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Technical and clinical developments have raised challenging questions about the concept and practice of brain death, culminating in recent calls for revision of the Uniform Determination of Death Act (UDDA), which established a whole brain standard for neurologic death. Proposed changes range from abandoning the concept of brain death altogether to suggesting that current clinical practice simply should be codified as the legal standard for determining death by neurologic criteria (even while acknowledging that significant functions of the whole brain might persist). We propose a middle ground, clarifying why whole brain death is a conceptually sound standard for declaring death, and offering procedural suggestions for increasing certainty that this standard has been met. Our approach recognizes that whole brain death is a functional, not merely anatomic, determination, and incorporates an understanding of the difficulties inherent in making empirical judgments in medicine. We conclude that whole brain death is the most defensible standard for determining neurologic death—philosophically, biologically, and socially—and ought to be maintained. [ABSTRACT FROM AUTHOR]

The article presents a case study of a 43-year-old woman with insomnia whose spiritual concerns were addressed by her physician through referral to a hospital chaplain. Topics discussed include the role of physicians in addressing patients' spiritual needs, ethical considerations surrounding religious practices in medical settings, and the importance of respecting patients' beliefs and identities.

The authors reflect on the biological, ontological and epistemological status of the patient/donor during the process of controlled donation following circulatory determination of death. They initially express gratitude to Nielsen Busch for their article "Does Controlled Donation After Circulatory Death Violate the Dead Donor Rule?" They explain the rational foundations proposed as to when to declare death, namely, capacity for life approach and potentiality for life approach.

One major argument against prohibiting euthanasia and physician-assisted suicide (PAS) is that there is no rational basis for distinguishing between killing and allowing to die: if we permit patients to die by forgoing life-sustaining treatments, then we also ought to permit euthanasia and PAS. In this paper, the author argues, contra this claim, that it is in fact coherent to differentiate between killing and allowing to die. To develop this argument, the author provides an analysis of Saint Augustine's distinction between martyrdom and suicide, highlighting the relevance of intention in the assessment of an agent's actions. As a general matter of ethics, the intentions of agents, not just the outcomes of their actions, matter enormously for drawing distinctions between what is permissible and what is impermissible. Constructing an Augustinian account of this distinction between killing and allowing to die, the author argues that it is coherent to hold that assisted suicide is wrong, while also accepting that it is permissible to withhold or withdraw life-sustaining treatments. [ABSTRACT FROM AUTHOR]

Euthanasia and rational suicide were acceptable practices in some quarters in antiquity. These practices all but disappeared as Hippocratic, Jewish, Christian, and Muslim beliefs took hold in Europe and the Near East. By the late nineteenth century, however, a political movement to legalize euthanasia and physician-assisted suicide (PAS) began in Europe and the United States. Initially, the path to legalization was filled with obstacles, especially in the United States. In the last few decades, however, several Western nations have legalized euthanasia, and several US jurisdictions have now legalized PAS, giving state sanction to these once forbidden practices. With increasing social and political pressure to accept PAS, Christians need to understand how to think about this issue from an explicitly Christian perspective. Independent of the question of legalization, there are significant theological and ethical questions. This special issue aims to address those concerns, including: how does the practice of PAS or euthanasia impact our attitudes toward death, and what does it mean to "die well?" Should physicians, as healers, be involved in assisting patients who wish to bring about their own death? Are these methods significantly distinguished from other ethically justified practices in end-of-life care that also lead to a person's death? Can Christians, both as patients and practitioners, justify the use of these methods to relieve suffering in this manner as compatible with the faith? Although these questions are not new to the debate, it is increasingly important that these controversies are addressed as the practice of PAS is popularized. [ABSTRACT FROM AUTHOR]

New Natural Law Theory and the Catholic medico-moral tradition often lead to similar conclusions in hard cases regarding end-of-life care. Considering the provision of artificial nutrition and hydration to patients suffering from post-coma unresponsive wakefulness, however, brings to light subtle ways in which NNL differs from the centuries-old natural law tradition. In this essay, I formalize the methodology embedded within the casuistry of the medico-moral tradition and show how it differs from NNL with respect to the role played by double-effect reasoning and the perspective for analyzing cases regarding care for those who cannot speak for themselves. Importantly, the ordinary/extraordinary means distinction has never historically been understood as an application of double effect and logically cannot be so understood. Given the outsized role that double effect plays in NNL, the theory leads to conclusions that deviate from the Catholic medico-moral tradition and creates additional burdens and duties for the sick. [ABSTRACT FROM AUTHOR]

Most hospitalized patients die following a decision to forgo life-sustaining treatment and/or focus on comfort care. Since "Do not kill" is a general ethical norm, many healthcare professionals (HCPs) are uncertain or troubled by such decisions. We propose an ethical framework to help clinicians to understand better their own ethical perspectives about four end-of-life practices: lethal injections, the withdrawal of life-sustaining therapies, the withholding of life-sustaining therapies, and the injection of sedatives and/or analgesics for comfort care. This framework identifies three broad ethical perspectives that may permit HCPs to examine their own attitudes and intentions. According to moral perspective A (absolutist), it is never morally permissible to be causally involved in the occurrence of death. According to moral perspective B (agential), it may be morally permissible to be causally involved in the occurrence of death, if HCPs do not have the intention to terminate the patient's life and if, among other conditions, they ensure respect for the person. Three of the four end-of-life practices, but not lethal injection, may be morally permitted. According to moral perspective C (consequentialist), all four end-of-life practices may be morally permissible if, among other conditions, respect for persons is ensured, even if one intends to hasten the dying process. This structured ethical framework may help to mitigate moral distress among HCPs by helping them to understand better their own fundamental ethical perspectives, as well as those of their patients and colleagues. [ABSTRACT FROM AUTHOR]

It has been proposed that medical organizations adopt neutrality with respect to physician-assisted suicide (PAS), given that the practice is legal in some jurisdictions and that membership is divided. We review developments in end-of-life care and the role of medical organizations with respect to the legalization of PAS since the 1990s. We argue that moving from opposition to neutrality is not ethically neutral, but a substantive shift from prohibited to optional. We argue that medical organizations already oppose many practices that are legal in many jurisdictions, and that unanimity among membership has not been required for any other clinical or ethical policy positions. Moreover, on an issue so central to the meaning of medical professionalism, it seems important for organized medicine to take a stand. We subsequently review the arguments in favor of PAS (arguments from autonomy and mercy, and against the distinction between killing and allowing to die (K/ATD)) and the arguments against legalization (the limits of autonomy, effects on the patient-physician relationship, the meaning of healing, the validity of the K/ATD distinction, the social nature of suicide, the availability of alternatives, the propensity for incremental extension, and the meaning of control). We conclude that organized medicine should continue its opposition to PAS. [ABSTRACT FROM AUTHOR]

This is a response to the article by Susan Merel [ABSTRACT FROM AUTHOR]

Prestigious University is a large, private educational institution with a medical school, a university hospital, a law school, and graduate and undergraduate colleges all on a single campus. In the face of the Covid‐19 pandemic, students were told during spring break to return to campus only briefly to retrieve their belongings. Classes then went online. On March 23, 2020, the faculty, students, and staff were emailed the following by the university's director of infection control and public health:We have become aware that a Prestigious University staff member has tested positive for the virus that causes Covid‐19. The individual, who was last on campus on March 16, is now in isolation at their permanent residence and is doing well clinically. The university has already identified those members of our community who may have been in close contact with this individual, and we are working to notify them. Further, this individual's local health department has a protocol for identifying people who have been in direct contact with anyone testing positive for Covid‐19 (such as this Prestigious University staff member) so that they can self‐quarantine and watch for COVID‐19 symptoms for a period of 14 days from their last contact with the infected individual. A professor in the Philosophy Department has asked the ethicists at the medical school whether such contact tracing suffices. "Don't the members of the community deserve to know who this is? Isn't there a mandate to identify this person in order to maximize public health benefits and slow the spread of this deadly virus?" [ABSTRACT FROM AUTHOR]

Context: Patients with terminal illnesses often require surrogate decision makers. Prior research has demonstrated high surrogate stress, and that despite standards promoting substituted judgment, most patients do not want their surrogates to make pure substituted judgments for them. It is not known how best to help loved ones fulfill the surrogate role.Objectives: To test the effectiveness of an intervention to help surrogate decision makers.Methods: One hundred sixty-six patients (41% with amyotrophic lateral sclerosis and 59% with gastrointestinal cancers) and their surrogates at two university medical centers were randomized to an intensive nurse-directed discussion of the end-of-life decision control preferences of the patient (TAILORED) or a discussion of nutrition (CONTROL); 163 completed baseline interviews and underwent the intervention.Results: Twelve patients died during follow-up and 137 dyads completed the study. Post-intervention, using all available data, TAILORED patients and surrogates became more likely to endorse mutual surrogate decision making, that is, a balance of their own wishes and what the surrogate thinks best (adjusted odds compared with baseline for patients = 1.78, P = 0.04; adjusted odds for surrogates = 2.05, P = 0.03). CONTROL patients became 40% less likely to endorse mutual surrogate decision making (P = 0.08), and CONTROL surrogates did not change significantly from baseline (adjusted odds = 1.44, P = 0.28). Stress levels decreased for TAILORED surrogates (impact of events scale = 23.1 ± 14.6 baseline, 20.8 ± 15.3 f/u, P = 0.046), but not for CONTROL (P = 0.85), and post-intervention stress was lower for TAILORED than CONTROL (P = 0.04). Surrogates' confidence was uniformly high at baseline and did not change. Caregiver burden (Zarit) increased from 12.5 ± 6.5 to 14.7 ± 8.1 for TAILORED (P < 0.01), while not changing for CONTROL, yet satisfaction with involvement in decision making was higher at follow-up for TAILORED than for CONTROL (71% vs. 52%, P = 0.03).Conclusion: TAILORED patients and surrogates who completed the study adopted a more mutual decision-making style, balancing their own wishes with what the surrogate thinks would be best for them. Surrogates reported less stress and more satisfaction. Confidence was high at baseline and did not change. There was a modest increase in caregiver burden. These findings suggest that interventions like TAILORED might positively impact surrogate decision making. [ABSTRACT FROM AUTHOR]

Important discussions about limiting care based on professional judgment often devolve into heated debates over the place of physicians in bedside rationing. Politics, loaded rhetoric, and ideological caricature from both sides of the rationing debate obscure precise points of disagreement and consensus, and hinder critical dialogue around the obligations and boundaries of professional practice. We propose a way forward by reframing the rationing conversation, distinguishing between the scale of the decision (macro vs. micro) and its context (ordinary allocation vs. extraordinary re-allocation) avoiding the word "rationing." We propose to shift the terminology, using specific, descriptive words to defuse conflict and re-focus the debate towards substantive issues. These distinctions can clarify the real ethical differences at stake and facilitate a more constructive conversation about the clinical and social responsibilities of physicians to use resources ethically at the bedside and their role in allocating medical resources at a societal level. [ABSTRACT FROM AUTHOR]

Shortly after the Presidential Commission for the Study of Bioethical Issues was constituted in 2010 and days before the commission members were to join a conference call to discuss possible topics for their deliberation, Craig Venter held a press conference announcing that his lab had created a synthetic chromosome for a species of mycoplasma and had inserted this genetic material into organisms of another species of mycoplasma (the genes of which had been deactivated), transforming the host species into the donor species. While not overtly claiming to have 'created life in the test tube,' Venter's publicity seemed cleverly designed to provoke the media into reporting his discovery in just that way. The resulting uproar caused President Obama to give his new bioethics commission the assignment of investigating the ethics of the emerging field of synthetic biology. The commission went right to work. It formed working groups to deliberate about parts of the report, feeding ideas and language to the staff members who would do the actual writing, and then present the working group suggestions to the commission as a whole for public deliberation at open meetings. One of those working groups was charged with coming up with ethical principles that would guide the analysis. Having served as a member of that working group, I report here on the process by which these principles emerged and reflect upon the suitability of that process for the work of public bioethics commissions. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Reading the following brief piece depends on having some knowledge of the famous essay to which it refers, Francis W Peabody's "The Care of the Patient," published 90 years ago in the Journal of the American Medical Association (JAMA 88:877--82). Peabody's essay was based on a talk he gave to Harvard medical students in 1925, and it was published shortly before his premature death in 1927. At the time, he was highly regarded as a consummate clinician and teacher, and in his essay, he laments problems he already saw affecting medical practice, such as the overvaluation of science relative to clinical medicine and a diminishing spirit of attentiveness to the most deeply human needs of patients. He deals in an especially astute and compassionate way with the care of patients suffering from what is now known as somatization disorder. Peabody's essay has been widely anthologized, is often an assigned reading for medical students, and has been revered by practitioners and students for almost 100 years. But times are changing ... [ABSTRACT FROM AUTHOR]

As interest in medicine and religion has grown, some have called for a more fervent and explicit "witnessing" by Christian physicians in their practices. This essay presents a theological understanding of witness and how this theology might be applied to the case of Christian witness in health care. Witness must be understood first linguistically as encompassing two nouns and two verbs, all of which have theological meaning. Based on linguistic, scriptural, and theological reflection, suggestions are made regarding how physicians and the Church can both witness Christ and give witness to Christ in the care of the sick. This theological exploration offers new insight into what it means to witness and to heal as a Christian. [ABSTRACT FROM AUTHOR]

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]

This Viewpoint explores several spiritual considerations that may support clinicians in their work and also presents resources that may help clinicians in their professional and personal lives not only during the pandemic but also throughout their careers. [ABSTRACT FROM AUTHOR]

Abstract: Dear Norm, Thank you for sharing such a personal and heartfelt essay. I have been asked by the editors to comment. Reading it inspires me to do so in a similarly heartfelt way. Although I don't know you well, I thought I'd write to you as if you were my patient. I share your sense that Alzheimer disease is a terrible scourge. I've seen much of this disease over a lifetime of practice, and I deeply understand its ravages and the debility and suffering it causes. But what you propose is not a good solution for the problems that Alzheimer disease poses for patients, families, and society. It will ultimately do far more harm than good. Please let me try to explain. [ABSTRACT FROM AUTHOR]

Engelhardt argues that the correct interpretation of the marginalization of Christian voices in the recent history of bioethics is best explained as the acquiescence of Christian bioethicists to secularizing trends rather than as Christian bioethicists having been pushed aside by the philosophers who came to dominate the field. He identifies the origins of this secularization with natural law thinking, which he dubs as “amphibious” with respect to religious thinking and worldly thinking. I argue that this interpretation is incorrect. First, natural law thinking has been an acceptable mode of Christian moral thinking dating back to the Church Fathers. Second, any form of theology requires a philosophical framework, even one’s interpretation of scripture, so that there is no “pure” theology untainted by “worldly” reasoning. Third, Engelhardt’s account of this history commits the secular fallacy and strains credulity. Fourth, his interpretations of Ramsey and McCormick are idiosyncratic at best. By contrast, it is argued that in accepting Christianity one does not thereby reject reason and philosophy. Some guidelines for being “an amphibian”—for example, for doing natural law bioethics as a Christian— are proposed. [ABSTRACT FROM PUBLISHER]

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 to go 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. [ABSTRACT FROM AUTHOR]

The theory of principlism elaborated by Beauchamp and Childress in Principles of Biomedical Ethics has become extremely influential in bioethics. The theory employs the idea of the common morality as a foundation for the principles of autonomy, beneficence, nonmaleficence, and justice. According to this account, the content of the common morality is universal and constant, while variability in morals is due to the fact that the issue of who is included within the scope of moral status evolves over time. This suggests that issues of moral status are not part of the common morality at all, and this presents a conundrum: questions of moral status seem central to any substantive account of justice, and any conception of the common morality that excludes moral status therefore seems inadequate for supporting a robust principle of justice. We argue that proponents of common morality theory are left with four options: (1) making moral status a part of the objective common morality and ignoring evidence that views about moral status do seem to vary over time and place; (2) excluding justice from the substantive content of the common morality; (3) taking common morality to be an imperfect approximation of an independently justified and universal foundationalist ethic against which the common morality is judged; or (4) weakening claims about the universality of common morality, thereby allowing the common morality to support a variety of principles of justice applicable only within particular communities that have specified the scope of moral status. We suspect that proponents of common morality theory will not view any of these options favorably, which raises questions about the ultimate contribution of that account. [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]

Needle- and syringe-exchange programs aim to decrease infections among those who are dependent on injection drugs. Some have questioned whether church sponsorship of such programs constitutes illicit cooperation in the evil of drug abuse. This article examines the question under classical formulations of cooperation and in light of current empirical evidence and concludes that this is not the case. Questions are also raised about whether, if substance dependence is a disease and not a moral failing, an analysis based on cooperation is actually the appropriate category of analysis. [ABSTRACT FROM AUTHOR]

Background and Purpose: After Hurricane Katrina, despite investigations of "painkiller" usage among 140 Katrina-related deaths at hospitals and nursing homes, formal charges were never made, and allegations were dropped; the state paid legal fees of accused. Contested practices occur in plural cultures amidst counterclaims of bias. This aims to identify common metrics among diverse traditions as an ethics of palliative sedation and medical disasters. Methods: Palliative sedation practices raise three kinds of issues; clinical, ethical-legal-political, as well as public health and cultural arguments about accompanied rest (including religious claims). Quantitative data and detailed qualitative commentaries yield consensus among four traditions. Results: Aaron Mackler weighs Jewish practical reasoning. Daniel Sulmasy probes clinical applications of historically Christian double effect categories. Aziz Sachedina explores Muslim end of life decision-making, and William J. Buckley surveys palliative sedation and common law. Conclusions: Three issues demonstrate consensus: (1) who decides (patient-caregivers), (2) how (futility, last resort, no PAS, right to pain management, safeguarded therapy) and (3) why (accompanied rest). Seven practical maxims include: (I) Informed consent in shared decision making processes connects treatment refusals and the provision of palliative sedation (e.g., DNR choices). (II) Futility is collaboratively negotiated with severe, unremitting, refractory symptoms. (III) Palliative sedation is a therapy of last resort. (IV) Palliative sedation does not deliberately terminate terminal patients (not PAS/Euthanasia). (V) Palliative sedation enacts rights to aggressive pain management (VI) by converting mandated relief into cost-effective, safeguarded therapy with consultations, monitoring, and practical stakeholder re-assessments (VII) thereby ritualizing dying as an "anticipatory memory" of accompanied transformation. [ABSTRACT FROM AUTHOR]

The phrase 'the value of life' is important in bioethics, particularly for those who hold the traditional views that life has intrinsic value and that the distinction between killing and allowing to die is valid. Ambiguities in the meaning of 'the value of life,' however, can lead to errors in medical ethical analysis by those who hold these traditional views. This essay notes three sources of such ambiguity: (1) three senses of the verb 'is,' (2) the difference between the transcendent and the transcendental, and (3) the difference between the transcendental and the empirical. On the basis of these distinctions, several conclusions are drawn: that the value of life is transcendental, not transcendent, both finite and priceless, that decisions to withhold or withdraw life-sustaining treatments are always judgments about the qualities of a person's life, so one cannot universally condemn "quality of life judgments," that the traditional distinction between killing and allowing to die tracks the distinction between the transcendental and the empirical, that "life itself" is not a benefit of treatment, and that foregoing treatments that are not futile can be consistent with respect for the value of life. [ABSTRACT FROM AUTHOR]

The article presents a study that explored the patients' justifications for their estimate of expected therapeutic benefit when enrolling in clinical trials. The study seeks to understand what patients mean when they express hope and optimism in the context of early phase clinical trials. An in-depth interview was conducted on research patients enrolling in early phase oncology trials. The study cites that the expressions of high expected therapeutic benefit from trial participants represent expressions of optimism rather than factual knowledge.

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 compares the attitudes and beliefs of attending internists, medical house officers and staff nurses on do-not-resuscitate (DNR) orders and who should conduct DNR discussions with patients and their families in the U.S. Also cited are the various issues' implications for critical care medicine.

Background: Little is known about the long-term effectiveness of recent efforts to improve end-of-life care education at U.S. medical schools. Objective and design: Longitudinal, observational study using national data from the Graduation Questionnaire of the Association of American Medical Colleges from 1998–2006, comparing national trends with those at New York Medical College (NYMC), where a required 1-day clinical rotation to a palliative care hospital began in 1998. Results: The fraction of graduating U.S. students reporting that their instruction time on death and dying was at least adequate rose from 70.8% in 1998 to 79.5% in 2006 ( p < 0.001); instruction time in pain management rated as at least adequate rose from 34.3% in 1998 to 55.3% in 2005 ( p < 0.001); training in palliative care rated as at least adequate rose from 59.9% in 2000 to 74.8% in 2006 ( p < 0.001). Improvement began earlier at NYMC compared with national trends, but by 2004 NYMC was no longer significantly different. In multivariate analyses, women, Asians, and older students gave lower ratings of the quality of their end-of-life care education. Conclusion: While much remains to be done, there have been significant improvements since 1998 in graduating U.S. medical students' ratings of the adequacy of their instruction time in end-of-life care. [ABSTRACT FROM AUTHOR]

As Implantable Cardioverter Defibrillators (ICDs) have become more common, ethical issues have arisen regarding the deactivation of these devices. Goldstein et al., have shown that both patients and cardiologists consider ICD deactivation to be different from the discontinuation of other life-sustaining treatments. It cannot be argued ethically that ICDs raise new questions about the distinction between withholding and withdrawing treatment, and neither the fact that they are used intermittently, nor the duration of therapy, nor the mere fact that they are located inside the body can be considered unique to these devices and morally decisive. However, frequent allusions to the fact that they are located inside the body might provide a clue about what bothers patients and physicians. As technology progresses, some interventions seem to become a part of the patient as a unified whole person, completely replacing body parts and lost physiological functions rather than merely substituting for impaired structure and function. If a life-sustaining intervention can be considered a "replacement"--a part of the patient as a unified whole person--then it seems that deactivation is better classified as a case of killing rather than a case of forgoing a life-sustaining treatment. ICDs are not a "replacement" therapy in this sense. The deactivation of an ICD is best classified, under the proper conditions, as the forgoing of an extraordinary means of care. As technology becomes more sophisticated, however, and new interventions come to be best classified as "replacements" (a heart transplant would be a good example), "discontinuing" these interventions should be much more morally troubling for those clinicians who oppose euthanasia and assisted suicide. [ABSTRACT FROM AUTHOR]

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.

Based on arguments from theology and the philosophy of science, a miracle may be defined as: (1) a real, individual event, the occurrence of which must be (or must have been), at least in principle, susceptible to empirical verification; (2) an event which must be extremely unusual or historically unprecedented from the perspective of empirical scientific knowledge; (3) must evoke wide-spread wonder; (4) must be something freely given by God and not conjured; (5) must be understood as a special sign from God that transcends the bare facts of the case and communicates a spiritual message; and (6) must have been affirmed as a miracle by the community of believers to whom the message of the miracle must be addressed, at least indirectly. [ABSTRACT FROM AUTHOR]

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]

This is a response to the article by Merel et al. [ABSTRACT FROM AUTHOR]

Every ethos implies a mythos. That is, every ethical system depends upon some fundamental story disclosing its assumptions about human nature, freedom, good and evil, and the workings of the universe. A romanticized version of the myth of Prometheus, who stole fire from the gods and was punished by being chained to a rock and having his liver plucked out by vultures, seems to undergird much of contemporary healthcare. Christianity offers a different view—one in which the universe is not a zero sum game and human beings do not need to steal fire because God has already freely given them all the fire they need in Christ and in his spirit. A critical virtue for physicians, taught by Christianity, is sagacious engagement—the ability to engage the world practically, discerning what can and should be changed and what should be accepted as unchangeable and given. The illusory quest for immortality through the practice of regenerative medicine using stem cells is a gross violation of that virtue. [ABSTRACT FROM AUTHOR]

Background: Some institutions require patients and families to give signed consent for Do Not Resuscitate (DNR) orders, especially in New York State. As this may be a barrier to discussions about DNR orders,we changed a signed consent policy to a witnessed verbal consent policy,simplified and modified the DNR order forms, and educated the staff at 1 hospital, comparing the effects with an affiliated hospital where the policy was not changed.Design: Prospective natural experiment with intervention and comparison sites.Subjects and Measurements: Pre- and postintervention, we surveyed house officers' confidence and attitudes, reviewed charts to assess the number of concurrent care concerns (CCCs) addressed per DNR order (e.g., limits on intubation or blood products or need for hospice),and at the intervention hospital, measured the stress levels of surrogates consenting for DNR orders using the Horowitz Impact of Event Scale. We also surveyed staff perceptions about the policy following the change.Results: At the intervention hospital, the percentage of house officers reporting low confidence in their ability to obtain consent for DNR orders declined postintervention (24% to 7%, P=.002), while there was no significant change at the comparison hospital (20% vs 15%, P=.45).Among intervention hospital house officers, there were declines in percent reporting difficulty talking to patients and families about DNR orders, but no significant changes at the comparison hospital.At the intervention hospital, the mean number of CCCs/DNR order Increased (1.0 pre to 4.2 post, P<.001). but did not change significantly(1.2 pre to 1.4 post) at the comparison hospital. The mean total stress score for intervention hospital surrogates declined postintervention(23.6 to 17.3, P=.02), indicating lower stress. House officers(98%), attendings (59%), and nurses (79%} thought the new policy was better for families.Conclusions: The policy change was well received and associated with improved house officer attitudes, more attention to patients'concurrent care concerns, and decreased surrogate stress. The results suggest that DNR orders can be made simpler and clearer, and raise questions about policies requiring signed consent for DNR orders. [ABSTRACT FROM AUTHOR]

Spiritual issues arise frequently in the care of dying patients, yet health care professionals may not recognize them, may not believe they have a duty to address these issues, and may not understand how best to respond to their patients' spiritual needs. The case of a patient with a strong religious belief in a miraculous cure of metastatic pancreatic cancer is used to explore how better understanding of this belief and more explicitly spiritual conversation with the patient by his treating team might have provided opportunities for an improved plan of care. This article distinguishes spirituality from religion; describes the salient spiritual needs of patients at the end of life as encompassing questions of meaning, value, and relationship; delineates the role physicians ought to play in ascertaining and responding to those needs; and discusses the particular issue of miracles, arguing that expectations of miraculous cure ought not preclude referral to hospice care. [ABSTRACT FROM AUTHOR]

The article discusses the spiritual issues which arise in the care of dying patients in the United States. Health care professionals must recognize and address spiritual issues though they may not be aware as to how best to respond to the patient's spiritual needs. The article distinguishes spirituality from religion. The spiritual needs of the patient at the end of life deal with meaning, value and relationships. The role of the physician in meeting these spiritual needs is highlighted and a case study given in which physician, patient and a pastor discuss these issues. Assessment tools are given for spiritual issues raised by the seriously ill.

Comments on the Roman Catholic Church teaching about the use of life-sustaining treatments. Presumption in favor of providing nutrition and hydration to all patients; Criteria by which the treatment could be considered extraordinary or morally optional; Fundamental change in Catholic teaching about life-sustaining treatments.

Background Care plans for patients with do-not-resuscitate (DNR) orders often fail to define limits other than cardiopulmonary resuscitation and fail to address other patient care needs. We studied the explicitness and comprehensiveness of care plans for patients with DNR orders and what factors were associated with this aspect of the quality of their care. Methods A cross-sectional study was conducted at Georgetown University Medical Center (GUMC), Washington, DC, and St Vincent Catholic Medical Centers (SVCMC), St Vincent's Hospital–Manhattan, New York, NY. Participants included 189 consecutive medical inpatients with DNR orders. Results A previously validated medical chart review technique termed concurrent care concerns (CCCs) measured whether 11 possible patient care needs had been addressed within 2 days of the DNR order. Reasons for the DNR order were documented in only 55% of cases, and a consent conversation was documented in only 69%. The mean number of total CCCs per DNR order was 1.55 (1.84 at GUMC and 1.29 at SVCMC; (P = .007). In a multivariate logistic regression analysis of low (≤1) vs high (≥2) CCCs, patients with malignancy (P = .002), higher APACHE III (Acute Physiology and Chronic Health Evaluation III) scores (P = .007), and a documented consent conversation (P = .009) and those at Georgetown (P = .005) were more likely to have high attention to CCCs. Patients with dementia were the least likely to have high attention to CCCs. Conclusions Documented consent conversations and care plans for patients with DNR orders are less than ideal. Care plans differ in quality by diagnosis, institution, and whether or not a consent conversation is documented. These observations might help to guide interventions that aim to improve the care of patients with DNR orders. [ABSTRACT FROM AUTHOR]

The movement in bioethics toward disclosure of financial conflicts of interest is well and good, most of the time. But in some cases, disclosure is not only unnecessary but destructive. When bioethicists advance arguments whose premises and logical moves are open to scrutiny, disclosure—far from clearing the air of bias—introduces bias. [ABSTRACT FROM AUTHOR]

Discusses the material considerations in giving health care justice to people through hospice care in the U.S. Characteristics of human beings; Assumptions of health care justice theories; Comparison on the alternatives to hospice and flu vaccines.

Objective: To elicit ratings of quality and satisfaction with care from medical inpatients, especially those near the end of life. Methods: We conducted a cross-sectional survey of 84 seriously ill medical inpatients at 2 academic medical centers. Forty-five had do-not-resuscitate orders. Patients were interviewed using a valid and reliable instrument, the Quality of End-of-Life Care and Satisfaction With Treatment scale (scored from 1.0-5.0) and standard measures of symptoms, anxiety, depression, and delirium. Results: Mean patient ratings of quality of care were higher regarding physicians than nurses (4.39 vs 4.24; P = .01). Mean patient ratings of satisfaction with physicians were also higher, but not significantly (4.53 vs 4.43; P = .32). In analysis of variance models, patient ratings of physician quality were lowest for patients with do- not-resuscitate orders who were treated by a house-staff service compared with other patients (P = .01). These patients were also least satisfied with their physicians (P = .03). Nondepressed patients with private attending physicians rated nursing quality the highest (P = .16). These patients also reported the highest satisfaction with nurses (P = .002). Quality and satisfaction were not related to severity of illness, and pain was only weakly associated with satisfaction with physicians. Conclusions: Patients with do-not-resuscitate orders who were treated by a house-staff service gave the lowest ratings of physician quality and satisfaction. Only private patients who were not depressed were highly satisfied with their nursing care. Further study is required to better understand these findings and whether they are amenable to quality improvement. [ABSTRACT FROM AUTHOR]