Dilemmas about resuscitation and life-prolonging treatment for severely compromised infants have become increasingly complex as skills in neonatal care have developed. Quality of life and resource issues necessarily influence management. Our Institute of Medical Ethics working party, on whose behalf this paper is written, recognises that the ultimate responsibility for the final decision rests with the doctor in clinical charge of the infant. However, we advocate a team approach to decision-making, emphasising the important role of parents and (...) nurses in the process. Assessing the relative burdens and benefits can be troubling, but doctors and parents need to retain a measure of discretion; legislation which would determine action in all cases is inappropriate. Caution should be exercised in involving committees in decision-making and, where they exist, their remit should remain to advise rather than to decide. Support for families who bear the consequences of their decisions is often inadequate, and facilitating access to such services is part of the wider responsibilities of the intensive care team. The authors believe that allowing death by withholding or withdrawing treatment is legitimate, where those closely involved in the care of the infant together deem the burdens to be unacceptable without compensating benefits for the infant. As part of the process accurate and careful recording is essential. (shrink)

While Orthodox Christianity does not find explicit statements about the morality of prolonging life in the usual doctrinal sources, the Scriptures and the Fathers of the Church, there are elements in Tradition which bear upon the issue. These include Orthodox spirituality's emphasis on the “wholeness” of the human person, its liturgical and synergistic view of human life, and its understanding of our moral ambiguity as fallen human beings in a fallen world. This last point, in particular, means (...) that we do not usually have a clear choice between right and wrong, and that we cannot always trust ourselves to know which choice is the right, or even the better one. Therefore, we must always approach decisions about death and dying with humility and in a spirit of repentance, aware of the imperfection of all we do and trusting in the mercy of God. (shrink)

Critical care is in an emerging crisis of conflict between what individuals expect and the economic burden society and government are prepared to provide. The goal of critical care support is to prevent suffering and premature death by intensive therapy of reversible illnesses within a reasonable timeframe. Recently, it has become apparent that early support in an intensive care environment can improve patient outcomes. However, life support technology has advanced, allowing physicians to prolong life (and postpone death) in (...) circumstances that were not possible in the recent past. This has been recognized by not only the medical community, but also by society at large. One corollary may be that expectations for recovery from critical illness have also become extremely high. In addition, greater numbers of patients are dying in intensive care units after having receiving prolonged durations of life-sustaining therapy. Herein lies the emerging crisis – critical care therapy must be available in a timely fashion for those who require it urgently, yet its provision is largely dependent on a finite availability of both capital and human resources. Physicians are often placed in a troubling conflict of interest by pressures to use health resources prudently while also promoting the equitable and timely access to critical care therapy. In this commentary, these issues are broadly discussed from the perspective of the individual clinician as well as that of society as a whole. The intent is to generate dialogue on the dynamic between individual clinicians navigating the complexities of how and when to use critical care support in the context of end-of-life issues, the increasing demands placed on finite critical care capacity, and the reasonable expectations of society. (shrink)

This paper studies the connections between the notions of prolonging life and a good death in Antiquity. It is demonstrated that while prolonged life generally meant forestalling the human constitution’s death, ancient philosophers also pointed to the limitations of prolongation. The paper shows how philosophers welcomed prolonged life when it was shown to foster movement toward the good, such as self-realization and social usefulness. Yet, they rejected prolongation when it led to the perpetuation of evil, such (...) as social uselessness and suffering. We ask whether a contemporary good death is a mercy killing or an improvement of prolonged life, as the ultimate end of “goods practicable for man”. (shrink)

This article addresses death as a biological event and attempts to approach it as a mystery within the light of the Orthodox Christian theology and tradition. First, the value of the last moments of the life of a human being is analyzed; then the state of living is differentiated from the state of surviving that results, in some extreme cases, from the intrusion of technology in medicine. The article elaborates on the sacred and spiritual character of death which, when (...) viewed within the light of Christ’s resurrection, is transformed into a great blessing. The last part of the article focuses on the newly emerged issue of euthanasia and the reasons behind it. It poses certain vital questions that ought to be answered before legalization gets on its way. Finally, the conclusion summarizes the position of the Orthodox Church of Greece on death, dying and euthanasia. (shrink)

Although many do not seem to recognize it, the half‐millenium‐old tradition of Catholic teachings on providing care at the end of life offers a nuanced, carefully balanced doctrine, centering on a finely tuned distinction between ordinary and extraordinary care. Given the significant Catholic contribution to the contemporary pluralist debate about end of life care, getting clear on that tradition is important.

In this paper we contrast the simple role of FOXO in the seemingly non‐aging Hydra with its more diversified function in multicellular eukaryotes that manifest aging and limited life spans. From this comparison we develop the concept that, whilst once devoted to life‐prolonging cell‐renewal (in Hydra), evolutionary accumulation of coupled functionality in FOXO has since ‘distracted’ it from this role. Seen in this light, aging may not be the direct cost of competing functions, such as reproduction or (...) growth, but the result of a shift in emphasis in a protein, which is accompanied by advantages such as greater organismal complexity and adaptability, but also disadvantages such as reduced regeneration capacity. Studying the role of FOXO in non‐aging organisms might, therefore, illuminate the path to extend life span in aging organisms.Editor's suggested further reading in BioEssays Stem cells and aging from a quasi‐immortal point of view Abstract. (shrink)

Background Making the right decisions, while simultaneously showing respect for patient autonomy, represents a great challenge to nursing home staff in the issues of life-prolonging treatment, hydration, nutrition and hospitalisation to dying patents in end-of-life. Objectives To study how physicians and nurses protect nursing home patients' autonomy in end-of-life decisions, and how they justify their practice. Design A qualitative descriptive design with analysis of the content of transcribed in-depth interviews with physicians and nurses. Participants Nine physicians (...) and ten nurses in 10 nursing homes in Norway. Results and interpretations Assessment of the patient's competence to consent to treatment is almost absent. The physicians build their practice on the principles of beneficence and nonmaleficence. Nurses tend to trust the patients' rejection of life support, even when the patients have difficulty speaking or suffer from dementia. Relatives were, according to the health personnel, included in decision-making processes to a very limited extent. However, futile life support is sometimes provided contrary to the physicians' judgement of what constitutes the patient's best interest on occasions when they are pressurised by next of kin. Conclusions The study reveals a need to improve decision-making routines according to ethical ideals and legislation. Conflicts between relatives and healthcare professionals in the decision-making process deflect the focus from searching for the best possible treatment for the terminal patient. Further discussion is required as to whether the concept of autonomy is applicable in situations in which the patient is impaired and dying. (shrink)

In Japan, people are negative towards life-prolonging treatments. Laws that regulate withholding or discontinuing life-prolonging treatments and advance directives do not exist. Physicians, however, view discontinuing life-prolonging treatments negatively due to fears of police investigations. Although ministerial guidelines were announced regarding the decision process for end-of-life care in 2007, a consensus could not be reached on the definition of end-of-life and conditions for withholding treatment. We established a forum for extended discussions and (...) consensus building on this topic. (shrink)

Recent biotechnological advances pose topical challenges to Christian ethics. One such development is the attempt to try and enhance human beings and what it means to be human, also through radical life extension. In this contribution I am especially interested in limited human lifespan and attempts to radically prolong it. Although there are a number of ethical issues raised by critics, one of the most profound ethical and theological issues raised by these efforts is the question of equity and (...) justice. This artice looks at questions such as whether this biotechnology could exacerbate existing social divisions. Who will be experimented on in the development of this technology, as well as who will have access to it and be able to afford it, should it become commercially available? Being created in God’s image is a relational concept, referring not only to humanity’s relationship with God, but also with each other. Disrupting these relationships through the possible enlarging socioeconomic divisions between people through the utilisation of enhancement technology is a serious bioethical and theological question. (shrink)

Objectives: To compare non-treatment decision making by general practitioners and geriatricians in response to vignettes. To see whether the doctors’ decisions were informed by ethical or legal reasoning.Design: Qualitative study in which consultant geriatricians and general practitioners randomly selected from a list of local practitioners were interviewed. The doctors were asked whether patients described in five vignettes should be admitted to hospital for further care, and to give supporting reasons. They were asked with whom they would consult, who they believed (...) ought to make such decisions, and whether the relatives’ preferences would influence their decision making.Main measures: To analyse the factors influencing the doctors’ decisions not to admit otherwise terminally ill patients to hospital for life prolonging treatment.Results: Seventeen GPs and 18 geriatricians completed the interview. All vignettes produced strong concordance in decision making between both groups. Ten per cent of the doctors would provide life prolonging treatment to patients with severe brain damage. Most would admit a surgical patient regardless of age or disability. Medical reasons were largely used to explain decision making. The wishes of relatives were influential and resource considerations were not. There was variability regarding decision making responsibility.Conclusions: Little attempt was made to link decision making with ethical or legal concepts and there may have been non-recognition, or denial, of the ethical consequences of failure to admit. The process of decision making may involve deception. This may be conscious, because of the illegality of euthanasia, or unconscious , because of deepseated medical and societal reluctance to accept that intentionally withholding life prolonging treatment may equate with intentionally causing death. (shrink)

What makes killing morally wrong? And what makes killing morally worse than letting die? Standard answers to these two questions presuppose that killing someone involves shortening that person's life. Yet, as I argue in the first two sections of this article, this presupposition is false: Life-prolonging killings are conceivable. In the last two sections of the article, I explore the significance of the conceivability of such killings for various discussions of the two questions just mentioned. In particular, (...) I show why the conceivability of life-prolonging killings renders Frances M. Kamm's attempt to provide an answer to the second question problematic. (shrink)

This article explores how the law of England and Wales1 has responded thus far to medical and clinical advances that have enabled patients with prolonged disorders of consciousness to survive. The authors argue that, although the courts have taken account of much of the science, they are now lagging behind, with the result that some patients are being denied their legal rights under the Mental Capacity Act 2005. The article further argues that English law does not comply with the United (...) Kingdom’s commitments under the United Nations Convention on the Rights of Persons with Disabilities. Stressing the need for the law to keep in step with advances in science, the article concludes with robust recommendations for improvements, based on the latest research in neuroscience, to the way in which life-sustaining treatment decisions are made. This would mean that the wishes of patients, including those with covert awareness, can be better reflected in best interests assessments. (shrink)

BackgroundEnd-of-life decisions remain a hotly debated issue in many European countries and the acceptance in the general population can act as an important anchor point in these discussions. Previous studies on determinants of the acceptance of end-of-life interventions in the general population have not systematically assessed whether determinants differ between withdrawal of life-prolonging treatment and euthanasia.MethodsA large, representative survey of the Austrian adult population conducted in 2014 included items on WLPT and EUT. We constructed the following (...) categorical outcome: rejection of both WLPT and EUT, approval of WLPT but rejection of EUT, and approval of both WLPT and EUT. The influence of socio-demographics, personal experiences, and religious and socio-cultural orientations on the three levels of approval were assessed via multinomial logistic regression analysis.ResultsHigher education and stronger socio-cultural liberal orientations increased the likelihood of approving both WLPT and EUT; personal experience with end-of-life care increased only the likelihood of approval of WLPT; and religiosity decreased approval of EUT only.ConclusionThis study found evidence for both shared and different determinants for the acceptance of WLPT and EUT. (shrink)

The question a judge has to ask in deciding whether or not life-sustaining treatment should be withdrawn is whether the continued treatment is lawful. It will be lawful if it is in the patient’s best interests. Identifying this question gives no guidance about how to approach the assessment of best interests. It merely identifies the judge’s job. The presumption in favour of the maintenance of life is part of the job that follows the identification of the question.The presumption (...) is best regarded as a presumption of law. It has long been recognised as part of the way in which the English law discharges its obligations under Article 2 of the European Convention on Human Rights (the right to life). But even if it is a ‘mere’ evidential presumption it cannot, on the facts of most cases involving applications for the withdrawal of life-sustaining treatment from patients in prolonged disorders of consciousness, be rebutted. (shrink)

People who suffer from eating disorders often have to be treated against their will, perhaps by being detained, perhaps by being forced to eat. In this paper it is argued that whilst forcing compliance is generally acceptable, there may be circumstances under which a sufferer's refusal of consent to treatment should be respected. This argument will hinge upon whether someone in the grip of an eating disorder can actually make competent decisions about their quality of life. If so, then (...) the decision to refuse therapy may be on a par with other decisions to refuse life‐prolonging therapy made by sufferers of debilitating chronic, or acute onset terminal illness. In such cases, palliation might justifiably replace aggressive therapy. The argument will also draw heavily on the distinction between competent refusal of therapy and passive euthanasia, and the distinction between incompetent and irrational decisions. Both distinctions will then be applied to decisions to refuse food. The extent to which sufferers from anorexia nervosa can be categorised as either incompetent or irrational will be examined. It is against this background that it will be argued that at least some of those who suffer from eating disorders should have their refusals respected, even if they may die as a result. (shrink)

Some form of agent-relative constraint against the killing of innocent personsis a central principle in deontological moraltheories. In this article I make two claimsabout this constraint. First, I argue that somekillings of innocents performed incircumstances usually not taken to exculpatethe killer are not even pro tanto wrong.Second, I contend that either there is noagent-relative constraint against the killingof innocents or this constraint has a verydifferent shape from that which deontologistsnormally take it to have. My defence of theseclaims rests on two (...) propositions. First, inkilling someone one may actually prolong thatperson''s life. Roughly, life-prolongingkillings are possible, because to kill someoneis to perform an act that causes someone''sdeath and it might well be true that, had onenot performed this act, one''s ``victim'''' wouldhave died earlier. Second, all other thingsbeing equal, killing and causing a person to beunconscious are morally equivalent. Both ofthese propositions are defended in thearticle. (shrink)

The Royal College of Physicians of London published the 2013 national clinical guidelines on prolonged disorders of consciousness in vegetative and minimally conscious states. The guidelines acknowledge the rapidly advancing neuroscientific research and evolving therapeutic modalities in PDOC. However, the guidelines state that end-of-life decisions should be made for patients who do not improve with neurorehabilitation within a finite period, and they recommend withdrawal of clinically assisted nutrition and hydration . This withdrawal is deemed necessary because patients in PDOC (...) can survive for years with continuation of CANH, even when a ceiling on medical care has been imposed, i.e., withholding new treatment such as cardiopulmonary resuscitation for acute life-threatening illness. The end-of-life care pathway is centered on a staged escalation of medications, including sedatives, opioids, barbiturates, and general anesthesia, concurrent with withdrawal of CANH. Agitation and distress may last from several days to weeks because of the slow dying process from starvation and dehydration. The potential problems of this end-of-life care pathway are similar to those of the Liverpool Care Pathway. After an independent review in 2013, the Department of Health discontinued the Liverpool Care pathway in England. The guidelines assert that clinicians, supported by court decisions, have become the final authority in nonconsensual withdrawal of CANH on the basis of “best interests” rationale. We posit that these guidelines lack high-quality evidence supporting: 1) treatment futility of CANH, 2) reliability of distress assessment from starvation and dehydration, 3) efficacy of pharmacologic control of this distress, and 4) proximate causation of death. Finally, we express concerns about the utilitarian-based assessment of what constitutes a person’s best interests. We are disturbed by the level and the role of medical authoritarianism institutionalized by these national guidelines when deciding on the worthiness of life in PDOC. We conclude that these guidelines are not only harmful to patients and families, but they represent the means of nonconsensual euthanasia. The latter would constitute a gross violation of the public’s trust in the integrity of the medical profession. (shrink)

BackgroundThere has been no in-depth research of public attitudes on withholding or withdrawing life-prolonging treatment, euthanasia, assisted suicide and physician assisted suicide in Croatia. The aim of this study was to examine these attitudes and their correlation with sociodemographic characteristics, religion, political orientation, tolerance of personal choice, trust in physicians, health status, experiences with death and caring for the seriously ill, and attitudes towards death and dying. MethodsA cross-sectional study was conducted on a three-stage random sample of adult (...) citizens of the Republic of Croatia, stratified by regions, counties, and locations within those counties. In addition to descriptive statistics, ANOVA and Chi-square tests were used to determine differences, and factor analysis, correlation analysis and multiple regression analysis for data analysis.Results38.1% of the respondents agree with granting the wishes of dying people experiencing extreme and unbearable suffering, and withholding life-prolonging treatment, and 37.8% agree with respecting the wishes of such people, and withdrawing life-prolonging treatment. 77% of respondents think that withholding and withdrawing procedures should be regulated by law because of the fear of abuse. Opinions about the practice and regulation of euthanasia are divided. Those who are younger and middle-aged, with higher levels of education, living in big cities, and who have a more liberal worldview are more open to euthanasia. Assisted suicide is not considered to be an acceptable practice, with only 18.6% of respondents agreeing with it. However, 40.1% think that physician assisted suicide should be legalised. 51.6% would support the dying person’s autonomous decisions regarding end-of-life procedures.ConclusionsThe study found low levels of acceptance of withholding or withdrawing life-prolonging treatment, euthanasia, assisted suicide and physician assisted suicide in Croatia. In addition, it found evidence that age, level of education, political orientation, and place of residence have an impact on people’s views on euthanasia. There is a need for further research into attitudes on different end-of-life practices in Croatia. (shrink)

In The Netherlands, it is openly acknowledged that the parents' ability to take care of their child plays a role in the decision-making process over administration of life-prolonging treatment to severely defective newborn babies. Unlike other aspects of such decision-making process up until the present time, the ‘ability to take care’ has not received specific attention in regulation or in empirical research. The present study is based on interviews with neonatologists in two Dutch NICUs concerning their definition of (...) the ability to take care and its relevance in non-treatment decisions. All of the respondents think that the ability to take care consists of more than one factor. Most doctors mention the parents' emotional state, social network and cognitive abilities. Some doctors mention the presence of psychological conditions in the parents, their financial situation and physical condition. A few refer to the parents' experience and age, their chances to have another baby and their cultural background. Most doctors think the ability to take care has a secondary relevance in the decision-making process, while the primary concern is assessing the condition of the child. A substantial minority thinks the ability to take care does not play any role, while one doctor thinks it is a factor of primary importance. The study constitutes an important stepping-stone for future research in The Netherlands and elsewhere. (shrink)

Contrary to the widespread concern about over-treatment at the end of life, today, patient preferences for palliative care at the end of life are frequently respected. However, ethically challenging situations in the current healthcare climate are, instead, situations in which a competent patient requests active treatment with the goal of life-prolongation while the physician suggests best supportive care only. The argument of futility has often been used to justify unilateral decisions made by physicians to withhold or withdraw (...) life-sustaining treatment. However, we argue that neither the concept of futility nor that of patient autonomy alone is apt for resolving situations in which physicians are confronted with patients' requests for active treatment. Instead, we integrate the relevant arguments that have been put forward in the academic discussion about ‘futile’ treatment into an ethical algorithm with five guiding questions: (1) Is there a chance that medical intervention will be effective in achieving the patient's treatment goal? (2) How does the physician evaluate the expected benefit and the potential harm of the treatment? (3) Does the patient understand his or her medical situation? (4) Does the patient prefer receiving treatment after evaluating the benefit-harm ratio and the costs? (5) Does the treatment require many resources? This algorithm shall facilitate approaching patients' requests for treatments deemed futile by the physician in a systematic way, and responding to these requests in an ethically appropriate manner. It thereby adds substantive considerations to the current procedural approaches of conflict resolution in order to improve decision making among physicians, patients and families. (shrink)

Modern medicine provides unprecedented opportunities in diagnostics and treatment. However, in some situations at the end of a patient’s life, many physicians refrain from using all possible measures to prolong life. We studied the incidence of different types of treatment withheld or withdrawn in 6 European countries and analyzed the main background characteristics.

오늘날 발달한 의학기술로 인해 우리는 연명치료와 호스피스 · 완화의료 등 죽음과 관련된 의료, 즉 웰다잉(Well-dying)의 문제에 관심을 가지게 되었다. 웰다잉 문제의 핵심은 임종기 환자의 삶의 질뿐만 아니라 죽음의 질의 문제이다. 이러한 문제들은 우리에게 연명치료 중단 및 호스피스・완화의료의 증대와 관련하여 법적, 제도적 과제와 함께 임종기 환자의 죽음교육의 문제를 제기한다. 이 논문은 연명치료 중단과 호스피스 · 완화의료에서 비종교인에 대한 죽음교육의 문제를 다루고 있다. 비종교인들이 내세 관념 없이도 평안한 죽음을 맞이하기 위해서 해결해야 할 과제는 죽음의 두려움을 어떻게 극복하는가의 문제이다. 이 논문은 비종교인의 죽음에 (...) 대한 두려움을 극복하는 문제를 니체와 에피쿠로스의 철학을 통해 살펴본다. 니체는 “삶을 완성시키는 죽음”, “주인으로서 당당하게 맞이하는 죽음”을 위해 이성적이고 자유로운 죽음을 강조한다. 이러한 니체의 죽음관을 통해 연명치료 중단의 철학적 근거를 살펴보고 ‘죽음의 의료화’에 의해 야기되는 현대인의 소외된 죽음에 대해 니체의 사상을 통해 대안을 제시한다. 또한 내세 관념이 없어도 죽음에 대해 두려워할 근거가 없음을 논거를 통해 제시하는 에피쿠로스의 철학을 살펴본다. 에피쿠로스는 죽음에 대한 두려움으로부터 우리를 해방시켜주고, 니체는 죽음이 삶의 끝이 아니라 삶의 완성임을 일깨워준다. 우리는 이 두 철학자의 가르침을 통해 연명치료 중단과 호스피스 · 완화의료를 선택할 때의 정신적 위안을 얻을 수 있을 것이다. 이러한 철학적 위안이 환자 및 환자 가족에 대한 의미 있는 죽음교육의 근거가 될 것이다. (shrink)

This book offers an in-depth analysis of the wide range of issues surrounding "passive euthanasia" and "allow-to-die" decisions. The author develops a comprehensive conceptual model that is highly useful for assessing and dealing with real-life situations. He presents an informative historical overview, an evaluation of the clinical settings in which treatment abatement takes place, and an insightful discussion of relevant legal aspects. The result is a clearly articulated ethical analysis that is medically realistic, philosophically sound, and legally viable.

In a recent paper, Charles Foster argued that the epistemic uncertainties surrounding prolonged disorders of consciousness make it impossible to prove that the withdrawal of life-sustaining treatment can be in a patient’s best interests and, therefore, the presumption in favour of the maintenance of life cannot be rebutted. In the present response, I argue that, from a legal perspective, Foster has reached the wrong conclusion because he is asking the wrong question. According to the reasoning in two leading (...) cases —Bland and James —the principle of respect for autonomy creates a persuasive presumption against treatment without consent. Therefore, it is the continuation of treatment that requires justification, rather than its withdrawal. This presumption also works as the tiebreaker determining that treatment should stop if there is no persuasive evidence that its continuation is in the best interests of the patient. The presumption in favour of the maintenance of life, on the other hand, should be understood as an evidential presumption on a factual issue that is assumed to be true if unchallenged. However, the uncertainties regarding PDOC actually give reasons for displacing this evidential presumption. Consequently, decision-makers will have to weigh up the pros and cons of treatment having the presumption against treatment without consent as the tiebreaker if the evidence is inconclusive. In conclusion, when the right question is asked, Foster’s argument can be turned on its head and uncertainties surrounding PDOC weigh in to justify the interruption of treatment in the absence of compelling contrary evidence. (shrink)

In English law there is a strong (though rebuttable) presumption that life should be maintained. This article contends that this presumption means that it is always unlawful to withdraw life-sustaining treatment from patients in permanent vegetative state (PVS) and minimally conscious state (MCS), and that the reasons for this being the correct legal analysis mean also that such withdrawal will always be ethically unacceptable. There are two reasons for this conclusion. First, the medical uncertainties inherent in the definition (...) and diagnosis of PVS/MCS are such that, as a matter of medical fact, it can never be established, with the degree of certainty necessary to rebut the presumption, that it is not in the patient’s best interest to remain alive. And second (and more controversially and repercussively), that even if permanent unconsciousness can be unequivocally demonstrated, the presumption is not rebutted. This is because there is plainly more to human existence than consciousness (or consciousness the markers of which can ever be demonstrated by medical investigations). It can never be said that the identity of the patient whose best interests are at stake evaporates (so eliminating the legal or ethical subject) when that person ceases to be conscious. Nor can it be said that the best interests of an unconscious person do not mandate continued biological existence. We simply cannot know. That uncertainty is legally conclusive, and (subject to resource allocation questions and views about the relevance of family wishes and the previously expressed wishes of the patient) should be ethically conclusive. (shrink)

Autonomous decision-making over therapy options is not reducible to the refusal of unwanted medical intervention. This is a myth that has been imported from questionable assumptions in political economy, and is of little benefit to medical practice and the sometimes agonizing decisions which have to be taken by patients and their relatives. An individual's right to therapy abatement can be protected from abuse only in the context of a full understanding of autonomous choice; not merely the right to refuse, but (...) the opportunity to receive assistance and consider alternatives. Limits are also required on the role of the surrogate in the refusal of therapy. Policies endorsing therapy abatement and exercise of the right to forego life-sustaining therapy should carry cast iron guarantees that they will not be disadvantageous to the poor and undereducated members of society. It should also be noted that fears of unlimited life-prolongation have been greatly exaggerated. In an atmosphere of governmental indifference to the plight of the sick, with the notion of welfare tuned to market forces, there is a danger that self-determination can have a restricted meaning; the option of death in the context of an underfunded health service. This may not be the time to campaign for the right to refuse therapy, but rather the time to campaign for improvements to existing therapy. (shrink)

Bec explores the significance of gestures in Flusser’s work, linking them to Flusser’s writing activity as well as to Flusser himself. Through his gestures, his gesticulating, he moved to move others. The world manifests itself in gestures. New gestures may appear, influencing and changing how we relate to reality. The new gestures of photographing, filming, and videotaping will alter our ways of existence in that they anticipate a new cybernetic form of life.

Currently, in England and Wales, Court of Protection’s Practice Directive 9E (PD9E) requires all cases of proposed withdrawal or withholding of life-sustaining treatment in relation to adults in a permanent vegetative state (PVS) or minimally conscious state be referred to the Court. This paper looks at the origins of PD9E and contrasts the routine requirement to refer cases to court with the complex clinical terrain that comprises those suffering from prolonged disorders of consciousness. We look at the role of (...) the court in decision making in these contexts and we ask what role the courts are called on to play in these decisions. We argue that PD9E, as currently drafted, is too imprecise to achieve its purpose. With our focus always on the best interests of patients, we argue that most decisions of this nature should be made according to a strict protocol but without the need for court approval. Court overview should be reserved for cases of disagreement between those involved in the decision that cannot be resolved by other methods, where there are serious doubts about the individual’s best interests or where there are legally untested aspects to the decision. (shrink)

“Playing God” is the charge frequently leveled when physicians and patients agree to withdraw life-sustaining medical treatments and let the patient die. The accusation rings hollow in the context of four hundred years of moral reflection on the duty of an individual to undergo medical treatments to preserve life. From the teachings of Soto and Banez in the 16th century through the President's, Commission 1983 report ‘deciding to forego life-sustaining treatments’ there is a clear and constant teaching (...) that though life is sacred it is not an absolute and our moral duty to preserve it is limited and based on rational reflection. No patient need undergo any treatment or procedure that is “disproportionately” costly, burdensome, or painful. The assessment of whether to accept or reject a proposed treatment is in part subjective and belongs to the individual patient. The only remaining issue is how to make that judgment for those unable to speak for themselves. (shrink)