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Searching for international consensus.

Searching for International Consensus

A group of thirty-five physicians and ethicists from ten countries has produced "The Appleton Consensus: Suggested International Guidelines for Decisions to Forgo Medical Treatment" (published in the March edition of the Journal of the Danish Medical Association). The guidelines apply to decisions in four different categories: (1) competent patients or patients who executed an advance directive before becoming incompetent, (2) previously competent patients, who have not issued an advance directive, (3) patients who have never been competent, (4) decisions in any of these categories significantly influenced by scarcity of medical resources.

The first section affirms that life-prolonging treatment should not be imposed on patients against their will; that advance directives by competent patients to reject treatment should be respected, that even while respecting treatment refusals, institutions have an obligation to continue to offer supportive care; and that requests, including advance directives, to continue life-prolonging treatment should also be respected except in certain specified circumstances--one of which is scarcity. In regard to requests for active euthanasia, the statement affirms in four terse sentences that there are conditions under which such requests may be justified; that this does not necessarily mean that such requests should be honored; that doctors have an obligation to "provide a peaceful, dignified, and humane death with minimal suffering"; and that at this time it would be "against the public interest" to legalize the "intentional killing of patients by physicians." This portion of the statement reveals important areas of disagreement from two directions. Three signatories dissented, claiming that active euthanasia is not only contrary to the public interest, but a violation of basic morality. Several other signatories felt that it was not clear, especially in light of several recent polls in the U.S., that legalizing euthanasia would in fact be contrary to the public interest.

For decisions about patients who were once competent but are not now competent and who have not executed an advance directive, the statement affirms the desirability of discovering in so far as possible what the patient would have wanted done. If efforts fail to reconstruct reliable substituted judgment, the statement endorses reliance on a best interest test (defined as "what would most generally be thought to advance most such patients' interests"). The examples of interest it might be presumed "most such patients" would endorse omits any reference to simple continuation of life. Indeed, the signatories specifically reject "the simple vitalist assumption that prolonging life is always in a patient's interests." They affirm that active euthanasia, "as distinguished from forgoing treatment that is deemed inappropriate, has no place in the treatment of permanently incapacitated patients." On the other hand, the statement affirms (with five dissents registered) that patients in a "reliably diagnosed" persistent vegetative state (PVS) can have "no self-regarding interest," and that life-prolonging treatment in such cases may be discontinued.

The statement affirms the necessity of setting reasonable limits in providing life-prolonging treatment for patients who have never been competent, specifically endorses the "weighing of the ratio of benefits and burdens" as a tool in assessing such limits, and catalogues the interests that may conflict and may require protection in these decisions. However, decisional discretion guided by the clinical wisdom of a trustworthy doctor more than any "layers of external mandatory audit" will be most valuable in interpreting those limits and interests and resolving those conflicts.

As the signatories themselves acknowledged, the section addressing decisions influenced by scarcity is the document's weakest part. However, three very important areas of agreement appear: (1) the recognition of the inevitability of scarcity and the necessity to make choices between alternative uses of scarce resources, (2) the recognition that those choices should be open and undisguised, and (3) the endorsement of cost-effectiveness analysis as an indispensible tool in responsibly addressing problems of scarcity.
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Title Annotation:euthanasia, life-prolonging medical treatment
Author:Stanley, John M.
Publication:The Hastings Center Report
Date:Jul 1, 1989
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