Patients Rights

WHEN COLORADO GOVERNOR RICHARD LAMM said recently in an oft-misquoted speech that "we have a duty to die and get out of the way with our artificial hearts," he was not advising that anyone put a ceiling on the life span of a useful human being. What he was referring to are the questions raised by the extraordinary and expensive advances of medical technology, and the fact that society must attempt to allocate its resources in the most ethical and fair way. He wasn't suggesting that old people exit en masse, but rather that it is time for doctors to reevaluate the circumstances under which they will prolong the dying process for terminal patients. It is time that doctors reconsidered the validity of the wishes of terminal patients who simply do not want to extend their lives artificially. An article published recently in the New England Journal of Medicine by a group of prominent doctors convening at the Harvard Medical School should go a long way towards doing just that.

The article entitled "The Responsibility of the Physician Towards the Hopelessly III," was written by doctors from all over the country. It addresses specifically the issue of the terminal patient's right to dictate his course of treatment, and it comes up with some rather startling recommendations. It is acceptable, the authors state, for a mentally competent patient to refuse treatment, even to refuse food, if he or she does not want to prolong an already difficult process of dying. "We're not advocating breaking the law but since the [legal and medical] context is changing, physicians have to make some judgments where the situation is unclear," said one of the study's authors. "We're saying they should use a measure of compassion."

The article makes two major points. First, that the wishes of the patient should be considered paramount in the decision-making. And second, that doctors should not feel compelled, as many traditionally do, to continue "aggressive" or extraordinary treatment to keep a terminal patient alive.

Many doctors feel uncomfortable with an attitude that is anything less than completely "aggressive" towards treatment, citing the Hippocratic Oath that all physicians take before practicing, which states that they will do all in their power to prolong or sustain life. But it is essential to remember that the oath was written thousands of years ago. The medical capabilities of the physician then were highly limited, so much so that it was safe to make such a promise without fear of the impending ethical questions raised by devices such as respirators or organ transplants. But many aspects of this oath are simply outdated; in fact, it includes a promise never to remove kidney stones, a standard procedure today which was fatal at the time the oath was written.

The article limits its discussion to terminal patients who are mentally competent to evaluate their own situation. The doctors say nothing of parents who must choose whether to allow deformed infants to die, or of the so-called "death doctors" who are empowered to choose for them. It does, measure of say in what their treatment will be. If a patient is no longer competent, for example senile, the article insists that doctors honor "living wills," written testaments made by patients previous to their incompetence, which state their wish never to be kept alive artificially. If there is no written will, then they simply emphasize the importance of listening to the family's opinions, particularly if they believe the patient expressed such wishes orally. If there is no consensus, the doctors must continue to make judgment calls, but the authors hope that with higher awareness, such situations will become increasingly rare.

A central goal of the study is to encourage doctors to discuss more openly with patients their prognoses and the possibility of future decisions--they hope that doctors will be able to understand their patients feelings before it is too late and they must resort to guesswork.

This is a crucial point in medical decision-making today; it is imperative that the medical community begin to take stock of the implications of their technology, and the emphasis on patient rights, in terminal cases, is entirely appropriate. While laws and hospital regulations vary from state to state and among public and private hospitals, there is not always a clear directive for action in cases with difficult ethical and medical implications.

It will take a great deal of time and effort to change outdated laws and attitudes, but it is time that society as a whole begins to evaluate its treatment of the terminally ill. And the sensitive and courageous stance taken by the doctors in the Harvard article is an appropriate beginning; we hope that other physicians and lawmakers will follow their lead.