End-of-Life Decisions: Modern and Ancient Insights

One of the great myths of medicine is that "end-of-life" patient autonomy issues are new, somehow related to advances in diagnosis, treatment, technology and the law. Not so. "Patient autonomy" is an ancient principle of medicine in Western civilization. So are the legal and moral complexities that patient autonomy creates for physicians.

And if we now believe that a competent adult patient is (or should be) free to refuse even life-saving medical treatment – "Patient's Body, Patient's Right" – it's still a complicated affair.

In addition to the "First, do no harm" precept, Hippocrates more than 2,500 years ago counseled: "... For where there is love of humankind there is also love of the Art. For some patients, though conscious that their condition is perilous, recover their health simply through their contentment with the goodness of the physician."

In other words: Hang in there, Doc.

Of course, not everybody shares such faith. In Moliere's 17th century play "Love Is the Best Doctor," Lysetta asks, "What will you do, sir, with four physicians? Is not one enough to kill any person?" This "Unholy Four" was caricatured from the disagreeing and disagreeable doctors who attended the fatal illness of Cardinal Mazarin in 1661. According to legend, when one of them was later stuck in Parisian traffic, a cart driver shouted: "Let the doctor go ahead. He's the one who did us the service to get rid of the Cardinal."

However, between these two polar beliefs – the doctor's very presence works miracles AND the more medical attention you get, the more doomed you are – lie all the complexities we've created for ourselves. People are living longer and better lives.

Medicine can do so much more today. But more complicated treatments are ever more expensive, and death is still our necessary end. And where there's death, you can expect to find the lawyers and courts nearby. Relatively simple treatments, such as pain relief for the terminally ill or those in severe chronic pain, are often passed over in favor of more complicated – and more risky – treatments, such as surgery.

Speaking of miracles, in 1990 and again in 1993 and 1996, the Los Angeles County Medical Association and LA Bar Association agreed on "Guidelines for Withdrawing/Withholding Life-Sustaining Treatment."

Section B, "Rights of Patients," states:

"An adult person capable of giving informed consent has the right to make his or her own decisions regarding medical care after having been fully informed about the benefits, risks and consequences of treatment alternatives, even when such decisions might result in shortening the individual's life."

Section C, "Surrogate Decision Makers for Incompetent Patients," clearly notes:

"If the surrogate does not know of any treatment preferences stated by the patient while competent, the surrogate is to act in the patient's best interest by analyzing the comparative benefits and burdens of continued treatment, as well as the patient's attitudes and beliefs, and such factors as relief of suffering, the preservation or restoration of function, and the quality and the extent of life sustained."

Further, Section E, "General Treatment Principles," states:

"Medication should be given as indicated for pain or discomfort even if it may tend to hasten death. ..." (See here our last column, "

Significantly, under section H, "Role of The Courts, the code notes:

"Most cases involving the foregoing of life sustaining treatment can be, should be, and are, resolved without the involvement of the courts."

Finally, the California Court of Appeals has ruled, "If the right of the patient to self-determination as to his own medical treatment is to have any meaning at all, it must be paramount to the interests of the patient's hospitals and doctors."

We've quoted from these "Guidelines" at length because we believe that, in the aggregate, they provide a reasonable approach to end-of-life decisions. Especially the one about keeping the courts and, by implication, the DEA out of it.

Michael Arnold Glueck, M.D., writes on medical-legal and related policy issues. Robert J. Cihak, M.D., is a former president of the Association of American Physicians and Surgeons (AAPS).

Contact Drs. Glueck and Cihak by e-mail.