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In the recent medical ethics literature, several authors have recommended terminal sedation and refusal of hydration and nutrition as important, morally acceptable, and relatively uncontroversial treatment options for end-of-life suffering. However, not all authors use these terms to refer to the same practices. This paper examines the various ways that the terms terminal sedation and refusal of hydration and nutrition have been used in the medical literature. Although some of these practices are ethically appropriate responses to end-of-life suffering, others (at least as they are currently described in the medical ethics literature) are not. This paper identifies and discusses the principles that morally distinguish these practices from one another and specifically describes different features of medical practices and moral principles that affect the moral acceptability of various medical treatments. These distinctions reveal the complexity of the issues surrounding terminal sedation and refusal of hydration and nutrition, a complexity that has not been adequately addressed in recent discussions.

Medical professional codes have long prohibited physician involvement in assisting a patient's suicide. However, despite ethical and legal prohibitions, calls for the liberalization of this ban have grown in recent years. The medical profession should articulate its views on the arguments for and against changes in public policy and decide whether changes are prudent. In addressing such a contentious issue, physicians, policymakers, and society must fully consider the needs of patients, the vulnerability of particular patient groups, issues of trust and professionalism, and the complexities of end-of-life health care. Physician-assisted suicide is prominent among the issues that define our professional norms and codes of ethics. The American College of Physicians-American Society of Internal Medicine (ACP-ASIM) does not support the legalization of physician-assisted suicide. The routine practice of physician-assisted suicide raises serious ethical and other concerns. Legalization would undermine the patient-physician relationship and the trust necessary to sustain it; alter the medical profession's role in society; and endanger the value our society places on life, especially on the lives of disabled, incompetent, and vulnerable individuals. The ACP-ASIM remains thoroughly committed to improving care for patients at the end of life.

Background: Patients' loved ones often make end-of-life treatment decisions, but the accuracy of their substituted judgments and the factors associated with accuracy are poorly understood. Objective: To assess the accuracy of judgments made by surrogate decision makers; ascertain the beliefs, practices, and clinical and sociodemographic factors associated with accuracy of surrogates' decisions; assess the preferences of patients for life-sustaining treatments; and compare differences in accuracy across diagnoses. Design: Cross-sectional paired interviews. Setting: Outpatient practices of three university hospitals. Patients: 250 patients with terminal diagnoses of congestive heart failure, AIDS, amyotrophic lateral sclerosis, lung cancer, and chronic obstructive pulmonary disease (50 patient-surrogate pairs in each group) and 50 general medical patients and their surrogates. Measurements: The accuracy of surrogate predictions was measured by using scales based on 10 potential treatments in each of three hypothetical clinical scenarios. Results: Preferences varied according to mode of treatment and scenario. On average, surrogates made correct predictions in 66% of instances. Accuracy was better for the permanent coma scenario than for the scenarios of severe dementia or coma with a small chance of recovery (P [is less than] 0.001). In a binary logit model, the accuracy of substituted judgments was positively associated with the patient having spoken with the surrogate about end-of-life issues (odds ratio [OR], 1.9 [95% Cl, 1.6 to 2.3]), the patient having private insurance (OR, 1.4 [Cl, 1.1 to 1.71), the surrogate's level of education (OR, 1.5 [Cl, 1.2 to 1.9]), and the patient's level of education (OR, 1.7 [Cl, 1.4 to 2.2]). Accuracy was negatively associated with the patient's belief that he or she would live longer than 10 years (OR, 0.6 [Cl, 0.5 to 0.7]), surrogate experience with life-sustaining treatment (OR, 0.4 [Cl, 0.3 to 0.5]), surrogate participation in religious services (OR, 0.67 [Cl, 0.50 to 0.91]), and a diagnosis of heart failure (OR, 0.6 [Cl, 0.5 to 0.8]). Age, ethnicity, marital status, religion, and advance directives were not associated with accuracy. Conclusions: The accuracy of substituted judgments is associated with multiple clinically apparent patient and surrogate factors. This information can help clinicians identify conditions under which substituted judgments are likely to be accurate or inaccurate and can help target populations for education designed to improve the accuracy of surrogate decision making., Substituted judgments may not always accurately reflect the wishes of terminally ill patients. Substituted judgments are decisions about medical care made by the friends or family of the patient when the patient can no longer make them. Researchers interviewed 250 patients and their surrogate decision makers to assess the accuracy of the surrogates' judgment. Surrogate accuracy was 66% on average but varied depending on several factors. Accuracy was greater if the patient and surrogate had discussed end-of-life issues. Other factors were associated with less accurate judgment.

Over the last decade, the number of pharmaceutical benefits managers has increased, and their influence has expanded rapidly. These managers now provide prescription drug coverage to more than 100 million Americans. The effect of pharmaceutical benefits managers on health care delivery remains unclear. We review the development of these organizations, their current role in the delivery of pharmaceutical therapies to patients, and their relationship with pharmaceutical manufacturers. We discuss potential advantages and disadvantages of pharmaceutical benefits manager practices and suggest ways in which these organizations can be made more accountable to the employer groups that hire them., There needs to be more accountability from pharmaceutical benefits managers. Employers and health maintenance organizations hire pharmaceutical benefits managers to reimburse and track drug costs as well as oversee approved drug lists. Researchers surveyed the literature and interviewed a series of pharmaceutical benefits managers, employers, and drug companies to evaluate their current practices of prescription drug management and suggested areas for improvement. Pharmaceutical benefits managers reimburse drug costs to participants either from a defined list of drugs or at a discount if the defined list is used. These managers update participating doctors on current drug recommendations and report on costs generated by these doctors. It may be advisable for pharmaceutical benefits managers to maintain open drug lists due to the recent purchases of many benefits managers by drug companies. These managers could more effectively track cost and drug benefits.