Medical Care at the End of Life

Contents

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Acknowledgments

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pp. vi-vii

I wish first to acknowledge the essential role played by the St. Francis Health System, a multi-institutional system of hospitals and nursing homes owned and run by the Sisters of St. Francis of Millvale, Pennsylvania, and to the remarkable people who worked there prior to its closing for financial reasons in 2002. Without my ...

Introduction

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pp. ix-x

For the past thirty years I have written about medical ethics and taught the subject to physicians, nurses, social workers, hospital chaplains, undergraduates, and graduate students. During this time I have been active in American hospitals and nursing homes, helping patients and their families deal with the difficult and often painful ...

Abbreviations

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pp. xi-xii

Chapter 1. Ordinary and Extraordinary Means

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pp. 1-11

From the 1960s to the 1980s, Americans were unable to reach a consensus on the morality of forgoing medical treatment. Scholars disagreed about many of the issues—this continues today, as we will see—the basic stance of U.S. law had not been determined, the medical profession was largely unsure of what to do, and hospital policies varied widely. ...

Chapter 2. Killing and Allowing to Die

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pp. 12-20

The second pillar of the American consensus is based on the distinction between killing and allowing to die, a distinction that Catholic tradition, in its analysis using the principle of double effect (PDE), has provided. According to this distinction, the direct killing of an innocent person is never morally right, but allowing a person to die is sometimes morally right....

Chapter 3. Decisions by Competent Patients

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pp. 21-36

In chapters 1 and 2 I discussed the first two pillars that support the present American consensus on forgoing treatment, the two that are based in Catholic medical ethics. The third pillar has its basis in law and derives from the legal concept of the right to privacy, autonomy, and liberty. This has been interpreted to mean that patients capable of making ...

Chapter 4. Decisions for Incompetent Patients

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pp. 37-65

Thus far in my discussion of the third pillar of the American consensus, I have focused on the decisions of competent patients, cases in which the problems are not as difficult as those concerning incompetent patients. As we have seen, the ‘‘gold standard’’ or the ‘‘ace of trump’’ in these matters is the decision of a competent patient. ...

Chapter 5. Advance Directives

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pp. 66-86

An advance directive is an instruction made in advance by a competent person specifying what that person wants if and when he or she should become ill and unable to make treatment decisions. There are two kinds of advance directives: proxy directives and treatment directives. Proxy directives appoint someone to make decisions if a person no longer can do so....

Chapter 6. Hydration and Nutrition

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pp. 87-117

The ethical issue of withholding and withdrawing nutrition and hydration involves a specific application of the general principles developed in the previous chapters. There has been considerable controversy over whether or not nourishment and hydration can ever be omitted or discontinued for a dying or comatose patient, ...

Chapter 7. Physician-Assisted Suicide and Euthanasia

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pp. 118-132

We have seen that the American consensus on forgoing treatment has as one of its ethical bases the claim that there is a difference between killing terminally ill patients and allowing them to die of their underlying condition. The general agreement has been that while it is often right to withhold or withdraw medical treatment that would prolong the ...

Chapter 8. Medical Futility

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pp. 133-154

When I began working at St. Francis Medical Center in Pittsburgh in 1989, during a sabbatical year, I began with a number of preconceived notions about what I would find, some explicit and many implicit. One of these was that most instances of conflict about forgoing treatment between health care providers and patients or patient surrogates ...

Glossary

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pp. 155-158

Cases Cited

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pp. 159-160

References

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pp. 161-172

Index

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pp. 173-180