Financial and Legal Incentives for Non-Beneficial Treatment

From the Health Business Blog:

"Hopeless patients on their last legs can be highly profitable for providers and drugmakers, who in a fee for service environment can make money from the very high utilization. It would be interesting to break down an oncology practice’s profitability by stage of patient illness."

"The current medical system makes it very difficult for physicians to moderate the irrational use of care during the end of our patient’s lives. Even if patients themselves are not demanding “every possible intervention”, family members frequently do. Fear of litigation fuels provider’s use of medical futile interventions as much or more than desire for economic gain.”

New Case - Juanita Wallace v. MidCentral District Health Board, NZ

The New Zealand press is reporting a case in which a family alleges that a doctor at Palmerston North placed a do-not-resuscitate order on the file of 85-year-old Juanita Wallace without discussing it with either her or her family.  

Wallace, a Woodlands Rest Home resident, was taken by ambulance to the hospital for the second time in as many days last Friday with a serious chest infection.  Her son, Tim, said that, whenever the subject had been discussed, his mother had refused a not-for-resuscitation order, the last time being a couple of months ago when the rest home updated records.  Mr. Wallace was shocked when he visited his mother to find the yellow do-not-resuscitate order had been filled out by a doctor. 

Otago University law professor Peter Skegg said that, "it is usually good practice to consult with others before entering a do-not-resuscitate order on the patient's chart."  Mr. Wallace said that, in the ward, his mother had been given morphine and no fluids, was largely unconscious, and her oxygen supply was not turned on.  "I feel they are playing God and making arbitrary decisions about who should be treated."  Mr Wallace said he turned his mother's oxygen back on, insisted the morphine be cut back and that she be given fluids. The next day, she was sitting up in an armchair and talkative.  The investigation is continuing.

There Was No Paternalism in the Li Case

Over at Oxford's Practical Bioethics, Domenic Wilkinson suggests that Sunnybrook Health's providers were paternalistic in issuing the unilateral DNR order in Toronto's Li case.  He writes:  "The statement by Sunnybrook hospital executive appears to be based on the first reason. What doctors are saying in effect is, “we know that you want this treatment, and you think that it would benefit you, but we know better”  I disagree.

I do not think that refusals to provide non-beneficial treatment are paternalistic.  It is almost never the patient herself contemporaneously asking for the aggressive interventions.  It is the patient's surrogate.  When providers resist the surrogate's demands, they usually doubt that the surrogate is really doing what the patient wanted.  Here, in the Li case, the patient had an extensive written advance directive.  But he did not anticipate the precise circumstances that obtained this week.  Therefore, it is not the case that the patient AUTONOMOUSLY chose X and the providers chose Y.  Rather, the providers (and ultimately the family too) was skeptical that the patient actually chose or wanted X.  This is soft paternalism (aka weak paternalism), not really a form of paternalism at all.

Consider the Conversation: A Documentary on a Taboo Subject

Consider the Conversation: A Documentary on a Taboo Subject is a film that is now in limited release.  It examines multiple perspectives on end-of-life care and includes information and experiences gathered from interviews with patients, family members, doctors, nurses, clergy, social workers, and national experts on death and dying. The film sheds light on a natural life event that many avoid. Throughout the film there are intimate accounts of the emotional, spiritual, physical and financial burdens associated with the historical shift that has occurred with dying.  Among the national experts interviewed or consulted:

• Ira Byock, M.D., Director of Palliative Medicine at Dartmouth-Hitchcock Medical Center


• Elliott Fisher, M.D., head of the Dartmouth Atlas of Health Care


• Stephen Kiernan, author of Last Rights: Rescuing the End-of-Life from the Medical System


• Bernard "Bud" Hammes, Ph.D., Clinical Ethicist, Gundersen Lutheran Health System


• Susan Dolan and Audrey Vizzard, co-authors of The End-of-Life Advisor: Personal, Legal, and Medical Considerations for a Peaceful, Dignified Death


• Doug C. Smith, author of Caregiving: Hospice-Proven Techniques for Healing Body and Soul


• James Cleary, M.D., Director of Palliative Medicine at the University of Wisconsin Hospital and Clinics


• Anne Moore, author of Harry and Louise Must Die: We Could Save Billions in Healthcare if We Could Accept Death and Say Goodbye Outside the Hospital


• Thomas Cathcart and Daniel Klein, authors of Heidegger and a Hippo Walk Through Those Pearly Gates


• Loretta S. Downs, President, Chicago End-of-Life Care Coalition

Medical Futility and the ED

At its annual conference a few weeks ago, the ACEP sponsored a panel on providing "medically futile" care in the emergency department.  (Hospitalist News)  Gregory Henry explained that while the default in EDs is to stabilize patients with poor prognoses, ED physicians should reflect on their role in starting a "cascade of expensive care rolling down the hill."  Daniel Sullivan said we "need clear cut legislation."  





Gregory Larkin said that "we docs provide this kind of care all the time, even though we don't believe in it. . . .  Rationing is part of our job . . . try to be more affirmative about what you will do . . . and don't put [an intervention] on the menu if you don't think it's appropriate . . . .  Don't even bring it up . . . ."

Li v. Sunnybrook Health -- Family Accedes to Provider Recommendation

Man Kee Li's wife had begun litigation against Sunnybrook Health for writing a unilateral DNR order. As Mr. Li had left rather clear instructions, his wife was acting to implement his wishes.  But today, she dropped the case, determining that his previously request to receive CPR was not applicable to his current circumstances, where his “skin was breaking down” and “extremities falling off."  (Toronto Star)  

While it might appear that the surrogate was back-tracking and contradictory, this is not necessarily so. Past CCB cases have permitted providers to override clear advance directives by arguing that the patient's current circumstances were outside the patient's contemplation at the time the advance directive was completed.  Surely, the surrogate could make the same determination.

New Case Mann Kee Li v. Sunnybrook Health Sciences Center

Just as I arrived in Philadelphia this morning from Los Angeles I read about a rather unique new futility dispute involving  Mann Kee Li li, a 46-year-old Toronto accountant.  What makes it unique is that the patient created an extraordinarily detailed record documenting that he wants doctors to use all medical measures possible to save him in the event of a life-threatening emergency.  (Toronto Star)  While his doctor initially agreed to respect those wishes, physicians unilaterally reversed the decision a week ago without consultation and imposed a “do not resuscitate” order.

On Friday, lawyers for Li, the hospital and the two doctors treating him sought an order from a Superior Court judge clarifying rights and obligations.  Madam Justice Barbara Ann Conway issued an order that effectively revoked the “do not resuscitate” order imposed by Sunnybrook physicians but made clear that it didn’t compel them to actually resuscitate Li in case of emergency, leaving the matter to their own judgment.  Justice Conway then directed that the Consent and Capacity Board conduct a hearing.

After We Die: The Life and Times of the Human Cadaver

What will become of our earthly remains? What happens to our bodies during and after the various forms of cadaver disposal available? Who controls the fate of human remains? What legal and moral constraints apply? Legal scholar Norman Cantor provides a graphic, informative, and entertaining exploration of these questions. After We Die chronicles not only a corpse’s physical state but also its legal and moral status, including what rights, if any, the corpse possesses.

In a claim sure to be controversial, Cantor argues that a corpse maintains a “quasi-human status" granting it certain protected rights—both legal and moral. One of a corpse’s purported rights is to have its predecessor’s disposal choices upheld. After We Die reviews unconventional ways in which a person can extend a personal legacy via their corpse’s role in medical education, scientific research, or tissue transplantation. This underlines the importance of leaving instructions directing post-mortem disposal. Another cadaveric right is to be treated with respect and dignity. After We Die outlines the limits that “post-mortem human dignity” poses upon disposal options, particularly the use of a cadaver or its parts in educational or artistic displays.

Contemporary illustrations of these complex issues abound. In 2007, the well-publicized death of Anna Nicole Smith highlighted the passions and disputes surrounding the handling of human remains. Similarly, following the 2003 death of baseball great Ted Williams, the family in-fighting and legal proceedings surrounding the corpse’s proposed cryogenic disposal also raised contentious questions about the physical, legal, and ethical issues that emerge after we die. In the tradition of Sherwin Nuland's How We Die, Cantor carefully and sensitively addresses the post-mortem handling of human remains.

Lydia Paillard - Doing Well After Being Declared Dead

Lydia Paillard entered a clinic in Bordeaux for a chemotherapy session.  But things took a bad turn.  She slipped into a coma and was subsequently declared dead.  Still, despite the doctors' assurances, the patient's sons could not bring themselves to switch off respiratory support and she was transferred to another wing of the hospital.  Later, some 14 hours after she had officially died, Mrs Paillard suddenly woke up. Turning to her incredulous son, she said: "Ah, I feel so good, I had a wonderful sleep."  (Telegraph; Daily Mail)

My ASBH Legal Update on Medical Futility Laws

I delivered my 10-minute talk on legal developments regarding medical futility this morning at the ASBH meeting in San Diego.  It seemed to go well.  And I've been having some great hallway talks with lawyers and physicians from around the country, especially Texas.  I posted my slides here.

"Year to Live” Study Group

This blog and the project it documents seems like an interesting and rewarding endeavor.

In an ideal world, I’d live out my 80+year life expectancy and die quietly in my sleep.  “She was healthy & sharp until the very end,” they’d all say.

 But I’m trying something different here.  This time around I’ll take my final breath at age 43.  I’m participating in a “Year to Live” study group, based on the book of that name by Stephen Levine.  We’re a group of about 25 who meet once a month . . . .  We’ve all been given the hypothetical date of January 20, 2011 to live.

 “What a downer,” some have said.  “Why on earth would you do that?” others manage.  For me, this is really an exercise in living.  It may seem counter-intuitive at first, but I believe that there can be no better way to learn to live fully than to live with a sense of the immediacy and the impermanence of it all.  After all, wiser men & women than I have undertaken similar quests since the beginning of time.  Many of them have been transformed by it.

 

Voluntarily Stopping Eating and Drinking (VSED)

Last week, while driving home and listening to oral argument in Quill v Vacco, I was surprised to hear the following awesome quote by Chief Justice Rehnquist.  We certainly will work this into the revised draft of “Voluntarily Stopping Eating and Drinking: A Legal Treatment Option at the End of Life.”

CJ:  It seems odd that your bodily integrity is violated by sticking a needle in your arm but not by sticking a spoon in your mouth.  I mean, how would you force-feed these people in a way not to violate their bodily integrity?

Pennsylvania and the Texas Advance Directives Act

Philadelphia Inquirer READER POLL

Should Pennsylvania adopt an advance directive act similar to the one in Texas?
Yes
	85 (79.4%)
No
	17 (15.9%)
Don't know
	5 (4.7%)
Total votes = 107

Robert Painter on the Texas 'Futile Care' Law

Attorney Robert Painter will address the Houston Disability Elder Law Association on the Texas 'Futile Care' law on Tuesday, October 19, 2010, at 11:45 a.m., at The Downtown Club at the Met, 340 West Dallas Street.  From the press release:

Many Texans are surprised to learn that the Advance Directives Act of 1999 allows a hospital committee to act as a 'death panel' that can override a patient or family's treatment wishes, even to the point of withholding care, treatment, food and water from a patient. Plus, if the committee follows the procedures of this poorly thought-out law, then the committee's actions are fully immune from civil, criminal or administrative prosecution or review.

Is it an exxageration to describe these hospital committees as 'death panels'? I do not think so. After all, in most cases they have the final say over life and death decisions and operate in an environment with more immunity than even government officials.

Medical Challenge: Finding More Balance in Decision Making at the End of Life

Pulitzer Prize winning reporter Michael Vitez has a thorough story on medical futility issues in today's Philadelphia Inquirer, titled "Medical challenge: Finding more balance in decision making at the end of life."  I am grading midterms and will make comments later.

Brief Summary of MOLST in Delaware

With a colleague, I wrote this brief piece in the Delaware Nurses Association DNA Reporter summarizing MOLST and current efforts in Delaware to adopt MOLST.

Resource Use in the Last 6 Months of Life

Three articles published Online First this week in the Archives of Internal Medicine examine health care at the end of life. Two articles report on health care use and costs of care for older patients with heart failure in the last 6 months of life. One study was performed in the United States and the other in Canada, two countries that have markedly different health care systems. The third article examines the use of hospice in men with prostate cancer in the United States.  

Unroe et al examine health care use and costs for US Medicare beneficiaries with heart failure in the last 6 months of life who died between 2000 and 2007. In a companion article, Kaul et al analyze resource use in the last 6 months of life among patients with heart failure in Alberta, Canada, who died between 2000 and 2006. Both studies report that use of health care services and the cost of care spiraled upward.

Crime or care? The problem of cause of death and 'intention to kill' in end-of-life care

When is 'allowing a person to die' classified as killing them?  When can patients choose to end their life by refusing life-saving medical care?  How much pain relief can be given legally when a side-effect of palliative medication is to shorten a patient's life?  These legal and ethical problems faced by doctors the world over will be examined in a symposium at the University of Sydney on Thursday 28 October.

Leading legal academics, Dr Andrew McGee from Queensland University of Technology, Associate Professor Cameron Stewart from Sydney Law School, and cancer surgeon Dr Charles Douglas, will each discuss the complex problems that arise when the law of homicide is applied to end-of-life-care.

Organiser Sascha Callaghan from the Centre for Values, Ethics and the Law in Medicine said that occasionally a doctor may feel it necessary to give large doses of sedatives, foreseeing that death may be hastened as a result.  "But they would not be guilty of homicide if their intention was only to relieve suffering," she said.  "This defence seems to be peculiar to the medical setting, and is arguably at odds with general criminal law principles."

Dr McGee believes that the existing law draws reasonable boundaries between unlawful killing and what we all recognise as legitimate palliative care, but Associate Professor Stewart argues that the law would do better to acknowledge that sometimes the best palliative care treatments involve a technical homicide and that a better approach would be to develop a new defence to a criminal charge for doctors, based on the doctrine of "necessity".

Finally, noted cancer surgeon Dr Charles Douglas will be presenting new empirical findings about doctors' self-reported intentions in end of life care, and consider whether the current law works in practice. While intentions are undoubtedly more complex than the law allows, and while many are skeptical about the Principle of Double Effect as a moral principle, Dr Douglas will argue that the intention - foresight distinction remains important in end of life care, and will stay that way regardless of the legal status of euthanasia or assisted suicide.

Voluntarily Stopping Eating and Drinking: A Legal Treatment Option at the End of Life

Link to the draft is available here:    

Critical Care Medicine: Evolution and Ethical Dilemmas

Yesterday, The Lancet posted a series of three papers about intensive care medicine. The papers describe the evolution of the specialty, the demand for and ability to supply appropriate levels of care, and some of the commonly faced ethical dilemmas and challenges. These topics are apt in this period of economic constraint. Intensive care medicine consumes a considerable proportion of health-care resources and these costs will need to be justified. The appropriateness and effectiveness of the care provided will need to be improved to ensure that these resources are directed to patients most in need of them. 

Intensive care medicine: a specialty coming to LIFE

Rui Paulo Moreno, Andrew Rhodes

Critical care and the global burden of critical illness in adults

Neill K J Adhikari, Robert A Fowler, Satish Bhagwanjee, Gordon D Rubenfeld

Critical care has evolved from treatment of poliomyelitis victims with respiratory failure in an intensive care unit to treatment of severely ill patients irrespective of location or specific technology. Population-based studies in the developed world suggest that the burden of critical illness is higher than generally appreciated and will increase as the population ages. Critical care capacity has long been needed in the developing world, and efforts to improve the care of the critically ill in these settings are starting to occur. Expansion of critical care to handle the consequences of an ageing population, natural disasters, conflict, inadequate primary care, and higher-risk medical therapies will be challenged by high costs at a time of economic constraint. To meet this challenge, investigators in this discipline will need to measure the global burden of critical illness and available critical-care resources, and develop both preventive and therapeutic interventions that are generalisable across countries.

Ethics and end-of-life care for adults in the intensive care unit

J Randall Curtis, Jean-Louis Vincent

The intensive care unit (ICU) is where patients are given some of the most technologically advanced life-sustaining treatments, and where difficult decisions are made about the usefulness of such treatments. The substantial regional variability in these ethical decisions is a result of many factors, including religious and cultural beliefs. Because most critically ill patients lack the capacity to make decisions, family and other individuals often act as the surrogate decision makers, and in many regions communication between the clinician and family is central to decision making in the ICU. Elsewhere, involvement of the family is reduced and that of the physicians is increased. End-of-life care is associated with increased burnout and distress among clinicians working in the ICU. Since many deaths in the ICU are preceded by a decision to withhold or withdraw life support, high-quality decision making and end-of-life care are essential in all regions, and can improve patient and family outcomes, and also retention of clinicians working in the ICU. To make such a decision requires adequate training, good communication between the clinician and family, and the collaboration of a well functioning interdisciplinary team.

Critical care: advances and future perspectives

Jean-Louis Vincent, Mervyn Singer

Intensive care offers a standard of monitoring, intervention, and organ support that cannot be readily delivered in a general ward. Its expansion in the past few decades, including the creation of emergency and outreach teams, emphasises that intensive care has an increasingly prominent role within the hospital. Although outcomes are clearly improving, intensive care remains a nascent specialty in which we are still learning how to harness a powerful ability to manipulate physiology, biochemistry, and immunology to achieve best outcomes for the patient. The results of many multicentre studies have not lent support to, or have even confounded, expectations, drawing attention to several issues related to patient heterogeneity, trial design, and elucidation of underlying pathophysiological processes. However, these results have generated constructive introspection and reappraisal of treatments and management strategies that have benefited the patient. In addition to the medical, financial, and logistical challenges in the future, exciting opportunities will arise as new developments in diagnostic tests, therapeutic interventions, and technology are used to exploit an increasing awareness of how critical illness should be managed.

Medical Futility & Maryland Law

Medical Futility & Maryland Law

University of Maryland

November 30, 2010

8:30 a.m. - 4:00 p.m.

Brochure here

Passed in 1993, the Maryland Health Care Decisions Act (HCDA) addresses various aspects of end-of-life medical decision-making, including when treatments may be withheld or withdrawn from patients at the end of life. Two provisions in the Act allow physicians to withhold or withdraw treatments considered "medically ineffective" or "ethically inappropriate," as long as specified due process procedures are followed.

Yet, according to a Dartmouth survey, Maryland rates among the highest for intensity of medical care for Medicare beneficiaries in the last six months of life. Debate has ensued among some lawyers, risk managers, and health care professionals in Maryland surrounding what constitutes "medically ineffective" or "ethically inappropriate" treatment, and how to proceed if a surrogate decision-maker does not agree with a physician's determination to withhold or withdraw treatment based on these criteria.

The morning plenary sessions will define medical futility and related concepts (i.e., treatments considered "medically ineffective," "ethically inappropriate," or "non-beneficial"), and explore their role and that of Maryland state law in providing good end-of-life care that does not waste critical care resources. The afternoon sessions will include small group discussions about whether revisions should be made to Maryland's HCDA, or whether education is needed as to how these laws should be interpreted.

Palliative Care Grand Rounds 2.10

Palliative-SW, a blog maintained by the Social Work Hospice & Palliative Care Network (SWHPN), is hosting the October 2010 Palliative Care Grand Rounds (PCGR) here.   Here is an outline of the topics that they cover:

• Media Coverage & the NEJM Study


• Other New Research Findings


• Social Work & Voice


• Let’s Speak Frankly


• Grief & Bereavement


• Technology, Treatment & the Web


• Therapeutic Social Media

End-of-Life Care for Children and Adults with Intellectual and Developmental Disabilities

The American Association on Intellectual and Developmental Disabilities (AAIDD),has published a new reference book, End-of-Life Care for Children and Adults with Intellectual and Developmental Disabilities, that addresses the medical, social, legal, and ethical issues in end-of-life care that people with intellectual and developmental disabilities face.  A downloadable podcast interview with the author is available here.  Here is the table of contents:





Part I: Historical Perspective

Chapter 1 Constructing a “Good Death”: Historical and Social Frameworks

Chapter 2 End-of-Life Policies and Practices

Chapter 3 Ethical Foundations and Legal Issues

Part II: Medical Conditions and Management

Chapter 4 Complex Medical Problems Affecting Life and Life Span in Children

Chapter 5 Medical Conditions in Adults Near the End-of-Life

Chapter 6 Medical Treatment and Management at the End of Life

Chapter 7 Nutritional Issues in End-of-Life Care

Part III: Current Controversies and Ethical Dilemmas

Chapter 8 Practical Guide to Health Care Decision Making

Chapter 9 Do-Not-Resuscitate Orders and Redirection of Treatment

Chapter 10 Ethical Issues in the Withdrawal of Support

Chapter 11 Forgoing Nutrition in Infants and Children With Intellectual Disabilities

Chapter 12 The Persistent Vegetative State

Part IV: Social, Emotional, and Spiritual Considerations

Chapter 13 Applying the Dignity-Conserving Model

Chapter 14 End-of-Life Through a Cultural Lens

Chapter 15 Spirituality Issues and Strategies: Crisis and Opportunity

Chapter 16 Struggling With Grief and Loss

Part V: Supports and Resources

Chapter 17 Use of Person-Centered Planning for End-of-Life Decision Making

Chapter 18 Supports and Resources for Families of Children With Special Health Care Needs

Chapter 19 Supports and Resources for Adults

Chapter 20 Palliative Care and Pain Management: Resources for Direct Care Providers

Legal Briefing: Organ Donation and Allocation

The Fall 2010 issue of the Journal of Clinical Ethics (vol. 21 no. 3) is out.  My 21-page “Legal Briefing” column in this issue covers legal developments pertaining to organ donation and allocation. 





This topic has been the subject of recent articles in JCE. Organ donation and allocation have also recently been the subjects of significant public policy attention. In the past several months, legislatures and regulatory agencies across the United States and across the world have changed, or considered changing, the methods for procuring and distributing human organs for transplantation. Currently, in the U.S., more than 100,000 persons are waiting for organ transplantation. In China, more than 1.5 million people are waiting. Given the chronic shortage of available organs (especially kidneys and livers) relative to demand, the primary focus of most legal developments has been on increasing the rate of donation. These and related developments are usefully divided into the following 12 topical categories:

1. Revised Uniform Anatomical Gift Act


2. Presumed Consent and Opt-Out


3. Mandated Choice


4. Donation after Cardiac Death


5. Payment and Compensation


6. Donation by Prisoners


7. Donor Registries


8. Public Education


9. Other Procurement Initiatives


10.  Lawsuits and Liability


11. Trafficking and Tourism


12. Allocation and Distribution

VOLUNTARILY STOPPING EATING AND DRINKING: A LEGAL TREATMENT OPTION AT THE END OF LIFE

Today, I finished the penultimate edits on "Voluntarily Stopping Eating and Drinking: A Legal Treatment Option at the End of Life," a 50-page law review article forthcoming in a Symposium issue of the Widener Law Review.   I will get this up on SSRN this week.  Here is the abstract

Despite the growing sophistication of palliative medicine, many individuals continue to suffer at the end of life.  It is well settled that patients, suffering or not, have the right to refuse life-sustaining medical treatment (such as dialysis or a ventilator) through contemporaneous instructions, through an advance directive, or through a substitute decision maker.  But many ill patients, including a large and growing population with advanced dementia who are not dependent upon life-sustaining medical treatment, do not have this option.  They have the same rights, but there is simply no life-sustaining medical treatment to refuse. 

Nevertheless, these patients have another right, another option to avoid suffering at the end of life.  Patients with decision-making capacity may choose (through contemporaneous instructions) to voluntarily stop oral eating and drinking to accelerate the dying process.  Moreover, patients without capacity often have the same option.  Voluntarily stopping eating and drinking (VSED) is a clinically validated “exit option” that enables a good quality death.  Significant and growing evidence supports VSED as a means of accelerating the dying process.  Nevertheless, VSED is widely resisted by healthcare practitioners either because they think that it is illegal or because they are uncertain of its legality. 

There has been little legal analysis of a right to VSED.  In this Article, we aim to fill this gap and to clarify the legal status of VSED.  Specifically, we argue that both contemporaneous and (most) non-contemporaneous decisions for VSED are legally permissible.  Individuals may refuse nutrition and hydration just as they may refuse other intrusions on their personal autonomy.  This right is grounded in the common law of battery, statutes, state constitutions, and even the U.S. Constitution.  Moreover, VSED does not, as many believe, constitute abuse, neglect, or assisted suicide.  Even ex ante decisions for VSED (exercised through an advance directive or a surrogate decision maker) are legal in most United States jurisdictions.

Delaware End-of-Life Coalition - Excellence Awards in Hospice & Palliative Care

Deadline Extended to Oct 8th Nominate your Colleagues Today! Excellence in Hospice & Palliative Care Due to the many requests we have received, DEOLC is extending the deadline for accepting nominations for their Excellence Awards in Hospice and Palliative Care.  This award will be bestowed upon a professional in each of the following categories for their outstanding and compassionate service to those at end of life: Physician Nurse Bereavement Professional  Nominate your deserving colleagues today!  Nomination Form

THE THRESHOLD FOR PERMISSIBLE WITHDRAWAL OF LIFE SUPPORT FROM DISABLED NEWBORN INFANTS

Oxford NICU physician and ethicist Dominic Wilkinson has a new article forthcoming in the American Journal of Bioethics later this Fall:  A LIFE WORTH GIVING? THE THRESHOLD FOR PERMISSIBLE WITHDRAWAL OF LIFE SUPPORT FROM DISABLED NEWBORN INFANTS.  Here is the abstract: 

When is it permissible to allow a newborn infant to die on the basis of their future quality of life? The prevailing official view is that treatment may be withdrawn only if the burdens in an infants’ future life outweigh the benefits. In this paper I outline and defend an alternative view. On the Threshold View treatment may be withdrawn from infants if their future wellbeing is below a threshold that is close to, but above the zero-point of wellbeing. 
I present 4 arguments in favour of the Threshold View, and identify and respond to several counterarguments. I conclude that it is justifiable in some circumstances for parents and doctors to decide to allow an infant to die even though the infant’s life would be worth living. The Threshold View provides a justification for treatment decisions that is more consistent, more robust and potentially more practical than the standard view.