The opinion of Mr. Justice Francis of the English High Court which denied the parents of Charlie Gard, who had been born with an extremely rare mutation of a genetic disease, the right to take their child to the United States for a proposed experimental treatment occasioned world wide attention including that of the Pope, President Trump, and the US Congress. The case raise anew a debate as old as the foundation of Western medicine on who should decide and on (...) what standard when there is a conflict between a family and the treating physicians over a possible treatment. This paper will explore the different approaches of the British and American courts on the issue and the various proposals from that of John Rawls in his A Theory of Justice to a processed-based approach for resolving such disputes. As carefully crafted as the opinion of Mr Justice Nicholas Francis in the Gard case proved to be, it left commentators unsatisfied. A widespread criticism, captured in an article by Michael Dougherty in The National Review was for the state to ‘get out of the way of the parents trying to act in the best interests of the child’.1 Although he conceded the parents could be adding to the suffering of the child by taking Charlie to America for an experimental therapy and agreed that such a choice ‘may be the wrong decision,’ in Dougherty’s view, it should still be ‘their decision’. Dougherty’s stand was the popular response to the question of ‘Who should decide?’ It fails, however, to propose any rationale for the decision. It provided no norms, no standards and no guidelines for the parents. Their motive could equally well be indifference to the suffering of the child as concern for his well-being. Furthermore, even good, loving parents may make …. (shrink)

Several recent articles raise an issue long unaddressed in the medical literature: physician compliance with patient or family requests for futile or ineffectice therapy. Although they agree philosophically that such treatment ought not be given, most physicians have followed the course described by Stanley Fiel, in which a young patient dying of cystic fibrosis was accepted “for evaluation” by a transplant center even though he has already passed the threshold of viability as a candidate for a heart-lung transplant. Dr. Fiel (...) reported this action was taken not in the hope of doing the transplant but so that the family could assure themselves they had done “everything possible.” The patient, after a long and stressful cross-country flight, arrived at the hospital in respiratory failure. He died soon thereafter far from home and familiar surroundings. (shrink)

As the only nation in the western world without a national health insurance program, the United States faces ongoing issues of access and fairness in health care coverage. The Clinton administration tried and failed to address the problem of universal coverage. Since then we have focused on the narrower, but nonetheless real, issues of fairness and equity in the benefits package provided in insurance plans. The LORAN Commission spent two years trying to devise agreed-upon principles to govern such issues. The (...) lesson learned was the same as that of the Ethics Force study: there was no possibility of getting agreement, let alone consensus, among the participants on how to decide what should be a covered benefit. There were, however, two generally agreed upon principles that emerged regarding health care: “Every individual should be treated alike,” and “When it comes to health, cost cannot be a consideration.” That formula translated into providing everyone with everything. The only certain outcome from such a policy would be fiscal insolvency and ultimately bankruptcy. (shrink)

It took nearly two thousand years for society to recognize the Hippocratic insistence that “the doctor knows best”1 was an inadequate approach to medical decisionmaking. Today, patient-centered medicine has come to understand that the individual patient has a significant role in the decisionmaking process.2.

(2011). Standards, Norms, and Guidelines for Permissible Withdrawal of Life Support From Seriously Compromised Newborns. The American Journal of Bioethics: Vol. 11, No. 2, pp. 33-34.

The children were nestled all snug in their beds.While visions of sugar-plums danced in their heads.Clement Moore's cherished ‘Twas the Night Before Christmas captures the hopes, dreams and visions...

The American Journal of Bioethics, Volume 11, Issue 11, Page 13-14, November 2011.

In a recent essay, George Annas, the legal columnist for The New England Journal of Medicine, observed that the resuscitation of extremely premature infants, even over parental objection, is not problematic because “once the child's medical status has been determined, the parents have the legal authority to make all subsequent decisions.” Annas himself is quick to concede that treatment in a high-technology neonatal intensive care unit frequently takes on a life of its own. He also acknowledges that although bioethicists and (...) courts agree that there is no ethical or legal difference between withholding or withdrawing a respirator from a patient, parents and physicians find the withdrawal much more emotionally troubling. (shrink)

Thirty years later we seem no closer to a consensus on the ethics of sterilizing profoundly mentally compromised young girls than was Judge Blumenfeld.

Volume 19, Issue 12, December 2019, Page 49-51.

When there is a conflict between parents and the physician over appropriate care due to an infant whose decision prevails? What standard, if any, should guide such decisions?This article traces the varying standards articulated over the past three decades from the proposal in Duff and Campbell’s 1973 essay that these decisions are best left to the parents to the Baby Doe Regs of the 1980s which required every life that could be salvaged be continued. We conclude with support for the (...) policy articulated in the 2007 guidelines of the American Academy of Pediatrics on non-intervention or withdrawal of intensive care for high-risk newborns. (shrink)

The American Journal of Bioethics, Volume 11, Issue 7, Page 16-18, July 2011.

How does a self-described “simple teacher of religion” at the College of the Holy Cross get involved in bioethics? Nothing in my training or experience had prepared me for involvement in medicine. Much like that of my moral theology professor and then mentor, Richard McCormick, my training was in moral theology and social ethics. I also had an abiding interest in the courts and constitutional law. That interest led to a doctoral dissertation at the University of Southern California's Program in (...) Social Ethics on “The Supreme Court's Understanding of Religion in Conscientious Objector Cases.” Interestingly, doctoral work in the late 1960s on the ethical dimension of war was the starting point for other ethicists such as Leroy Walters and James Childress who subsequently became early voices in bioethics. (shrink)

The Clinton administration's revised rules regulating but not prohibiting the common practice in managed care of linking physician compensation with cost cutting and control of services demonstrates the complexity of ethical issues in managed care. As originally proposed, the federal guidelines on payment for Medicare and Medicaid services would have precluded any interrelationship between payment to physicians and delivery of services. Such a restriction would have gutted the primary mechanism in managed care plans to curb the unacceptably high cost of (...) healthcare delivery: making physicians directly responsible for cost control by placing them at direct financial risk. At first blush such a linkage seems to involve an obvious and irreconcilable conflict of interest. How can a physician be responsible for the well-being of a patient while at the same time aware that a proportion of his or her income is linked to the provision of cost-conscious care? (shrink)

The issue of physician refusal of requested treatment has fueled a two-pronged debate in our society-one on the meaning of futility and the other on the limits of patient autonomy. The latter is a genuinely philosophic dispute; the former, it seems, is a modern relapse into nominalism.It is not the meaning of a word, but the moral basis for the actions of the par-ticipants that should be the focus of our attention, Yet the medical literature distracts us with articles titled (...) “Medical Futility: Its Meaning and Ethical Implica-tions” “The Problem with Futility” “Who Defines Futility?,” “The Illusion of Futility,” and even “Beyond Futility.”The history of the futility debate, which was launched by a 1983 study of Bedell and Delbanco that demonstrated the ineffectiveness of CPR for certain catego-ries of patients, has been documented elsewhere. Here we will inquire if the term, and its rapid intrusion into the medical lexicon, serves a useful purpose or if, as Truog suggested, we would all be better off if this new buzzword were jettisoned. (shrink)

Rosoff and Schneiderman's essay “Irrational Exuberance: Cardiopulmonary Resuscitation as Fetish” (2017) raises an issue first posed by the then Chairman of the Federal Reserve Board, Alan Greenspan...

The opening sentence of Christopher Meyers’ Target Article is “Lying to one’s patient is wrong”. The author continues, “This truism is one that bioethicists have heartedly endorsed fo...

To paraphrase Lewis Carroll’s poem “The Walrus and the Carpenter” from his Through the Looking Glass, “The time has come to talk of many things.” Not as the Walrus did in the nursery rhyme, “of sho...

Dostoevsky wrote that love in action is a harsh and terrible thing compared to love in dreams. That reality is particularly evident in medicine, where there is an almost universal, involuntary participation of physicians and other healthcare workers in the suffering of their patients. This paper explores this phenomenon through the paradigm of ‘mystery’ as explained by the French existentialist philosopher Gabriel Marcel. A mystery is different from a problem in the sense that the former requires the active immersion of (...) the person involved in order to be truly experienced. It is a ‘meta-problem’ that cannot be analyzed objectively and separately from the person that it affects, without changing the nature of the thing experienced. The authors contend that the human suffering encountered in medicine is one such phenomenon, and the paper draws on illustrations of this concept in art and literature. Awareness of the subtle but important difference between mystery and problem may help physicians better understand their personal entanglement with the suffering of patients. (shrink)

Intentionally or not, our clinical practice is informed by our philosophical premises. A subtle misunderstanding can have frequent, though insidious, implications in day-to-day clinical encounters....

This paper examines and critiques the ethical issues in postmortem sperm retrieval and the use of postmortem sperm to create new life. The article was occasioned by the recent request of the parents of a West Point cadet who died in a skiing accident at the Academy to retrieve and use his sperm to honor his memory and perpetuate the family name. The request occasioned national media attention. A trial court judge in New York in a two-page order authorized both (...) the retrieval and use of the postmortem sperm. (shrink)

Volume 20, Issue 7, July 2020, Page 147-150.

Death in the Clinic fills a gap in contemporary medical education by explicitly addressing the concrete clinical realities about death with which practitioners, patients, and their families continue to wrestle. Visit our website for sample chapters!