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Autonomy and the common weal.

Marion Danis is a professor in the department of medicine and Larry R. Churchill is a professor in the department of social medicine at the University of North Carolina at Chapel Hill.

When health care providers make decisions to use resources, their devotion to the patient at hand must be mediated by a framework that puts individual autonomy and social equity into focus simultaneously. The concept of citizenship yields such a framework.

Making choices about individual medical care toward the end of life has grown exceedingly complex. New, technologically sophisticated interventions continue to be developed at the same time that the number of elderly, chronically ill individuals that might take advantage of such developments is steadily growing.

In keeping with a strong American tradition of respect for individual rights, ethicists, physicians, and lawyers have argued that we must put the choice in the patient's hands in order to protect the individual's autonomy. If the individual is not able to decide, a surrogate decisionmaker is asked to make a substituted judgment.

Because little has been known about the wishes of the sick elderly regarding life-sustaining treatment, we and others have examined the wishes of older patients for such treatments as cardiopulmonary resuscitation and intensive care.[1] We interviewed individuals over age fifty-five who had previously received medical intensive care to learn how willing they would be to receive intensive care again. If the patient had died, we interviewed a member of the family. We asked how willing the patient or family would be to have the patient receive intensive care that would prolong life for a given period of time, varying from ten years to one month. The majority of the 160 patients and family members who were interviewed reported that they were extremely willing to undergo intensive care for very brief periods of life prolongation. Three-quarters of survivors who were interviewed were willing to undergo intensive care for one month of prolonged life. At the other extreme, 4 percent of patients were unwilling to go into intensive care for any period of life prolongation. Families' preferences were similar to those of surviving patients. When we asked whether there were any circumstances under which they would refuse intensive care, about 40 percent of patients and family members told us that they would not choose intensive care if they had either no hope of recovering, were only being kept alive by a machine, or if they were in a vegetative state. Thus 60 percent of respondents did not volunteer any circumstances under which they would refuse intensive care.

Chronic disease, functional ability, or perceptions about the quality of their lives were not related to patients' or their family members' willingness to have the patient receive intensive care. Characteristics of the prior stay in intensive care-including severity of the critical illness, length of stay, or charges for intensive care-did not correlate with willingness to receive intensive care.[2] Thus it seems that many patients and family members would avail themselves of extremely costly and labor-intensive care for what others might view as marginal gains.

These results pose a significant ethical dilemma. Tens of thousands of dollars are routinely expended to sustain an individual toward the end of life, at the same time that little or no health care coverage is provided, for one-fifth of the population of the United States.[3] When elderly individuals tell us that they would choose this treatment, their wishes conflict with the need to allocate health care resources in an efficient and equitable manner. This dilemma provides a stimulus for a more comprehensive formulation of ethical questions that puts individual autonomy and social equity in a single framework.

The Detachment of Autonomy from justice:

Ethicists have argued that the principle of autonomy justifies a patient's right to accept or refuse medical treatment.[4] The impact of the individual treatment choice upon the distribution of health care resources has been considered irrelevant. Because the right to self-determination was first used as a justification for refusal of treatment, there was no initial conflict between the individual's wishes and a fair distribution of resources. However, it is becoming increasingly evident that individual choices affect the resources available for others. While no one would argue that a patient has the ethical right to demand a useless treatment, the dilemma arises when a patient wishes to receive a costly treatment of debatable utility. Under these circumstances, ethical concerns about the fair distribution of health care resources cannot remain detached from the ethics of individual patient care.

The consequence of ignoring this conflict is becoming painfully clear. We face a paradoxical situation in which the power to make individual treatment decisions exists in the absence of any guaranteed access to medical care for all citizens.[5] The result is an almost unrestricted fight for those within the system, but no guarantee of initial access to anyone except the well-insured or those with specific entitlement programs. The right of specific patients to choose is provided with total disregard for the general fight of access for all.

Perhaps ethicists have failed to develop a stronger and more realistic ethic to speak to the conflict between patient wishes and societal needs because `society' is customarily portrayed as an abstract and vacant idea, used only as a foil for an ethic of individual allegiance. Paul Ramsey, for example, characterizes society as "an unfocused meshing" of many different, often conflicting human pursuits.[6] Under such a view, it is understandable why society commands so little allegiance. Those ethicists who have focused on social justice and equitable access have made notable contributions in articulating the moral underpinnings of a more just system.[7] Yet it is unclear how to reconcile the concept of individual patient autonomy with these more egalitarian proposals, and this makes them less appealing to patients and physicians, who are inclined to think individualistically about "my needs" and "my patients."

Dodging the Dilemma:

Physicians have deflected the morally troubling aspects of this dilemma by declaring that the physician is simply and exclusively a patient advocate. Physicians are, in the words of Norman Levinsky, "required to do everything they believe may benefit each patient without regard to costs, or other societal considerations."[8] The problem is perceived as one of divided loyalties and is to be resolved by choosing always for the patient. Medical ethics is seen as requiring unswerving allegiance, because, as Pellegrino and Thomasma say, "No physician can serve two masters."[9]

Lying behind this attitude of total patient advocacy is an ethical individualism. Both ancient and modem codes of medical ethics address the physician as an individual who relates to patients one to one. The possessive pronoun is frequently used to emphasize a high degree of attachment and loyalty. The Declaration of Geneva says, "The health of my patient will be my first consideration."[10] This first consideration" is often taken to be the only consideration.

Robert Veatch has canonized this view of medical ethics as "the Hippocratic tradition," which, he says, "mandates that the physician do what he or she thinks is in the patient's interest, and does not recognize a qualification such as `unless the costs are great in comparison to the benefits to be gained,' or take into account what economists call `alternative costs.'" He continues, "If physicians are asked to refrain from providing marginally useful care for patients in order to serve society, they must abandon their Hippocratic commitment."[11] Veatch's own reformulation of medical ethics retains the extreme individualism he finds in the Hippocratic tradition, as he calls for practitioners to be "exempt from the general moral requirements of the principles of justice" insofar as they are involved in relationships with patients.[12]

The idea that physicians have general, social obligations as well as special, patient ones is, to be sure, not absent from historical codes or contemporary theory. Past ethical codes describe general duties, such as promoting public health measures, that can be exercised at a remove from patient care.[13] Ethical conflict between societal needs and patient needs has been addressed in such areas as confidentiality of information or protection of society from dangerous patients. Yet the possibility of conflicting moral obligations with regard to the cost of care has generally been addressed by advising exclusive concern for the needs of the patient at hand.

This devotion to the patient at hand, without a framework for incorporating or arbitrating among other values, seems too narrow. Good done within a narrow sphere of accepted responsibilities must be weighed against those responsibilities not assumed-the good forgone, the patients or population groups left untreated, or what economists call the "opportunity costs." It is ethically short-sighted to assume that other duties do not exist or are insignificant.

Compounding the physician's incentive to dodge the ethical dilemma is the patchwork and often fragmented nature of health care organization and financing in the United States. Not only do traditional medical-ethical norms encourage a disregard for cost, but also physicians who do recognize the larger picture and attempt to be responsive to cost cannot be assured that reasonable restraint in treating individual patients will result in overall greater good. While physicians directly control roughly 80 percent of all health care resources in the U.S., they have no assurances that dollars saved on one patient will benefit that same patient at a later time, or other patients with greater needs or more malleable diseases. Hence there is no incentive for individual physicians to say no to marginal care for their patients. In the absence of a societal mandate and an organized system of distribution, every no seems ad hoc and arbitrary. Decisions of physicians to withhold even the most marginal treatments occur in the absence of a shared fiscal and moral context. As Norman Daniels says of our system of health care financing and distribution, "It is not closed under constraints of justice."[14] Thus physicians have understandably avoided or displaced the fundamental dilemma.

The lack of an integrated framework has made it difficult to resolve conflicts between individual and societal perspectives at both a theoretical and a practical level. Ethical theory encourages the physician to act as the patient's advocate, to respect individual wishes, and to ignore cost. In practical terms, government agencies, employers, and institutions concerned about the rising cost of those decisions make regulations based largely on cost containment, rather than on patient preference or medical grounds, because there is no moral consensus about just distribution. Moral philosophers who have worried about equitable distribution rather than efficiency alone have not yet articulated how equity can be reconciled with a commitment to respect patient autonomy. What is required is an integrated moral framework, one that puts individual autonomy and social equity questions into focus simultaneously. Such a framework will allow us to look at individual patient treatment decisions and at problems of efficiency and equitable distribution at the same time. These perspectives have heretofore been unrelated forces in the ethics of physicians because they have been taken as monolithic ideals which could not coexist in the same frame of reference. We propose a framework in which both individual autonomy and social equity can appear. We focus on the concept of citizenship, as it might function in the self-consciousness of both physicians and patients.

The Patient as Citizen/The Physician as Citizen:

A citizen is considered a member of a state, who owes allegiance to a government and is entitled to protection from it. The liberal, personal side of citizenship emphasizes the legal status of individual members as defined by rights and duties. In this understanding, citizenship is seen as a shell of protection for the underlying private self The moral, social, and communitarian side of citizenship emphasizes common purposes and shared vulnerabilities. This latter understanding of citizenship identifies the self as essentially social, as constituted by civic relationships. Both facets of citizenship are important to the ethics of medical care. In contemporary analyses, the more private and individual facet has dominated. We emphasize here the social aspect of citizenship in order to balance the discussion. Any workable ethic for medical care will need to acknowledge the importance of both sides.

Our reliance on the concept of citizenship is intended to evoke a sense of belonging to something larger than self, or particular individual relationships. Citizens are persons who perceive allegiances as extending beyond self-interest and beyond patient-specific professional duties to a sociopolitical order. Citizens both enjoy the rights and protections of that order and incur responsibilities for its maintenance and well-being.

The sick individual is not only a patient with rights but a citizen with duties. The right to make health care decisions should not be seen as an absolute without a context, but is bounded by the limited resources of society and the competing rights of others.

Traditionally, the patient has been seen as a powerless dependent. Talcott Parsons' classic definition of the "sick role" was for many years the paradigm for patient behavior-dependence, passivity, and compliance with doctor's orders combined with a pervasive desire to recover.[15] The progress in medical ethics over the past two decades can in part be measured by the extent to which more active and morally enfranchised roles for patients have developed. Concepts such as `the patient as person,' and patients' rights have become common currency. When taken alone, however, the notion of patients' rights is too narrow, and responsibilities that accompany the granting of rights are infrequently affirmed, and not widely recognized.[16]

The idea of patient as citizen can help to bring these responsibilities to the foreground. The patient as citizen has lights within health care, but also duties to make judicious and proportionate choices. In situations of scarcity, such choices are the only ones which will not infringe on the rights of other citizens to make similar choices.

This call for restraint is certainly not new. Daniels, for example, believes that proportionate judgments in the use of health resources would be the sort of "prudent" (or enlightened self-interested) choices made by his hypothetical "rational agents" who allocate fair shares of basic social goods over a lifetime.[17] The "prudential lifespan account" supports restrictions on some medical care at the end of life and favors intergenerational equity as a goal. Daniel Callahan argues for much the same goal in a different vein, claiming that our present all-out efforts to extend life at the edges are contrary to the purposes of medicine and prohibit attention to the true needs of the elderly for an independent and financially secure life.[18] The novel aspect of our thesis is the suggestion that citizenship can provide a moral bond for our diverse population and a motive force for judiciously restrained use of health care resources. Were we all fully "rational agents," or "life planners," such motivation would perhaps be unnecessary, an prudence, as enlightened self-interest, would be sufficient. Persons are moved to moral choices, however-as David Hume insisted-not only by the appeal of principles or scenarios of fair choice, but by common human sentiments. Hume believed that the recognition of such sentiments could help us rise above our "private and particular situation" to a common point of view.[19] Citizenship is one way though not the only way) of giving expression to such sentiments. It should play a larger role in medical ethics.

The ideas we propose here are usually associated with religious traditions rather than civic ones. For example, Christian doctrines of stewardship prohibit the extension of one's own life at a great cost to one's neighbor. This is not considered fatalism, but a simple matter of proportion. Despite enormous divergence among them, at least some traditions within judaism, Islam, Christianity, and Stoicism have insisted that life is not an unblemished good, or death an unmitigated evil. Within these perspectives, death is considered the necessary completion of a pattern and the important thing is to die at the right time and for the fight reason. Efforts to extend life beyond this "right time" are signs of not understanding divine purposes or human needs. Leon Kass puts it this way: "Man longs not so much for deathlessness as for wholeness, wisdom and goodness."[20]

What is seen as divinely sanctioned stewardship in some religious philosophies can be expressed as the virtue of judicious and fair use of resources in a public, civic philosophy. In a secular and pluralistic society assumptions about shared values between and among individuals and separate communities are difficult to justify. We do not suggest that a common life-philosophy, or a commonly accepted societal conception of the "good death" is a prerequisite for our approach. Nor do we suggest that religious ideals can or should be translated into social policy. Rather we argue that proportionate use of health resources is not a novel or foreign idea to many in our society and that there may well be civic as well as religious reasons for espousing it. Stewardship, for example, has reference in Christian doctrine to the use of God's gifts, but it also has a wide secular usage that denotes an "individual's responsibility to manage his life and property with proper regard to the rights of others."[21]

If all patients have obligations as citizens, then all citizens must have access to the rights of patienthood. If individuals can be asked to assume social duties, even when ill, it will be because all ill citizens can be recognized as having a fundamental right to adequate or basic care.[22] Without this umbrella of societal inclusion for all the sick, no patient would be motivated to judicious and proportionate use of resources out of citizenship. When only the upper classes have rights, each decision to forgo care at the margins is idiosyncratic, a gesture of altruism or particular beliefs. A societal decision to include all persons in health care services provides the backdrop against which proportionate choices can be seen as the usual duties of common citizenship rather than isolated, heroic acts. Choices to forgo marginal care can become forces for social cohesion, if they can draw at least a part of their authority from a public policy which extends access to health care benefits to all.

Rights within health care can then be seen as abiding in a context of rights to health care, with each modifying the other. Both rights can be seen as individual rights that are socially established, rights of citizenship with reciprocal obligations.

The physician must also be seen as a citizen. Historically, medical oaths, codes, and principles of ethics have recognized a variety of allegiances in addition to the physician's allegiance to the patient. The Oath of Hippocrates invokes the sanction of divine authorities and pledges fidelity to teachers, colleagues, and students. Medieval expressions of duty, such as the Prayer of Maimonides, place obligations to patients in the larger context of religious responsibilities. The American Medical Association's most recent "Principles of Medical Ethics," dating from 1980, lists responsibilities not only to patients "but also to society, to other health professionals and to self."

Citizenship as a source of moral obligation for physicians is noted explicitly in the AMA's first official effort to define its responsibilities, the Code of 1847. Chapter 3, article 1 of this code begins in the following way: "As good citizens, it is the duty of physicians to be ever vigilant for the welfare of the community and to bear their part in sustaining its institutions and burdens." What the authors of this code conceived as citizen duties were such things as advice on hygiene, quarantine regulations, the management of epidemics, and the location of hospitals, not fair distribution of medical agency or resource allocation. Yet the concept of citizenship as a moral component of medical ethics was recognized and presumably accepted by the profession. So the idea of citizenship as a source of medical obligations is not new. What is new is our contention that citizenship should play a different and larger role than in the past. A larger role is required because of the differences between American medical care in the mid-nineteenth and the late twentieth century.

If medical care were only marginally effective or of questionable value in preserving life and restoring health, physician responsibilities of citizenship could be carefully circumscribed, as in 1847, to matters of hygiene and quarantine. When, however, medical care becomes effective enough to be a socially recognized need, as soon as society invests substantially in its provision from public funds, the citizen responsibilities of physicians must be enlarged. Medical care has moved from being a privately paid, individual good of marginal value to the status of a largely public-supported individual and social good of great benefit. Some believe medical care is in fact overvalued. Yet even if there is debate about the extent of the value, or what constitutes an appropriate amount of care, few would disagree that at least a basic provision for care is essential to a minimally decent life.

With this increase in value comes an increase in the importance of a citizen component in medical ethics. Michael Walzer puts it succinctly. "Doctors and hospitals have become such massively important features of contemporary life that to be cut off from the help they provide is not only dangerous but also degrading."[23] In other words, the rationale for a larger citizen ethic for physicians is at least partially grounded in the need in any democracy to preserve the self-respect of citizens.

Thus we argue for a robust citizen ethic for both the patient and physician. If health care resources are acknowledged to be scarce, both physicians and patients have a responsibility for helping to shape policies for fair allocation at the societal level and for participating self-consciously in enacting those policies humanely at the level of individual patient care.

One major reason that patient autonomy and societal well-being have not been brought into a single ethical context is that the first is considered a strict deontological value while the second is seen as the product of consequentialist thinking. Our argument for a citizen ethic is, to be sure, consequentialist in nature since it springs from a recognition of the outcomes of scarcity. However our argument is fundamentally deontological since it is motivated by principles of equity and fairness in access. Hence, a citizenship component in the ethics of medical care decisions does not pit deontology against utilitarianism in the usual way. Calculations about outcomes are in the service of a second deontic concept, a second duty, a concern for equity.


To bring to fruition the perspective we have outlined here, several changes in attitude and the structure of health care delivery in the United States would be needed. Patients would need to realize (as Daniels has proposed) that every wish for care will not equate with a reasonable need that should be met by the health care delivery system. While each of us may want to live an extra month toward the end of life it may not be feasible to meet such a wish if it costs several years of income to fulfill it. While each of us should expect the highest respect, care, and concern as we get older, or as our illnesses become less amenable to treatment, we should not expect ceaselessly to postpone death. As individuals in a highly technological society, patients need to reassess their appetite for technology and be more circumspect in their judgment of the benefits they gain from it.

Patients should expect that the domain in which they may exercise self-determination lies only within the range of treatment choices that can be expected to be medically beneficial. While there is always uncertainty in the prediction of medical benefit, and disagreement about the definition of benefit, the patient's light to choose should not exceed the boundary of reasonably expected benefit.

Beyond the level of individual expectations, organized comprehensive technological assessment is essential.[24] Most important, there must be a vigorous public discussion about the health needs of the nation, and of each state and region, to begin to establish priorities. Without such discussion change will be restricted to reactive, short-term fixes.

In the overview we have described, physicians would continue primarily to be advocates for sick individuals. Yet, the physician as citizen would also recognize a significant responsibility for the betterment of the health and welfare of all individuals in the society. The physician is then obliged to use some sense of proportionality in providing care to each patient. In situations of acute scarcity, it is acceptable to provide a treatment to the individual with the greatest probability of receiving benefit.

We believe that restraint in the name of the common good is desirable and morally acceptable even in the disorganized, patchwork system we now have in the U.S. Yet patients and physicians cannot be generally expected to act with restraint in the absence of changes in the organization and financing of health care in the United States. Individuals can only be expected routinely to meet standards of restraint when society meets its prior obligation as provider for its citizens. Restraint at the margins is more acceptable, both morally and politically, when routine services at the basic level are provided according to common societal purposes.

To come full circle in this discussion we return to the use of intensive care toward the end of life. Decisions to use or forgo life-sustaining treatment are ideally preceded by two-way communication between the patient (or family) and the physician in which information about the patient's wishes and the prognosis and therapeutic options are discussed. Following this exchange of information the patient (or family) and physician agree upon a decision.

We argue that, in reaching a decision, the physician should use the principle that it is best to strive for that choice that is respectful of both the patient's wishes and society's needs. When there is a conflict between what is best for the patient and what is best for society, the physician should respect self-determination and treat according to the patient's wishes, so long as the treatment option is available and is expected to yield some benefit. Thus we are proposing that it is ethical for the physician to take societal concerns into account while making decisions for individual patients, and ideal to make decisions that are acceptable to both.

Let us take as an example a patient who suffers a cardiac arrest, is resuscitated, and subsequently remains on a ventilator in a coma for more than two weeks. The family and physician will discuss what the family believes that patient's wishes for care would be if the patient were able to express them, and the physician would convey information about the unlikelihood of awakening from nontraumatic coma of this duration.[25] If it is not a direct violation of the patient's previously expressed wishes, or if the patient had not expressed wishes that pertain to such circumstances, the physician should encourage discontinuation of artificial ventilation. If the patient had expressed an unqualified desire for life support it should be continued, with plans to reassess the benefits and burdens of ongoing therapy periodically.

Other examples of patients whose prognosis would warrant withholding or withdrawal of intensive care include patients with at least three organs that have failed to function for three days, patients with chronic diseases for which there is no therapy to alter prognosis who have failed to respond to ICU therapy, or physiologically stable patients who are at low enough risk of life-threatening events that monitoring is unwarranted.[26] Whereas the Task Force on Guidelines for the Society of Critical Care Medicine suggests that ICU directors should utilize these guidelines in deciding whether to admit or discharge patients from intensive care units, we would suggest that patients, families, and physicians should each be cognizant and respectful of these guidelines in their individual decisions.

Thus while physicians have been guided to advise discontinuation of life support solely because it is best for the patient, we believe it is ethically appropriate to advocate discontinuation in cases such as those mentioned above because it is also consonant with the social good. Resources used to achieve marginal gains for these patients could be more fruitfully used to provide medical benefits to others. A citizen ethic in health care decisions will give moral weight to some choices that would otherwise only be sanctioned by reference to a patient's wishes. A citizen ethic of the social good can never justify active euthanasia, but it could serve to temper maximalist predilections in both physicians and patients. A widely felt and well grounded citizen ethic could also diminish patient (or family) requests for treatments at the margins, substantially relieving physicians of the burdens of recommending cessation of treatment. A citizen ethic that applied solely to physicians or solely to patients would clearly be unworkable.


In part, we have been dissuaded from providing equitable access to all individuals in the United States because of the exorbitant cost of providing exhaustive entitlements to a few categories of individuals. It will be necessary to limit benefits we have provided through entitlements in order to guarantee a basic level of care to all. The past history of entitlement programs suggests that once access is granted, an ethic of individual autonomy, which respects all wishes of its recipients, reigns supreme. A citizen ethic for both doctor and patient is necessary in order to distinguish between insatiate individual wishes and a responsible choice for needed care.

Some critics of this proposal may argue that it would be easier for physicians to provide proportionate and avoid heroic care if proportionate' and `heroic' are defined in advance rather than left to physicians' and patients' judgments on a case-by-case basis. In general it seems both wise and necessary for major allocation decisions to be made at a societal level, at a remove from the physician-patient encounter. Yet no policies, however well conceived, can cover the diverse range of choices involved when care becomes complex. Even the best and most thorough policies will not relieve the physician and the patient of all choices, and no policy-level decision will be feasible without the concurrence of physicians and patients who see the wisdom of such policies and are morally motivated to live within them.

Some may object that what we propose will dilute the physician's ability to assist patients in need because of state or bureaucratic controls. We believe that just the opposite is more likely. The current reactive and patchwork system of health care financing hampers continuity and results in sporadic care and extreme fluctuations in access. A rationalized and more efficient system, combined with a citizen ethic of judicious use, would likely eliminate the need to micromanage physicians through utilization review and cost-accounting of thousands of separate procedures. Within accepted policy limitations, physicians should enjoy a greater degree of freedom in clinical judgment and an enhanced capacity for continuity of care.

Others may object that a physician-patient relationship which includes an element of common obligations for citizens will make the therapeutic alliance less private or confidential. Yet a citizen ethic does not subject doctor-patient encounters to public scrutiny. It simply means that the limits on what therapies can be offered have a larger social sanction than that determined by employability, commercial forces of distribution, institutional or professional largesse, or idiosyncratic entitlements. To be sure, some limits on the marginal benefits that patients can expect to receive or physicians can offer will be necessary. This does not drive a wedge into the patient-physician relationship; rather, it safeguards its continuation and gives social weight to its significance. It will provide both physicians and patients a common allegiance in addition to the mutual pull of their individual interaction at the point of the therapeutic encounter.

Some may object that the son of proportionality we recommend will require supererogatory acts of individuals, forgoing care they believe they are entitled to in order to benefit others. Yet the notions of `supererogatory acts' and `entitlements' will be altered in a system that includes not only autonomy for self, but enough restraint to ensure a measure of autonomy for others as well. A social ethic of judicious use of resources does not reject autonomy for utility, as if these were mutually exclusive choices. Rather it seeks to extend and give more equitable force to autonomy. Only the tyranny of a monolithic and privatized autonomy is rejected.


The experiences of both physicians and patients have outgrown the older models of medical ethics. New intellectual paradigms are needed to reflect these more complex relationships. Developing a citizen ethic for both physicians and patients is a step toward a more adequate model. Even the most elegant model will not, of course, resolve all the tensions between respect for patient autonomy and equity of distribution, nor will it resolve the many complex issues of institutional and financial change. What we propose, however, does give explicit voice to a basic moral conflict, and engage it realistically. Engagement is the first step toward resolution.


1. Marion Danis, D.L. Patrick, L.I. Southerland, and M.L. Green. "Patient and Family Preferences for Medical Intensive Care," JAMA 260 (1988): 797-802; T.J. Starr, R. A. Pearlman, and R.F. Uhlmann, "Quality of Life Resuscitation Decisions in Elderly Patients," Journal of General Internal Medicine (1986):373-79.

2. Danis et al. "Patient and Family Preferences."

3. J. Lubitz and R. Prihoda, "The Use and Cost of Medicare Services in the Last Two Years of Life," Health Care Financing Review 5 (1984): 117-31.

4. Almost any contemporary bioethics text can be cited to substantiate the point. Two of the most prominent and widely quoted are Tom L. Beauchamp and James E Childress, Principles of Biomedical Ethics (New York: Oxford University Press, 1979), pp. 56-94; and H. Tristram Englehardt Jr., The Foundations of Bioethics (New York: Oxford University Press, 1986), pp. 85-87ff.

5. Charles Fried has given definitive expression to the way in which this light of the patient to make decisions within a health care encounter should be separated from the concept of a general right of access to health care sciences. See Charles Fried, "The Primacy of the Physician as Trusted Personal Advisor and Not as Social Agent," in Bioethics: Readings and Cases, ed. Baruch Brody and H. Tristram Engelhardt (Englewood Cliffs, N.J,: PrenticeHall, 1987), pp. 223ff.

6. See Paul Ramsey, The Patient as Person (New Haven: Yale University Press, 1970), p. 275.

7. For example, see Norman Daniels, just Health Care (Cambridge: Cambridge University Press, 1985); Howard Hiatt, America's Health in the Balance (New York: Harper & Row, 1987); or L. R. Churchill, Rationing Health Care in America: Perceptions and Principles of Justice (Notre Dame: University of Notre Dame Press, 1987).

8. Norman Levinsky, "The Doctor's Master," NEJM 311 (1984): 1573.

9. Edmund Pellegrino and David Thomasma, For the Patient's Good: The Restoration of Beneficence in Health Care (New York: Oxford University Press, 1988), p. 189.

10. "Declaration of Geneva," in World Medical Journal 3, Supplement 10- 12 (1956).

11. Roben Veatch, "Justice and the Economics of Terminal Illness," Hastings Center Report 18, no. 4 (1988): 35.

12. Roben Veatch, A Theory of Medical Ethics (New York: Basic Books, 1981), p. 330.

13. See, for example, Principles of Medical Ethics," Proceedings of the American Medical Association House of Delegates, 129th Annual Convention, 20-24 July 1980; or American Medical Association, "Code of Medical Ethics," in the Encyclopedia of Bioethics, ed. Warren T Reich (New York: The Free Press, 1978), p. 1745.

14. Norman Daniels, "Why Saying No to Patients in the United States Is So Hard," NEJM 314 (1986): 1380-83.

15. See Talcott Parsons, The Social System (New York: The Free Press of Glencoe, 1951), pp. 428-47.

16. A notable exception to the pattern can be found in Edmund Pellegrino and David Thomasma, A Philosophical Bask of Medical Practice (New York: Oxford, 1981), p. 218. Pellegrino and Thomasma list five "patient obligations," yet judicious use of health care resources is not among them.

17. Norman Daniels, Am I My Parents' Keeper? (New York: Oxford University Press, 1988), especially chaps. 3 and 4,

18. Daniel Callahan, Setting Limits: Medical Goals in an Aging Society (New York: Simon and Schuster, 1988), especially chap. 5.

19. Hume is eloquent on this point. See especially his Inquiry Concerning the Principles of Morals (1777; La Salle, Ill.: Open Court Publishing, 1966). The quotation is taken from the Conclusion," p.111.

20. Leon Kass, "The Case for Mortality," The American Scholar 52, no. 2 (1983): 187.

21. Webster's Ninth New Collegiate Dictionary.

22. Even if there is no consensus in the United States that individuals have a right to health care, the President's Commission for the Study of Ethical Problems in Medicine has made a compelling argument that a humane society has the obligation to provide medical care to its citizens. See the President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research, Securing Access to Health Care: A Report of the Ethical Implications of Differences in the Availability of Health Services (Washington, D.C.: U.S. Government Printing Office, 1983).

23. Michael Walzer, Spheres of Justice (New York: Basic Books, 1983), p. 89.

24. See Office of Technology Assessment, Life-Sustaining Technologies and the Elderly, OTABA 306 (Washington, D.C.: U.S. Government Printing Office, 1987).

25. D. E. Levy et al. "Prognosis in Nontraumatic Coma," Annals of Internal Medicine 94 (1981): 293-301.

26. See the Task Force on Guidelines for the Society of Critical Care Medicine, "Recommendations for Intensive Care Unit Admission and Discharge Criteria," Critical Care Medicine 16 (1988): 807-8.
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Title Annotation:life-sustaining care
Author:Danis, Marion; Churchill, Larry R.
Publication:The Hastings Center Report
Date:Jan 1, 1991
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