Nephrologists' subjective attitudes towards end-of-life issues and the conduct of terminal care.

Decisions which determine the duration and outcome of terminal care should be influenced by patient autonomy. Studies suggest, however, that end-of-life decision-making is more complex than a single principle and that physicians may be responsible for selected aspects of terminal care independent of patient choice. To study how nephrologists' perceptions toward end-of-life issues may affect decision-making, we anonymously surveyed 125 of them. The study employed the straightforward terminology of "hastening death" rather than adopting the ambiguous term "euthanasia" or the narrow term "assisted suicide." Subjective physician profiles demonstrated that nephrologists who are less comfortable with dying patients were significantly less likely to report that they omitted life-prolonging measures (p = 0.02) and more likely to report that they would not initiate measures in order to hasten death even were it legal (p = 0.04). Ninety-eight percent of nephrologists reported omissions in terminal care with patient knowledge and 80% without patient knowledge. In contrast, forty-three percent of the nephrologists said that were it to become legal to initiate measures in order to hasten death, they would "never" do so. The ethical framework utilized for discontinuation of dialysis decisions incorporated medical benefit (cancer as criterion, 48%; multisystem complications, 84%; dementia 79%) and quality of life criteria. Twenty-five percent of nephrologists admitted difficulty with advance directives if the directives clashed with heir beliefs. ESRD end-of-life decision-making in the USA may be altered by the subjective characteristics of nephrologists. In particular, nephrologists' level of discomfort with patient mortality is linked with their reported management of terminal patients.

Congenital diaphragmatic hernia. In utero therapy and ethical considerations.

Despite advances in neonatal medicine, the mortality rate for congenital diaphragmatic hernia remains high. The results of work in animal models suggest that this anomaly may be amenable to in utero surgical correction. In this article, the natural history of congenital diaphragmatic hernia in humans is reviewed, and the development of antenatal management strategies is traced. The ethical issues surrounding the management of fetuses with diaphragmatic hernias are also discussed. The ground-breaking nature of the development of strategies for management of congenital diaphragmatic hernia underscores the importance of establishing scientific and ethical guidelines for future endeavors with in utero therapy.

Physician-assisted suicide: what's the story?

After telling a story of a family's inquiry into physician-assisted suicide on behalf of a loved one, John F. Kilner uses the story to discuss some specific ways in which modern medicine often fails to supply life-affirming alternatives in situations like the one this family faced. Knowing about these alternatives is important for Christians, since God is the author of freedom, justice, and life itself. Moreover, when medicine has nothing more to offer suffering patients, it should be prepared to assist them in their suffering, rather than simply eliminate the sufferer. The example of Jesus' suffering is important here.

Healthcare reform: moving forward.

One of the toughest and most important issues facing America today is healthcare reform. To examine this issue more closely, four industry observers were invited to share their thoughts with Healthcare Executive.

Ethical issues in the initiation and termination of treatment.

This report addresses the ethical issues involved in decisions to initiate and terminate treatment. A general framework is constructed and then two illustrative cases are discussed. The framework is developed in three stages. First, the issue of guiding ethical principles is examined, with a multiple-principle approach being adopted. Second, common models of the care-giver/patient relationship (warrior, parental, contractual, covenantal) are identified, and their varying impacts on treatment decisions are explained and assessed. Third, specific criteria for determining when to initiate and terminate treatment are introduced. Two criteria (willingness and medical benefit) are commended in the context of initiating treatment, while three distinctions (willing v unwilling, passive v active, and terminal v nonterminal) are found to be particularly helpful when deciding if treatment should be terminated. Two illustrative cases involve end-stage renal disease (ESRD). The first describes a noncompliant and abusive intravenous (IV) drug user on hemodialysis who wants to continue on dialysis and eventually receive a living-related donor kidney transplant. The second describes a patient's decisions to refuse feeding gastrostomy and jejunostomy, any further surgical or diagnostic intervention, and eventually dialysis-though only after a period of time when he wants dialysis alone to continue.

Age criteria in medicine. Are the medical justifications ethical?

Age criteria are increasingly being advocated as means of determining who should receive treatment. Four types of medical justification have been proposed. Three of these, namely, length of medical benefit, quality of medical benefit, and likelihood of medical benefit, entail comparisons of patients. The fourth, medical benefit, involves identifying for each patient whether or not a significant benefit is likely to result from treatment. I contend that the three types of comparative justification are questionable. For example, they rest on statistical generalities that are misleading in particular situations, and they value characteristics of persons (such as life-years) more than they respect persons themselves. I also contend that the fourth type of medical justification, rooted as it is in response to human need, is ethically sound, but that it warrants a medical-benefit criterion rather than an age criterion.

Selecting patients when resources are limited: a study of US medical directors of kidney dialysis and transplantation facilities.

This study reports and discusses responses of 453 medical directors of renal dialysis and transplantation facilities to detailed patient selection questionnaires. The questionnaires examine selection criteria being used today as well as those which would be employed were resources to remain or become scarce relative to need. Selection criteria examined (and the number of directors supporting them when resources are limited) are: qualitative prognosis, psychological stability, likelihood of medical benefit, quantitative prognosis, medical benefit (virtually all); willingness, age (very large majority); unique moral duties, disproportionate resources, environment, progress of science, social value (majority); ability to pay, random selection, constituency (very large minority); sex (virtually none). Qualitative prognosis, quantitative prognosis, medical benefit, ability to pay, and especially age are the criteria employed today whose influence would increase if resources are further limited. Some of the ethical implications of various criteria are discussed.

Age as a basis for allocating lifesaving medical resources: an ethical analysis.

In light of the growing prominence of an age criterion in patient selection, it is essential to scrutinize the ethical legitimacy of arguments being offered both for and against using age as a criterion. Accordingly, the present study first explores the primary justifications for an age criterion, then examines the criterion's weaknesses. Weaknesses are grouped into two areas: deficiencies in the justifications of the criterion, and overarching critiques. Finally, a way forward in the midst of the present controversy is suggested. The study's conclusion is that an age criterion per se is unjustified, though age may play a carefully defined role in medical assessments relevant to patient selection.

Down's syndrome.

We discuss the ethical, psychosocial, economic, and medical dimensions of the treatment and management of a child with Down's syndrome and a congenital heart defect.

Who shall be saved? An African answer.

KIE: A report is presented of an anthropological study of the attitudes of the Akamba people of central Kenya toward the microallocation of scarce lifesaving medical resources. Health workers and traditional healers were interviewed concerning four values frequently invoked in treatment decisions in the U.S.: equality (selection for treatment on a first-come, first-served basis), usefulness (social benefit), need (saving those in the greatest danger), and life (saving as many lives as possible). Most of those interviewed placed a high value on need and life. Two-thirds of the respondents scored low on the equality scale, and two-thirds viewed usefulness as a legitimate consideration--at least sometimes--when deciding whose life to save. Level of education was linked to a rise in usefulness and life scores.^ieng