FOUR YEARS AGO, a presidential commission did ground-breaking work on the difficult ethical question of when to terminate life-sustaining treatment of the terminally ill. Now, a group of legal and medical experts has built on that work and produced a comprehensive set of guidelines on this issue. The project, which took 2 1/2 years, was conducted under the auspices of the Hastings Center, a research and educational organization specializing in medical ethics.
The guidelines are directed primarily at health-care providers, and the suggestion is made that some institutions might want to adopt them as regulations. The detail with which various medical situations are described, and factors to be considered are enumerated, is laudable. The general recommendation of the report is that decisions on terminating life-sustaining care should be made by patients and doctors. Fair enough. But the really tough questions always arise when the patient is incapable of making this decision and a surrogate must act for him. These guidelines would considerably cut the red tape involved when the doctor and the surrogate agree to stop a respirator or discontinue dialysis, for example. But in this most difficult situation when the patient cannot speak for himself and the surrogate's own interests may not be identical with the patient's, it is often useful to provide review by an in-house panel of experts.
The Hastings experts tackled another problem that hospitals are facing with increasing frequency: How long should nourishment and hydration be provided artificially when there is no hope of a patient's recovery? Karen Ann Quinlan lived in a deep coma for many years after she was removed from a life support system because she continued to be fed intravenously. This panel makes no distinction between providing nourishment and any other life-sustaining treatment and sets guidelines for discontinuing intravenous feeding. The panel also addresses the hardheaded question of the allocation of resources and suggests that "justice places ethical limits on the patient's liberty to demand, rather than forgo, scarce medical resources."
It is easy to understand why a group of specialists would take years to consider these questions, and it is impressive that a consensus has been reached on such a wide range of problems. Not everyone will agree with the entire report. But as technology improves medicine's ability to sustain life, these ethical questions will come up with greater frequency. The Hastings report will provide important guidance in working out solutions, not only to doctors and hospitals but to the public at large.