Hastings Center Report, Volume 52, Issue 3, Page 37-48, May–June 2022.

Mr. C is a twenty‐two‐year‐old who was flown to a level‐1 trauma center after diving headfirst into shallow water. Prior to this accident, he was in excellent health. At the scene, he had been conscious but was paralyzed and had no sensation below his neck. The emergency medical services team immobilized Mr. C's neck with a cervical collar and intubated him for airway protection before transport. As Mr. C's medical care proceeds, he expresses a desire for extubation, although it was (...) not clear that he had the capacity to make this (or any other) decision. It also was unclear whether this desire reflected his authentic wishes to be allowed to die or stemmed from feelings of discomfort and agitation. Over a period of several days, Mr. C's sedation was lightened, and the psychiatry service conducted a formal decision‐making capacity assessment. Mr. C continues to express a desire to withdraw life‐sustaining medical treatment. However, the psychiatry service is concerned that Mr. C seems to lack adequate insight into what it would mean to die.What does it mean to respect Mr. C's autonomy? (shrink)

I open the glossy cover of my alma mater's alumni magazine. Images of new frontiers in medicine abound—state‐of‐the‐art research buildings and the latest in high‐tech hospital innovations. Nestled among the articles on cutting edge medicine is a feel‐good story about medical students. The article profiles volunteer medical students and their uninsured patients with chronic health conditions. At one site, they are touted as providing “the only medical care.” Indeed. I think back to my medical student days and cringe.

The scenario is becoming achingly familiar to me: a woman in her fifties with no health insurance suffers a stroke. With luck, it is a small stroke—a "warning sign." But the patients I'm likely to see as a rehabilitation physician are usually not that lucky. The stroke is invariably large, causing significant disability. And the other familiar part of this scene? While treating her, I discover, unbeknownst to the patient, that her blood sugar and blood pressure are out of control. (...) Undoubtedly, the undiagnosed hypertension and diabetes contributed to the stroke.So what's the back story? Perhaps she works a job that doesn't provide insurance, or she can't afford the premiums. She has mouths to feed, rent to pay, and .. (shrink)

Amy's excellent home care was the only reason she was doing as well as she was. There was no one better at taking care of Amy than her husband. When she had a respiratory infection, Steve managed the necessary increased suctioning, nebulizer treatments, and ventilator, in addition to all the other intimate personal assistance she needed on a routine basis. Yet by law he could not be paid to be her personal care assistant. After a revolving door of unreliable, inadequate (...) assistants and recurring medical crises, Amy and Steve made the painful decision to divorce so he could quit his job and be paid by the state to care for her. (shrink)