Læknablaðið - 15.10.1989, Side 48

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LÆKNABLAÐIÐ
Thomas Beauchamp and theologian James
Childress, Principles of Biomedical Ethics,
Oxford University Press, 1978 (second edition,
1983), and are discussed by Raanan Gillon,
Philosophical Medical Ethics, John Wylie and
Sons, 1986. See also The Belmont Report: Ethical
Principles and Guidelines for the Protection of
Human Subjects. DHEW pub. no. (os) 78-0012,
Washington, D.C., 1978.
5. Several delegates felt that »respect for life«
should be added as a fifth principle coequal with
the other four.
6. The term competent (and all variations such as
incompetent, competence, etc.) is used
throughout this statement in its general ethical
sense indicating adequate decision-making
capacity for the specific decision or class of
decisions under discussion and not in its narrower
legal sense.
7. It should be remembered that in some religious
traditions (e.g. Orthodox Judaism) the right to
refuse lifesaving treatment is not recognized as
morally valid.
8. Some delegates felt that it was not at all clear
that legalizing such intervention was against the
public interest, especially in light of confirmation
in repeated polls (most recently Roper, 1988;
Harris 1987; and »A Survey of Opinions and
Experiences of Colorado Physicians,» 1988) that
a majority of the U.S. public and a substantial
minority of physicians state that there are
circumstances under which a physician should
accede (or be legally permitted to accede) to a
patient’s request for a lethal dose of medication.
Others felt that legalizing such intervention was
not only contrary to public interest but a violation
of »basic morality«. See dissents.
9. Some of the delegates argued that in situations
of real doubt as to whether a proposed treatment
is in the patient’s interest, the choice should be to
withhold that treatment (the common bias toward
treatment - whether resting on a technological
imperative or a vitalist assumption - being
unjustified). Others felt that although physicians
should never treat merely because a treatment is
available, in some cases where it was not clear
what the interests of the patient were, prolonging
life of a quality that most patients would accept
would be justified. All delegates rejected the
simple vitalist assumption that prolonging life is
always in a patient’s interest.
10. Examining the rationale for the statements of
family, friends, and caregivers is an important
part of this process, including consideration of
the possibility of conflicts of interest with the
patient. Care should be taken, however, to guard
against discounting the views of disagreeing
parties merely because they are disagreeable or
inarticulate.
11. For cases where treatment would not be
physiologically futile, but nonetheless futile in the
context of the whole condition, the same advice
should apply as in Part I: Requests for
Treatment.
12. Some delegates argued that continued
treatment of PVS patients can be justified by the
benefit such treatment would offer to others (e.g.,
to parents or close relatives). Others argued that a
PVS patient should never be treated solely for the
benefit of others. Both deontological and
utilitarian arguments were adduced to support
this contention. Still other delegates argued that
the continued treatment of a PVS patient for the
benefit of others may be justifiable if such
treatment were continued only for a short time;
for example, until the diagnosis can be established
with a high degree of certainty or until tha family
has had a reasonable amount of time to recognize
the hopelessness of the situation. See dissents.
13. Third person quality of life judgments are
judgments made grammatically and logically in
the third person - i.e., judgments about the
quality of »his« or »her« life vis-a-vis first person
judgments about the quality of »my« life.
14. This form of third person quality of life
judgment must be carefully distinguished from
third person quality of life judgments based on
concepts of minimal social worth, which all
delegates felt are seldom or never morally
justifiable as a basis for medical decision making
in individual cases.
15. It is recognized, however, that the language of
benefits and burdens will not by itself resolve the
most difficult dilemmas, since irreconcilable
differences can always be reexpressed in terms of
a claim that their opponents have overestimated
burdens and have underestimated benefits, or vice
versa. These terms are nonetheless useful in
helping to focus on clinically significant variables
and to avoid employing judgments of social
worth.
16. A useful summary and discussion of these
mechanisms appears in Guidelines on the