Unknowability and Humility in Clinical Ethical Decisions
- Atsushi Asai, MD, MBioeth. (Monash), DMSc. (Kyoto),
Department of Biomedical Ethics, School of Public Health, Kyoto University Graduate School of Medicine, Kyoto, Japan
Eubios Journal of Asian and International Bioethics 12 (2002), 133-137.
The purpose of this paper is to show problems encountered in the clinical setting by analyzing a case of a senile demented patient and to reexamine the validity of existing ethical principles and procedures. It will be argue that although existing ethical guidelines and procedures are ordinarily quite useful, ethical decisions based on them could sometimes be inconclusive because unknowabililty and uncertainty inherent to real life situations such as the care of the demented elderly patient exist. It will also be claimed that in the face of uncertainty and unknowability all we can do is try to be a virtuous person on behalf of the patient although it is unknown about what the virtuous clinician who are imaginative, compassionate, benevolent, empathic, trustworthy, fair, altruistic, moderate, and modest would do for the demented patient. In the situation where we cannot surely know what is right or what is good, arrogance could be the worst character that clinicians, ethicists, and philosophers could have. Therefore, what is left to us is, I would argue, keeping listening to others, keep thinking what is good with humility and keep questioning the ethical validity of what we have done and what we will do in the name of the patient's benefits. No one can be modest without recognizing unknowability in reality and one's own limitations in ability to judge about what is good for patients.
Clinical ethics is one of applied ethics utilized in health care settings and its main function is to help health care workers make clinically and ethically sound decisions regarding problems in actual patient's care. Its function includes identifying ethical issues, analyzing the problems, and attempting to resolve annoying ethical dilemmas in the patient care. In this paper, I will present an ethical dilemma I experienced recently, which I believe is likely to confront many physicians in charge of the care of elderly demented patients in everyday basis. This kind of problem is probably regarded inconspicuous, but it is of no less importance than well-published dramatic life and death decisions such as withdrawal of life-support, physician-assisted deaths, and separation of conjoined twins. Nowadays, the elderly population is increasing, causing major clinical medical and ethical problems. Elderly demented patients vary widely in the ability of judgment, ability to feel pain, and state of consciousness, which also change in each patient. The activity level and degree of independence also differ among the patients. Therefore, it is sometimes difficult to evaluate how much medical care should be given to patients in such diverse and variable states (1).
Various ethical guidelines and approaches to resolve ethical dilemmas in the care of patients have already existed and they are usually useful and helpful. However, it is sometimes difficult for a clinician to apply them to actual patient care and ethical decision-making could be sometimes inconclusive. The purpose of this paper is to show problems encountered in the clinical setting and to reexamine the validity of existing ethical principles and procedures. This paper also aims to deliberate how far a good clinician should actively continue to provide medical care which is not necessarily life-sustaining treatment, with the elderly and to have a practical understanding of the grounds that can guide us in ethically sound clinical decision-making. I would conclude that although existing ethical guidelines and procedures are ordinarily quite useful, ethical decisions could sometimes be inconclusive because there exist unknowabililty and uncertainty inherent to real life situations and that all we could do is to keep thinking what is good by referring to these guidelines carefully and humbly. Not to mention, I have no intension to deny all existing ethical norms, guidelines, or proposed procedures. All I would like to argue is that because of practical limitations, all we can do sometimes is to be a virtuous person with humility. In this sense, this paper is not about what ought to be done in a particular case, but rather, about what we should be like as a person when we are confronted with various difficult ethical dilemmas. Nothing is perfect and nothing is easier than just criticizing others' proposals or theories without providing alternatives. Therefore, my proposal will be that on behalf of patient's best interests, health care professions and peoples involved should be as modest as possible and should try to be as empathic as possible in decision-making in the care of demented patients. No one can be of humility or modesty without recognizing unknowability in reality and one's own limitations in ability to judge about what is good for patients.
Furthermore, although I am also fully aware of the importance of consideration regarding resource allocation in the care of the elderly demented patients, I will not discuss the issue further. I believe that treatments decisions based on fair resource allocation in individual patient care, that is to say, micro allocation or bedside rationing can sometimes be inconsistent among clinicians, biased by individual clinicians' prejudice, and arbitrary. Such decisions would often be inaccurate because many busy clinicians cannot be well informed of current situations about health care resource and appropriate way of allocation. Unlike micro-allocation, ethical consideration based on macro-allocation for the care of the elderly is of significant importance and should be argued in terms of social policy or political philosophy. However, to argue that the problems relevant to resource allocation in society at large would carry us too far away from the main purpose of this paper because I will like to focus on what is good for the patient in the following case and practical limitations of existing ethical guidelines or procedures, but not what is fair resource allocation in health care as a whole.
An elderly man with severe dementia at the age of 90 visited a general medicine clinic. He was taken to my clinic, being accompanied by his son. The son told me that his father had not eaten well recently and it seemed that the patient became weaker, emaciated, and less responsive. The patient was sitting on a wheelchair. It turned out that he could not walk, could not speak, or could not communicate orally with us. He gave slight nods to virtually any question I asked, suggesting that the patient did not understand my words. It seemed that he did not suffer bodily distress or was not experiencing any pain. He was just sitting on his wheelchair quietly. The medical interview with the patient did not work at all. Physical examinations revealed slight anemia and mild liver enlargement. The son asked about what was wrong with his father and I answered that it was not certain about what was going on at this moment. I recommended the son that the patient undergo some basic diagnostic tests including blood test, urine test, chest and abdominal X-P, and abdominal ultrasound (US) test, which I thought were relatively easy, quick, and noninvasive.
After all screening tests had been done, the patient and his son visited my clinic again. A radiology specialist who interpreted the results of abdominal US suspected that the patient have several liver tumors they could be malignant. An abdominal CT scan using contrast media (contrast CT) as a further test was strongly recommended. However, the radiological recommendation bewildered me. I was not sure at all about whether or not contrast CT should be recommended to the 90-year-old, demented, incompetent person. No one knew his previous wishes regarding medical care and no living wills had been written. I had known this patient and his son only for two weeks and I did not them well at all.
I explained to the patient's son about the results of the abdominal US. I also informed the son of expected benefits and risks of contrast CT and what kind of medical interventions could follow in general if the result of the CT was positive, i.e., if the patient had a malignant live tumors. Medical interventions followed by the positive result might include angiographies, operations, arterial embolism therapy or doing nothing but palliative care. Although I could not make a recommendation regarding particular course of medical intervention, I did recommend the son to discuss what to do with other members of the patient's family. He agreed with my proposal and took the patient home with him. A week later, the son came back and informed me that they had decided not to have the patient to undergo the contrast CT scan.
I met the patient only twice and have not met him since then. According to existing bioethical principles and well-established procedures when the patient is not capable of deciding for him or herself, the course taken in the care for the patient is probably ethically justifiable. In general, family members are regarded as the most appropriate surrogate decision-maker and imposing medical technology on the fragile patient without considering the patient's quality of life have been perceived offense to humanity. However, there still remained vague doubts regarding what was done in the care of the patient in my mind.
3. Making medical recommendations and issues to consider
It is very natural for a clinician to listen to patient's problems, complete physical examination, and try to diagnose patient's problems. It is also quite natural for us to list up various therapeutic interventions and recommend to the patient one of treatment choices which the physician believes is the best for the patient. That is the job that the clinician ordinary does and is expected to do for suffering patients. As commonly mentioned, beneficence, one of the ethical principle in clinical ethics and/or bioethics requires the clinician to act in the best interests of patients, that is to say, act in a way to produce the greater balance of good over harms. Under the principle the clinician is supposed to recommend a diagnostic procedure or a therapy that is most likely to protect and promote patient health, based on estimates of medical benefits relative to burdens for the several treatment options. (2). It can be said that the benefit of recommended interventions must justify their burdens, risks, and harms to patients. In this sense, the doctrine "do good, or at least, do no harm" in the Hippocratic dictum is still valid and central in the professional obligation of clinicians as well as other health care workers. Furthermore, the principle of beneficence has explicitly been included in the name of recommendation in the elements of informed consent, which is fundamental in the doctrine to maximize the patient's autonomy, self-determination and value judgments (3). Thus, it may be fair to argue that the significant of making medical recommendations is clear and what the clinician should consider next is the substance of the recommendations. All questions that follow must be investigated in order to make specific recommendations: What would the patient want? What is the best interest of the patient in this case? What is the best course of care for this patient? Is quality of life judgment allowed to use in decision-making? What is the ultimate goal of the care of the patient? And finally, how far should we go in doing diagnostic and therapeutic interventions?
In the case in question, the patient did not or could not express any of his wishes. It would be more precise to say that the patient could not have any sorts of wishes with regard to medical interventions he will undergo because of his dementia. If he has current specific preferences towards medical care, it can be argued that we should respect them unless the realization of the patient's wishes is likely to lead harms to the patient him or herself or others. It is also claimed that the satisfaction of the preferences usually leads to his benefits. Of course, I am aware that there is some situations that decisions based on the patient's current wishes do not necessarily result in the best interests of the patient and that the conflict between the principle of patient autonomy and beneficence is not rare in the clinical setting. However, I will not discuss the antagonism among ethical principles in the care of currently capable patients further because this is irrelevant to the main subject discussed here. What is relevant to the patient in question is he could experience pain and distress, and we can assume that he did not like painful or uncomfortable diagnostic procedures or treatments. This is because he had certainly the ability to experience physical pain and discomfort. However, there was not any clue to judge whether or not he would want to undergo contrast CT in such a situation. As mentioned earlier in the case no one knew his previous wishes regarding medical care.
Inquiring what is good for a patient is the most relevant question that clinicians should consider when the patient is not currently capable enough to make autonomous decisions and when no one knows the patient's previous wishes or the goals in the end of life that the patient sets up. This is because the best course of care for the patient in question is the course that can maximize the patient's best interests. I would argue that living longer with higher quality of life is preferable to shorter life with the same level of quality of life or life of the same length with lower quality of life. Nevertheless, the claim that the patient can benefit from life with high quality of life is problematic in the care of the patient in question. There are questions about definitions and validity regarding benefits and quality of life. Clinicians cannot decide how far they ought to go in doing diagnostic and therapeutic interventions in the care of a demented elderly patient or when they should stop providing them without answering these issues
4. What is good?
First, what is the best interest of the patient in this case? As mentioned earlier, consideration with regard to what medical intervention benefits the patient most is crucial. However, what constitutes benefits for the patient in question? What is on earth the best interest of the patient? Given the situation where the patient himself cannot explicitly claim what is good or what is bad for him, judgment regarding the best interests for the patient should be determined by others including his family and/or health care workers in charge. However, despite that it is sometimes called "objective standard," the best interests judgments are often problematic and inherently unreliable in cases like ours.
Let us consider three cases of demented patients. The state of demented patients can be classified into some stages according to the pain or pleasure that they can feel. The following scenarios can be conceived (1).
In general, we consider both the experience of pain and discomfort to be disadvantages. The principle of beneficence, that is to say, "elimination of pain = benefit" may be applied to the patient No. 1. This is because we can assume that to get rid of pain and suffering is a good act and can serve the best interests of the patient. Cases such as the patient No.2, however, give no warrant for withholding any medical interventions. This might be true even when advance directives have been made. The patient No2 is happy and a decision not to act in order to prolong his or her happy life could not automatically be regarded as benefits to the patient. Finally, I think that the patient in our case can be similar to the patient No. 3 or No.4. To be honest, it is completely uncertain for me about what are the best interests of these groups of patients.
Lo (2000) lists common and serious problems with medical decision-making based on the best interests. It is claimed that different people may disagree over what is best for a patient (the goals of care, the assessment of the benefits and burdens of intervention, and the evaluation of the patient's quality of life); the best interests judgments by others may be affected by wishes and self-interests of those who judge the benefits of the patients; pain and distress can sometimes be perceived serving a spiritual purpose (4). Especially, the first problem that different people may disagree over what is best for a patient is empirically true and significant. Of course, one can argue that to live longer is unconditionally good and it is the most valuable goal. This claim is usually true for many independent and capable persons. However, we can still ask whether or not to live longer is good for the patient without exception regardless of his or her subjective judgments regarding the quality of life. It can also be argued that it is good as long as the quality of the life is perceived good by the patient him or herself. In the case in question, however, the patient cannot either make or present his own judgments in this regard and all we can do is to judge his quality of life from other's point of view. Then, we need to inquire into the validity of quality of life judgments made by others even if the others are the patient's close family. I would claim that justifiable quality of life judgments should be made by referring to the value of quality of life that an individual determines, especially when the evaluation is difficult. Therefore, it is doubted that we can surely tell that whether or not the quality of someone's life is so low as to be not worth living or worse than no further life at ill in the No.3 or No.4 patient, that is to say my patient in question. Other things being equal, a life with extreme pain or suffering has low quality of life and that a life with pleasure has higher quality of life. But this kind of simple decision does not work in the case in question at all. Therefore, it should not be assumed that we could correctly make ethical decisions based on "objective" evaluation of the interests of the patient or "objective" quality of life judgments in the case presented here.
5. A procedural solution: leaving decisions to patient's family when a problem is difficult to resolve
Can we always rely on family's judgments as surrogate decision makers for demented patients. Arras claimed: "The opinions of trustworthy surrogates should be given priority simply because they are usually in the best position to assess the prior wishes and best interests of incompetent patients, and because their familial and emotional bonding to patients usually gives them a greater claim than members of the health care team."(5) When discussing ethical decision making for the severely demented minimally functional patients, Arras suggests that if a proposed course of action falls into the gray area of uncertainty, an involved and well-intentioned family should have discretion to decide as they see fit. He claims that when we think through what is the most preferable decisions for demented patients we inevitably reach an impasse because we can never know clearly correct answers for sure. Then he renounces ethical consideration regarding what ought to be done and recommends a procedural solution, that is to say, who should decide. He argues that well-meaning and ethically sensitive surrogates will reach different conclusions about the care of such patients and that the conclusion should be accepted unless a clear violation of best interests can be pointed out (5).
However, as we see, in the case in question, it is quite uncertain about what is the interest of the patient and therefore what constitutes a clear violation of the patient's interest can also never logically be shown. Furthermore, use of such a procedural solution without reservation may sometime constitute abandonment of the missions of health care professions who are expected to act in the best interests of the patients in charge. Furthermore, I would argue that the more the interest of the patient becomes gray, the more health care professionals have to recommend what may be good for the patient for the patient family members. This is because the more the problem involved becomes gray or uncertain, the more the family members request professional opinions regarding what benefits the patient. Although it is empirical, when ethical problems fall in the gray areas of uncertainty, many family members often ask the clinician who is in charge of their patient what the clinician would do if his or her parents were in the same situation. It should be added that in the situation where the family members are less certain about what is good for the patient, they are more likely to be influenced by recommendations made by clinicians. Therefore, it can be claimed that, clinicians should go on thinking what is good for the patient and try to tell their views to the patient's family. Again that is the job that the clinicians are expected to do. Here, I would not deny the necessity of surrogate decision-making by the patient family, rather, I would argue that the clinician should not leave all cardinal decisions to the family without thinking with his or her experiences and expertise.
It can also be argued that deciding who should decide is relatively easier than determining what should be done because we do not need to judge the content of the decision is really preferable to other alternatives. In addition, it should be pointed out that there are additional several problems with surrogate decision-making. Lo makes a long list of problematic aspects of surrogate decision-making (6). They include emotional barriers to decisions, decisions inconsistent with the patient's preferences or values, conflicts of interests between the patient and the family, and disagreements among potential surrogates. In everyday practice, disagreements among potential surrogates happen quite often and the most problematic. It is also suggested that that family members often do not know the precise wishes of their relatives although no other group come closer to correctly judging what the patient would have want in a particular situation (7). It is also claimed that the reality is that the surrogates are often unclear about the real choices available and about how to participate meaningfully in decision making." Therefore, we cannot take it for granted that patient's family is the one and only who can make the best decisions for the patients when the patient is demented. Therefore, substituted judgments and surrogate decision-making based on the best interest standard should be considered as ethically permissible because no other method to decide exists. It should by no means be perceived ethically preferable. I would claim that leaving critical and grave decisions solely to the patient's family without recommending what a clinician believes is the best course to take should be regarded as neglecting his or her duty and that making a medically best recommendation is essential and what the clinician is for.
6. Useful guidance?: The limitations of ethical guidelines and rights in health care
Let us consider the practical usefulness and limitations of ethical guidelines presented by a group of geriatrics specialists and various patient rights declaration. Can these guidelines suggest anything regarding how far the clinician should go in providing the senile demented patient in question with medical interventions or when the clinician stops doing it? First, I will list my translation of the first four statements included in the position paper in terms of terminal care for the elderly issued in 2000 by the Japanese Geriatric Society for the Terminal Care in the Elderly, which I think are the most relevant to the care of the patient in question (8). Overall, I would say that there is no strong reason to oppose them. Many would think that these are ethically acceptable guidance in principle. Particularly, prohibition of discrimination merely on the ground of old age must be warranted. However, close word-by-word scrutiny will reveal that these generally acceptable statements include unusable, and sometimes problematic concepts.
Position statement No.1: Ageism should be rejected. Appropriate health care should be guaranteed for severely demented persons as an inviolable fundamental human right.
The appropriateness of the care provided is decided based on benefit-harm ratio of the given interventions and if we could not estimate what is beneficial no one would be able to estimate the benefit-harm ratio. I will consider the significance of human rights later.
Position statement No.2: The values and preferences of the elderly patients should guide terminal care that the patients have unless their values and wishes are inconsistent with social morality.
We may not know the patient's values or preferences with certainty. Moreover, even if we knew patient's previous wishes or have his or her advance directives, as mentioned above, respecting them unconditionally would not necessarily constitutes serving to the best interests of the patients. Canter provided perfect examples suggesting that respecting advance directives without seriously considering what is currently good for the patient could sometimes be problematic. One of the examples was:
"Person A, a Jehovah's Witness, prescribes in an advance directive that blood transfusions should not be administered regardless of the life-saving potential of such medical intervention. She is aware of the life and death implications of his religiously motivated instruction. Later, A becomes prematurely senile and incompetent. Still later, the senile patient develops bleeding ulcers which demands transfusions. With blood transfusions, she will survive and continue to live as a "pleasantly senile" person for a number of years. The senile A no longer has recollection of, interests in, religion; however, she remained avid Jehovah's Witness up until the time of incompetence. Should the attending physician administer a life-saving blood transfusion?" (9)
The discussion about ethical validity of advance directives and real significance of respecting autonomy of those who have already lost it is beyond the scope of this paper and I will not discuss this issue further here. However, the scenario shown above questions whether we should respect the advance directives refusing blood transfusion with conviction or without any regret? I would argue that a clinician who tries to think what is good for the patient in the above scenario cannot literally follow the patient's previous wishes without reservation.
In addition, what is social morality and how it should be determined is a really important issue to consider. I do not believe that an individual clinician can be fully informed of social morality of the society where he or she belongs. Furthermore, why we should observe social morality is another significant question. Even if we can know what social morality is, we still ought to question that obeying social morality whatever it is can bring the good for the patient in our case.
Position statement No.3: Terminal care should be regarded as one subspecialty made up mainly of palliative care medicine. It should be aimed to improve the quality of life of the patients.
We cannot exactly know what the improvement in quality of life really means to the patient in question. Unless the patient is exceptionally happy or suffering, superficial judgments about the patient's quality of life by others cannot be trustworthy and often do not work. Of course, we can project our value judgments about the patient's current situations in our case, but as I have already argued, it is not the quality of life of the patient.
Position statement No.4: Terminal care for the elderly should include the care for the patient's family. When the patients loose capacity for self-determination, the patient's family plays important roles in decision-making.
We have already questioned how much we can rely on family decisions. In addition, from my experience, some family members, although they are a minority in number, may not always prioritize the patient's welfare over their own benefits. Family members, although they are loving the patient deeply and their presence is significant, are after all others. It should also be asked what culture is in this context. We can ask the exactly same questions made regarding social morality about the problems relevant to culture.
Furthermore, I should discuss the practical limitations of human rights and patient's rights consideration as well as their utility and significance. Examples I will consider include the European Human Rights Acts 1998 and the Declaration of Lisbon on the Rights of the Patients issued in 1995. The statements included in the Human Right Acts and the Declaration of Lisbon on the Rights of the Patients are, for examples, right to life, prohibition of torture, right to liberty and security, right to respect for private and family life, rights to medical care of good quality, right to dignity (10, 11). Like ethical principles, guidelines, and procedures that I previously referred to, these are the results of our ethical developments and invaluable statements. One glance is enough to tell that all human rights and patient's rights listed are ethically correct and no one would object to them and I cannot stress their importance in health care too much. These issues should be taken into consideration when clinicians try to figure out what is good for the patient in question. However, as soon as we tried to use them as a ground to make a specific recommendation for the care of the demented elderly, the situation would suddenly become totally unclear.
In many cases, medico-ethical decisions based on human rights and patient rights in health care could conflict and arguments can be made both in support of and against a certain course of action (12). Almost all right statements are inevitably open to diverse, sometimes completely opposite interpretations. We can always ask what they really mean and in what circumstances which right should be prioritized over the other kinds of rights. For instance, what would the right to life suggest in the care of the patient in question? What medical intervention would or should those who intend to protect the right to the patient's life in question recommend? Can performing contract CT to the patient who cannot understand the aim or benefits be regarded as torturous? How far should we continue medical intervention on behalf of the dignity of the patient? I do not sincerely know. We can continue the same sorts of questions endlessly. Again, in my opinion, living longer with high quality of life is good. Prolonging the life in pain or discomfort is not good although it depends the intensity of the pain or suffering or the tolerance of the patient. As long as the quality of judgments can only be made by others, whether or not the current quality of life is valuable to the patient is beyond our ability to know except in extreme situations where the suffering is apparently and undoubtedly overwhelming or the case where the patient is certainly and always experiencing pleasure or happiness.
Those who are confident in their particular ethical point of views might easily reach to the specific conclusion. On the one hand, those who believe that a life without autonomy does not deserve living might conclude that no further interventions should be given to the patient in question. On the other hand, those who claim that a human life is intrinsically valuable regardless of its quality would choose to get the patient to have contrast CT without reservation. I would argue, however, that uncertainty and unknowability in the real life situations require us to be at least modest when we make health care decisions on behalf of the demented persons who are vulnerable, dependent, and are easily to exploit. Arrogant dogmatism should be avoided. A word of an ancient philosophy Confucius would give us a valuable lesson: "If one learns from others but does not think, one will be bewildered. If, on the other hand, one thinks but does not learn from others, one will be I peril" (13).
7. Inconclusive conclusions: What is left to us
From what has been examined and argued above, I come to the conclusion that it is sometimes not possible for us to reach a certain decision with confidence. However, in the clinical setting, those who are involved in the care of the patients similar to the one in question have no choice but choosing one particular choice in spite of uncertainty and unknowability. Existing ethical guidelines and proposed decision-making procedure is in principle useful and it is important to respect them, but they are not either perfect or practical in the care of the patient in question. The reality is that we do not have an ethical panacea. Decisions are often compromised by unknowability regarding what benefits are, what harms are, and how we can assess quality of life of the demented senile person. In addition, substituted judgments or surrogate decisions should be regarded as ethically unavoidable and, at best, permissive procedures, not preferable ones due to its limitations.
In the face of uncertainty and unknowability, I cannot help but feel that all I can do is trying to be a virtuous person when I cannot recommend a certain recommendation for a patient care with confidence. However, while virtue ethicists might claim that virtuous individual can say what is right or what is good for the patient in question correctly, I feel compelled to say that I does not know what the virtuous clinician would do in the care of severely demented patients in the amid of overwhelming unknowability. What kind of recommendations would be made by the clinician who is imaginative, compassionate, benevolent, empathic, trustworthy, fair, altruistic, moderate, and modest?
In the situation where we cannot surely know anything or many things, arrogance could be the worst character that the clinicians, ethicists, and philosophers could have. What is left us to is, I would argue, is to keep listening to others, keep thinking what is good with humility and keep questioning the ethical validity of what we have done and what we will do in the name of the patient's benefits.
Finally, may I have a question? What recommendation would you make for the care of the patient if you were the clinician in charge? How far would you go and when would you stop and why? There are many differences in value, preferences, and goals between different peoples around the world and what to do may be to be committed to resolving clinical ethical problems without arrogance, without being too more confident in existing guidelines and procedures. I will finish my paper by quoting one lesson of the great ancient philosopher Confucius, "I shall tell you what is to know. To say you know when you know, and to say you do not know when you do not, that is knowledge (14)."
This paper is based on the presentation made in the 7th Tsukuba International Bioethics Roundtable (TRT7), February 2002, Tsukuba, Japan.
1 Asai A and Ohnishi M: Reasons for Discontinuation of Treatments for Severely Demented Patients: A Japanese Physician's View. EJAIB 2001; 11: 141-144.
2 Sozos J. Fasouliotis, Joseph G. Schenker: Maternal-fetal conflict. European Journal of Obstetrics and Gynecology and Reproductive Biology 2000; 89: 101-107.
3 Tom L. Beauchamp, James F. Childress: Principles of Biomedical Ethics 4th edition. Oxford University Press, New York, 1994.
4 Bernard Lo: Resolving Ethical Dilemmas: A Guide for Physicians, 2nd edition. Williams and Wilkins, Baltimore, 2000, p94-107.
5 John D Arras. The severely demented, minimally functional patients: An Ethical Analysis. J American Geriatrics Society 1988; 36: 938-944 and President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research: Deciding to Forgo Life Sustaining Treatment. Washington, DC, US. Government Printing Office, 1983, 134.
6 Bernard Lo: Resolving Ethical Dilemmas: A Guide for Physicians, 2nd edition. Williams and Wilkins, Baltimore, 2000, p111-117.
7. Carol Levine, Connie Zuckerman: The trouble with families: Toward an Ethic of Accommodation. Ann Intern Med 1999; 130: 148-152.
8 A Position Statements by the Japan Geriatric Society for The Terminal Care in the elderly: Kazumasa Uemura, A Draft of JGS Ethics Committee. Journal of the Japan Geriatric Society 2000; 37: 719-721.
9. Norman L. Cantor: Testing the Limits of Prospective Autonomy: Five Scenarios from Advanced Directives and the Pursuit of Death with Dignity, Indiana University Press, 1993.
10 Human Rights Acts 1998, Convention for the Protection of Human Rights and Fundamental Freedom (4 _ 1950; TS 71; Cmd 8969)
11 World Medical Association Declaration Of Lisbon On The Rights Of The Patient, September 1995.
12. Veronica English, Gillian Romano-Critchley and Ann Sommerville Medical Ethics Department, British Medical Association: Human Rights Act, Ethics briefings. JME 2000; 26: 410-411.
13. Confucius: the Analects, translated by D.C. LAU, Penguin Books, London, 1979, p65.
14. Ibid, 65.
- The patient is feeling intolerable pain that is irreversible and untreatable.
- The patient always seems to be in a very happy state.
- The patient seems to simply present apparently without feeling anything, either pleasure or discomfort, but not in coma, i.e. not in a persistent vegetative state.
- The patient seems to feel pleasure or happiness sometimes and have pain or discomfort in other occasions. Pleasure and happiness seems to occupy the patient alternatively or randomly.
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