The legal consensus that has evolved through adjudication and legislation since the Karen Quinlan case in 1976 is founded on the premise that there is a bright line between passive euthanasia and active euthanasia. Indeed, the term passive euthanasia is often eschewed in favor of less emotionally-laden terminology such as "forgoing life-sustaining treatment" or "terminating life support" so as to further sever any possible connection with active euthanasia. Legal approval has been bestowed upon passive euthanasia under certain circumstances while active (...) euthanasia is routinely condemned. This consensus was put to a test in 1990 when the United States Supreme Court ruled on the Cruzan case. However, the Court's narrow decision did not upset the consensus, and in the most significant appellate decisions handed down by state courts since Cruzan, there has been a reaffirmation-and possibly even an extension-of the consensus. Two other threats to the legal consensus about forgoing life-sustaining treatment have begun to manifest themselves: the increasing pressure for mercy killing and "futility" cases. Both of these challenge the fundamental premises on which the consensus is grounded. (shrink)

The article examines the legal status of living wills and health care proxies in Germany, the United States and Japan. The investigation begins with the question of what protection these three legal orders provide for the right to self-determination. Whereas in Germany and the United States, legislation and legal practice take the theory of informed consent very seriously, the doctor-patient relationship in Japan is much less oriented toward the idea of patient autonomy. This basic attitude is reflected in the legal (...) disposition given advance directives. In the USA, most of the individual states have legislation on the living will and health care proxies. In Germany, the judiciary and scholarly literature at least carefully affirm that they are legally binding. In Japan, at least currently, there is nothing at all similar to this approach. The authors then conduct a micro-legal comparison of cases of first impression decided in the USA and Germany and emphasize the amazing similarity of the judicial decisions in two cases . Finally, the question is raised for German law of whether, and in what form, further legislative development of the judicially established right to die appears reasonable. Der vorliegende Beitrag untersucht den rechtlichen Stellenwert von living wills und health care proxies in Deutschland, in den USA und in Japan. Ausgangspunkt der Untersuchung ist die Frage, welchen Schutz das Selbstbestimmungsrecht in den erwähnten Rechtsordnungen genießt. Während in Deutschland und in den USA Gesetzgebung und Rechtspraxis die Theorie vom informed consent sehr ernst nehmen, ist das Arzt-Patienten-Verhältnis in Japan weit weniger vom Gedanken der Autonomie des Patienten bestimmt. Diese Basiswertung schlägt auch im Bereich der rechtlichen Beurteilung von advance directives durch. In den USA sind living will und health care proxy in den meisten Einzelstaaten gesetzlich geregelt, in Deutschland wird ihre rechtliche Verbindlichkeit von Judikatur und Literatur zumindest vorsichtig bejaht. In Japan fehlen - zumindest derzeit - entsprechende Ansätze noch gänzlich.Die Verfasser stellen sodann einen Mikrorechtsvergleich zwischen den in den USA und in Deutschland entschiedenen cases of first impression an und betonen den erstaunlichen Gleichklang der rechtlichen Beurteilung dieser beiden Fälle .Schließlich wird für deutsches Recht die Frage gestellt, ob - und in welcher Form - eine legislative Weiterentwicklung des judiziell bereits etablierten right to die angemessen erschiene. (shrink)

Mrs. F, seventy‐five, was diagnosed with Alzheimer's. She and her spouse often discussed how to handle the progression of the disease. She was adamant about not coming to the point where she would be unable to recognize herself, her husband, or their son and daughter. The manner she chose was voluntarily stopping eating and drinking (VSED), and she chose a specific date on which to carry out her plan. She asked her husband to promise, should she ever waver and request (...) nutrition or hydration, to remind her of the reasons she had chosen for pursuing this path.Mrs. F's ability to function was beginning to wax and wane. Sometimes she was her old self, and sometimes she had no recollection of her past identity. After she voluntarily stopped eating and drinking, the couple's promise created a dilemma for her professional caregivers. She asked for food and drink. Her husband and family reminded her of the reasons she had chosen VSED: “Remember, you didn't want to live in a nursing home, and you didn't want us to be responsible for caring for you at home. You believe that stopping eating and drinking will allow you to die with dignity.” Although they also asked Mrs. F, “What do you want to do?” the family asked the professional caregivers to respect her original choice to stop eating and drinking. Mrs. F still evidenced decision‐making capacity but often did not recall having chosen VSED. She again requested food and drink, from family and the professional caregivers.Can VSED be carried out for a patient whose advanced dementia makes disciplined voluntary action difficult? (shrink)

A letter from Alan Meisel on "The Evolution of Consent Forms for Research: A Quarter Century of Changes," by Ilene Albala, Margaret Doyle, and Paul S. Appelbaum.

This paper describes the first three-year experience of the Consortium Ethics Program (CEP-1) of the University of Pittsburgh Center for Medical Ethics, and also outlines plans for the second three-year phase (CEP-2) of this experiment in continuing ethics education. In existence since 1990, the CEP has the primary goal of creating a cost-effective, permanent ethics resource network, by utilizing the educational resources of a university bioethics center and the practical expertise of a regional hospital council. The CEP's conception and specific (...) components stem from recognition of the need to make each hospital a major focus of educational efforts, and to provide academic support for the in-house activities of the representatives from each institution. (shrink)