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    Sunday, March 27, 2005

    Ends of Life II: Then there's today's Times article on the shift of the end-of -life argument over the past several years from the right to die, to the right to live:

    Many right-to-die requests would not cause conflict with a hospital these days because they are more likely to be in sync with doctors' assessments. When there is a conflict, it typically involves families who feel their loved one would not want to endure surgery or treatment that might not succeed

    ...Chuck Ceronsky, a co-chairman of the ethics committee of Fairview University Medical Center in Minneapolis, said, "The right-to-die families find a more receptive audience in the hospital, as opposed to years ago when a doctor might say, My job is not to end life.

    ...Ethics committees resolve most cases, often through repeated family discussions over weeks or months.

    But at least three states, Texas, Virginia and California, have laws that let doctors refuse treatment against the wishes of a family, or even a patient's advanced directive in certain circumstances. In other states, like Wisconsin, doctors are seeking such laws.

    We are the experts, after all. We should be able to give a family an honest opinion about the chances of survival. Unfortunately, sometimes we're wrong. Constraints of time and resources also come into play. How does a patient know our opinion regarding futility isn't influenced by our rushed schedule, or dearth of hospital beds:

    Some are wary that doctors may be truncating treatment because of soaring medical costs, and Dr. Dianne Bartels, associate director of the Center for Bioethics at the University of Minnesota, said: "Sometimes there's also mistrust of the medical system. A doctor might have said, 'Your husband's never going to make it' and he's already survived two or three times, so why should they believe the doctor?"

    Thomas W. Mayo, an associate professor at Southern Methodist University law school and an author of the Texas law, cited another reason.

    "There are more specialists with less contact with the family," Mr. Mayo said. "As patient volumes have increased and reimbursement rates cut to the bone, there's less incentive for everyone in the system to provide that. When a stranger says, 'Well, there's nothing we can do other than turn things off,' you're hearing that from someone you have no reason to believe other than he's wearing a white coat.

    Don't underestimate the role of time and space limitations in these medical decisions. A doctor would have to be God to be able to make decisions without being influenced by those factors. (And we all know that none of us are God, even though we act like it sometimes.) That's why the laws that allow us to over-ride patient's advance directives are worrisome. There are cases, certainly, where care would be futile, even cruel. But there should be some check on our ability to over-ride advance directives that request we honor the life of the patient.

    posted by Sydney on 3/27/2005 09:57:00 AM 0 comments


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