The development and consultation experience of an ethics committee in an urban community hospital has been presented, and various approaches to case consultation have been considered. Our committee has concentrated on the clinical evaluation model. As expected, most consultations have centered on issues of withdrawing or limiting medical care. Most patients evaluated have been unable to clearly express their wishes concerning further treatments, highlighting the need for promoting advance directives. When resorting to substituted judgment, our committee has supported continued care (...) in a majority of cases. Limitation of the consultation process to the attending physician has, in our experience, actually served to increase the credibility of the committee and has promoted acceptance of its recommendations. The committee's most useful function seems to be in assisting physicians and their patients in defining realistic goals and limitations of treatment. Within this context, the coming decade may find ethics committees concerned less with promoting the autonomous wishes of individual patients than with defining the limits of that autonomy against the competing demands of the larger society. Such a shift be approached with caution. (shrink)

These last words are titled “Conclusion,” but they should be “Inception.” Professor Jacob Needleman encourages a vigorous conversation about commercialism in medicine. An honest conversation, he maintains, will spur understanding, indignation, and reformation. We do sincerely hope that such a conversation begins and is carried on to meaningful change. However, as the essays in this collection show, that conversation must take place in many different places and about many different things. All of our authors acknowledge that the problem of commercialism (...) is extremely complex. It cannot be understood as a simple fact or a single feature of modern healthcare. Thus, the conversation that discusses it must be varied and diverse. (shrink)

Don't you just know it. It's a relatively peaceful day and you are getting some quality work done when the phone rings. The caller requests help in the form of an ethics consult. When you first hear about it you think someone is pulling your leg, but no, this is the real world. A case like this exemplifies many of the twists and turns of fact, and belief, that accompany many clinical ethics consultations. Several of the facts of the case (...) generate an immediate emotional response that tempts the mind to run with them down enticing and confusing paths of thought. The age 19, is a minor in some states, but not in many. This introduces the whole notion of decisionmaking by parents or designated surrogates. Additional information suggests the comatose victim's mother is the prime motivator behind the request. The various motivations for the mother are revealed, primarily her desire to have a grandchild. The patient's own feelings are portrayed as ambivalent and the potential recipient, after the patient's sisters had been excluded because of consanguinity, is a 16-year-old girl who didn't even show up at the care conference. You are also told that the technical feasibility of the medical procedure under consideration is questionable and, of course, your legal department can't give you a straight answer—just hazard a guess. (shrink)

An icy wind blows through your cotton shirt while you sit outside the hospital door, waiting for your wife to bring up the car. The warm August day, when you entered the emergency room, has transformed into a gray November one. Your mind returns to Dr. Snipe.