The Journal of clinical ethics
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... While clinical practice is clearly moving toward more compassionate use of sedatives and analgesics in the care of the dying, the legal system has been lagging behind most ethical opinions in this area. The criminal investigation into the administration of morphine to a patient before ventilator withdrawal in Minnesota was a grim reminder of the hazards sometimes involved in the practice of good medicine. ⋯ The fact that the caregivers involved are willing to risk the potentially disastrous consequences of falsifying a medical record can be taken as evidence of their commitment to doing what they perceive to be morally required. Nevertheless, this practice should clearly be condemned, since it gives the impression that caregivers are engaged in an unlawful or unethical practice. Only through continued forthright discussion in the medical literature can we arrive at ethically defensible approaches to administering sedation and analgesia that assure the most compassionate care of the dying patient.
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In his carefully crafted article, which, it is hoped, will stimulate further dialogue about this issue, David J. Doukas reviews some of the literature on this subject. He does not seem to differentiate between the family's role in decision making for competent or incompetent patients. ⋯ He favors a family covenant, one in which trust accumulates over time, and he offers a model of such a covenant. At first blush, the notion of covenant rather than the notion of contract seems far more suited to the medical milieu. I have no problem with the idea of covenant and trust, but I have serious reservations about its implementation....
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Hospital policies...have a very limited role in addressing the substantive issue of authority with regard to nonbeneficial therapies. First, they could not be limited, as Mishkin suggests, to persons in a persistent vegetative state. Nonbeneficial therapies encompass many other scenarios including ineffective cancer chemotherapy or open-heart surgery on profoundly demented persons. ⋯ Third, the novel, declarative approach directly risks a precedent that would affirm the family's right to demand futile therapy.... Ultimately, when public policy on this kind of dispute is clearer, a declarative strategy may well be preferable. For now, the Wanglie case has outlined the fundamental issues of this novel legal question and has generated a fruitful discussion of a complex issue in patient care and public policy.
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Erich H. Loewy proposes to elevate the moral obligation to prevent and relieve suffering to the level of a prima facie moral duty by delineating which beings are of primary moral worth and which are of secondary moral worth. Sentient beings have a capacity to suffer and are therefore of primary moral worth. Beings that are insentient cannot suffer; therefore such beings are only of secondary moral worth. Objects of secondary moral worth include patients in a persistent vegetative state (PVS) and brain-dead patients. This proposal, he says, would solve a number of problems in clinical bioethics. First, it would help to clarify our moral duties at the bedside. And secondly, by creating a hierarchy of moral values, it helps to differentiate which patients are owed our primary allegiance and resources. Despite his extensive and painstaking proof, I believe several questions remain about the use of the "capacity of sentient beings to suffer" as a basis for a universal grounding in ethics.