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Medical professional societies have traditionally opposed physician-assisted suicide and euthanasia (PAS-E), but this opposition may be shifting. We present 5 reasons why physicians shouldn't be involved in PAS-E. 1. Slippery slopes: There is evidence that safeguards in the Netherlands and Belgium are ineffective and violated, including administering lethal drugs without patient consent, absence of terminal illness, untreated psychiatric diagnoses, and nonreporting; 2. Lack of self-determination: Psychological and social motives characterize requests for PAS-E more than physical symptoms or rational choices; many requests disappear with improved symptom control and psychological support; 3. Inadequate palliative care: Better palliative care makes most patients physically comfortable. Many individuals requesting PAS-E don't want to die but to escape their suffering. Adequate treatment for depression and pain decreases the desire for death; 4. Medical professionalism: PAS-E transgresses the inviolable rule that physicians heal and palliate suffering but never intentionally inflict death; 5. Differences between means and ends: Proeuthanasia advocates look to the ends (the patient's death) and say the ends justify the means; opponents disagree and believe that killing patients to relieve suffering is different from allowing natural death and is not acceptable., Conclusions: Physicians have a duty to eliminate pain and suffering, not the person with the pain and suffering. Solutions for suffering lie in improving palliative care and social conditions and addressing the reasons for PAS-E requests. They should not include changing medical practice to allow PAS-E.

Arguments against physicians' claims of a right to refuse to provide tests or treatments to patients based on conscientious objection often depend on two premises that are rarely made explicit. The first is that the protection of religious liberty (broadly construed) should be limited to freedom of worship, assembly, and belief. The second is that because professions are licensed by the state, any citizen who practices a licensed profession is required to provide all the goods and services determined by the profession to fall within the scope of practice of that professional specialty and permitted by the state, regardless of any personal religious, philosophical, or moral objection. In this article, I argue that these premises ought to be rejected, and therefore the arguments that depend on them ought also to be rejected. The first premise is incompatible with Locke's conception of tolerance, which recognizes that fundamental, self-identifying beliefs affect public as well as private acts and deserve a broad measure of tolerance. The second premise unduly (and unrealistically) narrows the discretionary space of professional practice to an extent that undermines the contributions professions ought to be permitted to make to the common good. Tolerance for conscientious objection in the public sphere of professional practice should not be unlimited, however, and the article proposes several commonsense, Lockean limits to tolerance for physician claims of conscientious objection.

It might seem ironic that the author in this mini-symposium who knew Edmund Pellegrino the best should be the one whose essay is the least personal,eschewing anecdote and reminiscence and concentrating on the substance of his scholarly contribution. I think, however, that for Ed, an exposition of his ideas would be the most fitting tribute one could offer. Accordingly, I will attempt to outline his main ideas and bring together his disparate writings in a constructive manner. I do this firstly because there really is no other such brief exposition of his main ideas anywhere in the bioethics literature. Moreover, Pellegrino himself made no attempt to provide an explicit synthesis of his various writings on various topics, and so I will attempt to make explicit a number of implicit connections.Lastly, inasmuch as bioethics has developed dramatically as a field over the last 40 years, there may be young scholars who are unfamiliar with Pellegrino’s truly seminal work. A brief overview of his body of scholarship might spur them togo to the primary sources. If I succeed in interesting such persons in reading the work of Edmund Pellegrino, or inspire others to look again at that work with fresh eyes, I believe they will be richly rewarded.

The value of cancer care has emerged at the center of a national discourse on fiscal responsibility and resource allocation. The cost of cancer care is rising at a higher pace than any other area of health care. As we struggle to address this unsustainable rise in cancer expenditures, oncology providers are forced to examine our practice patterns and our contributions to the overall health care cost burden. This article provides an oncologist-centered examination of our duties to individual patients and how they may seem at odds with our duties to society. It also discusses how oncology providers can do their part to contain health care costs while honoring their professional obligation to do their best for each patient.

Context: Debates persist about the relevance of "dignity" as an ethical concept in U.S. health care, especially in end-of-life care., Objectives: To describe the attitudes and beliefs regarding the usefulness and meaning of the concept of dignity and to examine judgments about a clinical scenario in which dignity might be relevant., Methods: Two thousand practicing U.S. physicians, from all specialties, were mailed a survey. Main measures included physicians' judgments about an end-of-life clinical scenario (criterion variable), attitudes about the concept of dignity (predictors), and their religious characteristics (predictors)., Results: Responses were received from 1032 eligible physicians (54%). Nine (90%) of 10 physicians reported that dignity was relevant to their practice. After controlling for age, gender, region, and specialty, physicians who judged that the case patient had either some dignity or full dignity, and who agreed that dignity is given by a creator, were all positively associated with believing that the patient's life was worth living (odds ratio [OR] 10.2, 95% confidence interval [CI] 5.8-17.8, OR 20.5, 95% CI 11.4-36.8, OR 4.7, 95% CI 3.1-7.0, respectively). Respondents who strongly agreed that "all living humans have the same amount of dignity" were also more likely to believe that the patient's life was worth living (OR 1.8, 95% CI 1.2-2.7). Religious characteristics also were associated with believing that the case patient's life was worth living (OR 4.1, 95% CI 2.4-7.2, OR 3.2, 95% CI 1.6-6.3, OR 9.2, 95% CI 4.3-19.5, respectively)., Conclusion: U.S. physicians view the concept of dignity as useful. Those views are associated with their judgments about common end-of-life scenarios in which dignity concepts may be relevant., (Copyright © 2012 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved.)

Current approaches to end-of-life decision making are widely considered inadequate. We explored these complexities by examining how patients with terminal diagnoses would choose to involve their physicians and loved ones in making medical decisions, assuming they were able and unable to participate. Cross-sectional interviews of 130 patients recently diagnosed with fatal conditions were conducted. Patients were recruited from two academic medical centers using a modification of the Decision Control Preferences Scale, ranging from independent decision making to decision making that relies upon others. Patients were asked how they would balance their own wishes relative to the input of physician and loved ones in making medical decisions, and to weigh the input of loved ones relative to physician. Most patients (52%), assuming they had the capacity, would opt to share decision making with their physicians, but 15% would defer to their physicians and 34% would make decisions independently. Similarly, 44% would share decision making with their loved ones, but fewer (6%) would defer to their loved ones. Thirty-nine percent would rely upon their physicians' judgments about what would be best for them rather than their own wishes if they became unconscious, compared with 15% who would do so if they were conscious (P < 0.001). Nonetheless, patients were more likely to weigh their loved ones' input more heavily than their physicians' input if they were unconscious (33%) than if they were conscious (7%, P = 0.05). Race, religion, gender, diagnosis, and health status were largely unassociated with patients' decision control preferences. Patients with terminal diagnoses report a wide diversity of decision control preferences, but most would opt to share decision making with their physicians and loved ones. If unable to decide for themselves, they shift toward greater reliance on physician input relative to their own wishes but would weigh loved ones' input more heavily than physician input. Deciding for patients who cannot speak for themselves may be more complex than has previously been reflected in law, policy, or clinical ethics.

Objectives: To assess whether older physicians have discussed their preferences for medical care at the end of life with their physicians, whether they have established an advance directive, and what life-sustaining treatment they wish in the event of incapacity to make these decisions for themselves., Design: Mailed survey to a cohort of physicians., Setting: Physicians who were medical students at the Johns Hopkins University in graduating classes from 1946 to 1964., Participants: Physicians who completed the advance directive questionnaire (mean age 68)., Measurements: Questionnaires were sent out to known surviving physicians of the Precursors Study, an on-going study that began in 1946, asking physicians about their preferences for life-sustaining treatments., Results: Of 999 physicians who were sent the survey, 765 (77%) responded. Forty-six percent of the physicians felt that their own doctors were unaware of their treatment preferences or were not sure, and of these respondents, 59% had no intention of discussing their wishes with their doctors within the next year. In contrast, 89% thought their families were probably or definitely aware of their preferences. Sixty-four percent reported that they had established an advance directive. Compared with physicians without advance directives, physicians who established an advance directive were more likely to believe that their doctors (odds ratio (OR) = 3.42, 95% confidence interval (CI) = 2.49-4.69) or family members (OR = 9.58, 95% CI = 5.33-17.23) were aware of their preferences for end-of-life care and were more likely to refuse treatments than those without advance directives., Conclusion: This survey of physicians calls attention to the gap between preferences for medical care at the end of life and expressing wishes to others through discussion and advance directives, even among physicians.

Physician recommendations have historically been a part of shared decision making. Recent literature has challenged the idea that physician recommendations should be part of shared decision making at the end of life, particularly the making of recommendations to surrogates of incapacitated patients. Close examination of the studies and the available data on surrogate preferences for decisional authority at the end of life, however, provide an empirical foundation for a style of shared decision making that includes a physician recommendation. Moreover, there are independent ethical reasons for arguing that physician recommendations enhance rather than detract from shared decision making. [ABSTRACT FROM AUTHOR]

Abstract: Every ethos implies a mythos in the sense that every systematic approach to ethics is inevitably based on some fundamental religious or religion-like story that gives answers to questions such as: Where did I come from? Where am I going? How am I to live? These narratives generally lay hidden beneath the plane of the interpersonal interactions that characterize all clinical encounters, but caring for patients who are approaching death brings them closer to the surface. For many patients and practitioners, these narratives will be expressed in explicitly religious language; others may invoke a sense of “immanent transcendence” that affords a spiritual perspective without requiring theism or notions of eternity. In caring for patients at the end of life, practitioners should strive to be more conscious of the narratives that undergird their own spiritual and ethical positions as well as seek to understand those of the patients they serve. [Copyright &y& Elsevier]

The article offers guidance on when to incorporate spirituality and religion in clinical care. According to the author, religions provide patients with specific moral guidance on several medical issues and suggest rituals that are important to patients. He stresses the positive and negative aspects of religious coping which can impact patient care. He also discusses the definition of spirituality and religion, spiritual issues that serious illness presents for patients and the moral obligations of physicians in addressing patients' spiritual concerns.

The article discusses the difference between authentic faith in miracles and the psychological denial in the middle of serious illness. According to the author, atheists who consider all religious beliefs are just a mere delusion would not bother to accept the meaningfulness of the distinction. However, this distinction will be easy in any clinical case. Thus, he suggests several questions that would distinguish between authentic faith in miracles and the psychiatric state of denial.

OBJECTIVES: To determine the role terminally ill patients would opt to have their loved ones and physicians play in healthcare decisions should they lose decision-making capacity and how this changes over time. DESIGN: Serial interviews. SETTING: The study institutions were The Johns Hopkins Medical Institutions in Baltimore, Maryland, and St. Vincent's Hospital, in New York. PARTICIPANTS: One hundred forty-seven patients with cancer, amyotrophic lateral sclerosis, or heart failure, at baseline and 3 and 6 months. RESULTS: Patients' baseline decision control preferences varied widely, but most opted for shared decision-making, leaning slightly toward independence from their loved ones. This did not change significantly at 3 or 6 months. Fifty-seven percent opted for the same degree of decision control at 3 months as at baseline. In a generalized estimating equation model adjusted for time, more-independent decision-making was associated with college education ( P=.046) and being female ( P=.01), whereas more-reliant decision-making was associated with age ( P<.001). Patients leaned toward more reliance upon physicians to make best-interest determinations at diagnosis but opted for physicians to decide based upon their own independent wishes (substituted judgment) over time, especially if college educated. CONCLUSION: Terminally ill patients vary in how much they wish their own preferences to control decisions made on their behalf, but most would opt for shared decision-making with loved ones and physicians. Control preferences are stable over time with respect to loved ones, but as they live longer with their illnesses, patients prefer somewhat less reliance upon physicians. [ABSTRACT FROM AUTHOR]

We report on the adaptation and evaluation of a previously developed patient-centered instrument that we call the Quality of End-of-life care and Satisfaction with Treatment (QUEST) scale. In a separate group of 30 inpatients, test–retest reliability for QUEST items ranged from 63% agreement (kappa = 0.43) to 93% agreement (kappa = 0.86) and construct validity was evidenced by correlations with a somewhat related satisfaction scale ranging from 0.38 to 0.47. QUEST was then administered to 206 consecutive medical inpatients (or their surrogates) with DNR orders and to a comparison group of 51 medical inpatients without DNR orders at 2 academic medical centers. Among these main study patients, internal consistency was reflected by Cronbach alphas of 0.88 to 0.93. QUEST scores showed modest inverse correlations with severity of symptoms, but were uncorrelated with severity of illness, anxiety, or depression, suggesting an appropriate relationship to symptom control but divergence of the underlying construct from degree of physical illness or affective state. QUEST scores were lower for patients with DNR orders compared to those without DNR orders (P = 0.02 to 0.06). Surrogate ratings of satisfaction and quality were uncorrelated with patient ratings. Although preliminary, these findings suggest that QUEST may be useful in assessing quality and satisfaction with the care rendered by physicians and nurses to hospitalized patients at the end of life. [Copyright &y& Elsevier]

Provides suggestions to physicians on how to respond when patients near the end of life or their families raise spiritual or religious concerns. Need for physicians to explore a patient's religious beliefs to help them think through their preferences regarding specific interventions; Recommendation for physicians to listen to patients and try to understand their viewpoint; Assertion that by responding to patients' spiritual and religious concerns and needs, physicians may help them find comfort and closure near the end of life.

Focuses on the ethical beliefs of physicians about cost-control arrangements in health care. Efforts by health care plans to discourage physicians from telling patients about expensive treatment options or their personal financial incentives; Decrease in physicians' ethic of undivided loyalty to patients; Impact of changes in American health care system on patients' trust in their physicians.

Comments on the morality of the clinical practice of the Doctrine of Double Effect in caring terminally ill patients. Misinterpretations of the meaning and scope of the doctrine; Distinction between responsibility and culpability; Clinical importance of intention in double-effect reasoning; Implications of the doctrine for administering medical treatment.

Rising health care expenditures have led to numerous cost-control proposals. An examination of the ethical questions surrounding the role that physicians play in the control of health care costs suggests that unilateral rationing decisions by individual physicians at the bedside are morally unacceptable. Such decisions are arbitrary, ineffective in redistributing health care resources, and formally unjust. Restrictive gatekeeping (the creation of financial incentives for physicians to limit care given to individual patients) also seems unacceptable because of its morally significant effects. First, it disguises the role of those actually responsible for cost-control decisions; second, it routinely creates a "moral stress test" by forcing physicians to act in ways that are contrary to their own interests in order to serve the needs of patients; third, it undermines the trust between doctor and patient; and fourth, it rations by class of persons rather than class of technology. In contrast, a morally sound system would attempt to control costs by honestly informing patients and assigning responsibility justly, would encourage physicians to act in the interests of patients, would foster trust, and would recognize the great importance of equal treatment for all patients. Such a system would depend on input from an informed public and would apply equally to all members of society. [ABSTRACT FROM AUTHOR]

In the Republic, Plato recounts the myth of Gyges, who wore a ring that allowed him to become invisible simply by turning the ring around his finger.[sup 1] Gyges misused the ring's powers to seduce the wife of the king, kill him, and take over the country. The lesson that Plato drew from this myth was that the person of true virtue is the one who can be trusted to do the right thing, even when no one is looking. In a way, two very different articles in this issue of the Journal of General Internal Medicine can both claim the myth of Gyges as a philosophical ancestor. One is about measuring trust in physicians,[sup 2] and the other is about educating medical students to become precisely those sorts of physicians who can be trusted to do the right thing for their patients.[sup 3] As Branch writes, "Medicine, after all, is a moral profession." Yet medicine is increasingly viewed as just another business, and the concept of medicine as a profession, as a "special" endeavor with a different set of moral obligations and expectations,[sup 4] has been denounced as elitist, self-serving, and detrimental to the spirit of the competitive marketplace.[sup 5-7] Some fear that the recent financial reorganization of health care, premised upon the notion that there is nothing special about medicine, poses a particularly grave threat to the essence of medicine as a profession.[sup 8,9] Others argue that the professionalism of medicine can be reconstructed in such a way that it can guard against the financial forces that threaten to undermine its moral potency. [ABSTRACT FROM AUTHOR]

Examines the moral implications of the physician's role as a gatekeeper to medical services. Problem of controlling health care costs; Factitious and restrictive gatekeeping; Institution of malpractice reforms; Use of morally sound rationing.

Looks at the controversy surrounding the role of spiritual beliefs in the patient-physician relationship. Results of a study of patients in Vermont who thought a physician had a right to ask about religious beliefs and how many felt it was the physician's responsibility to do so; Findings of other small studies on the topic; Studies on the role of religion in patients' disease management; Reasons for weaknesses in the studies.