irreversible brain damage. In 1968, the definition of death was moved from terms accessible to the layman (cessation of heart and lung activity) to a more arcane province as 'irreversible coma' became a new criterion. In the case of Karen Ann Quinlan, a 22-year-old who became comatose after allegedly ingesting alcohol and tranquilizers, her parents won the right to remove a ventilating machine, even though she did not meet the criteria for brain death. This landmark case, decided in 1975 by the New Jersey Supreme Court, opened the way for courts to decide matters formerly left to the medical profession. Discontinuing artificial and intravenous feeding has been another important subject of debate. In a 1983 survey, 73 percent of physicians, who responded to questions about a hypothetical comatose patient with no hope of recovery, said they would give sufficient fluids intravenously to maintain the patient, and 40 percent said they would even use invasive means to set up an intravenous line. However, 27 percent of the physicians responding to the survey said they would not give adequate intravenous fluids. Removal of such life-sustaining treatment was considered a deviation from standard practice in 1981, in the case of Clarence Herbert, when two physicians were prosecuted for discontinuing fluids and nutrition. Subsequently, the California trial court ruled that medical procedures to provide fluids and nutrition are more similar to other medical procedures than they are to typical human nourishment. However, today between 85 and 90 percent of critical-care workers would withhold hydration and feeding in certain cases. The Massachusetts Supreme Judicial Court's decision that Paul Brophy had the right to have a gastrostomy tube (a tube inserted directly into the stomach for the delivery of food) removed was controversial. Although the patient had remained in a vegetative state for two years after an aneurysm (weakened artery) in his brain ruptured, his condition was not life-threatening. Brophy had previously stated that if he was in a vegetative state he would not want his life to be prolonged. Similar cases are discussed. (Consumer Summary produced by Reliance Medical Information, Inc.)

The circumstances and decision processes which surrounds the medical decision to withhold or withdrawal life support from terminally ill patients in a major teaching hospital are explored. During a one-year period, 1,719 patients were admitted to two affiliated hospitals; life support was withheld from 22 patients (one percent) and withdrawn from 93 patients (five percent). Two days was the average hospitalization of patients who died following the withholding or withdrawal of life support. All but one of the patients died shortly after the decision was made. Approximately 45 percent of these patients died while still in the emergency room. The decision-making process usually begins during hospital rounds of the patients by their primary care physicians and intensive care teams. Five patients of the total group were competent and participated in the decision to discontinue support or elected not to authorize further medical procedures. However, the majority of the patients (110 of the 115) were judged incompetent, and medical decisions were made by family members (102 cases) or their physicians (eight patients). Once a decision was reached, "do-not-resuscitate" orders were written in 93 percent of cases. The presence of brain death was given as the sole reason for these medical orders for 18 patients. Other reasons for the decision to withhold or withdraw life support included a poor prognosis (97 patients), futility of continued support, and extreme suffering. By far, most patients for whom such action is taken are already judged incompetent by their physicians; the decision is usually made by family members. The effects of heroic efforts to save the unsalvageable patient and the contribution of these efforts to rising medical costs are also discussed. (Consumer Summary produced by Reliance Medical Information, Inc.)