Læknablaðið - 15.10.1989, Blaðsíða 41

LÆKNABLAÐIÐ 1989;75:303-11
303
THE APPLETON CONSENSUS:
INTERNATIONAL GUIDELINES FOR DECISIONS
TO FORGO MEDICAL TREATMENT
Proceedings of Guidelines for non-treatment decisions: An international
working conference May 15-19, 1988, Lawrence University Program in
Biomedical Ethics, Appleton, Wisconsin, U.S.A.
ABSTRACT
Thirty-three physicians, bioethicists, and medical
economists from ten different countries met at
Lawrence University, Appleton, Wisconsin, to
create The Appleton Consensus: International
Guidelines for Desicions to Forgo Medical
Treatment. The guidelines deal with four specific
decision-making circumstances.
1. Five guidelines were created for decisions
involving competent patients or patients who
executed an adcance directive before becoming
incompetent, and those guidelines fell into three
categories.
2. Thirteen guidelines were created for decisions
involving patients who were once competent, but
are not now competent, who have not executed an
advance directive.
3. Seven guidelines were created for decisions
involving patients who are not now and never
have been competent, for whom »no substituted
judgment« can be rendered.
4. Eleven guidelines were created for decisions
involving the scarcity of medical resources, which
exists in all communities. Five concepts were
identified as being critical in the establishment of
priorities given the reality of scarce health
resources.
INTRODUCTION
Thirty-three delegates from ten different
countries (1) convened in Appleton, Wisconsin,
U.S.A. from May 15-19, 1988, under the auspices
of the Lawrence University Program in
Biomedical Ethics, to create a first draft of what
they hoped might become international guidelines
for treatment abatement procedures. The
delegates attending committed themselves to
convene a forum at an appropriate level in their
home country or community for further
discussion of the statement produced at the
conference.
Twenty-five of the thirty-three delegates were
physycians, representing eleven different medical
specializations. Of the eight non-physicians, six
had extensive clinical experience in ethics
consultations. One of the eight was a medical
economist. Seven were bioethicists: two with
background in philosophy, two in theology, two
in law, and one in comparative religion and
ethics. Several of the delegates had had experience
in the creation of important medical ethics
guidelines in the past.
Twenty-six of the thirty-three delegates had met
together in a preparatory conference one year
earlier. Seven of the delegates were new (2).
Two particular sets of concerns had emerged in
the first Appleton working conference: 1)
concerns regarding decisions to forgo medical
treatment, including life-prolonging treatment,
precipitated by autonomus requests by patients or
their surrogates, and 2) concerns regarding
decisions to forgo medical treatment as a result of
pressures due to scarcity.
The goal of the second international conference
was to draft a statement addressing these
concerns in the form of guidelines for discussion
in medical and medical ethics communities
internationally.
The delegates were divided into four working
groups (3). In the first three plenary sessions of
the conference, the delegates studied existing sets
of guidelines, discussed the processes of searching
for consensus, and set their operational goals for
the working sessions. After four working
sessions, each working group reported its
progress for plenary discussion. During two
further group sessions, the working group