1. These refusals may be of all forms of therapy, including artificial nutrition and hydration, and they may involve both the withholding of life preserving therapy and the withdrawing of such therapy.

  2. Such refusals of life-prolonging therapy must be distinguished both from active euthanasia and from assisted suicide.

  3. When the patient is not competent, the attending physician, who normally makes that decision of incompetency, may rely upon a patient's advance directive to refuse treatment incorporated in such documents as living wills.

  4. If there is no living will or its equivalent, the patient's right to refuse treatment may be exercised on behalf of the patient by a surrogate decision maker appointed by the patient in advance (by use of such mechanisms as the durable power of attorney) or specified by some statutory scheme (usually, family members in some ordering of priority). The surrogates should apply a substituted judgment standard, or, if they cannot, a best interests standard.

  5. The same principles should apply to parental decision making about life-prolonging therapy for their children, especially severely ill newborns, but the emphasis must be on the child's best interests since the substituted judgment standard cannot apply.

With this statement of the current consensus in mind, I turn to an analysis of the work of the President's Commission and of the New York State Task Force on limiting life-prolonging treatment.

ACCOMPLISHMENTS OF THE PRESIDENT'S COMMISSION

As indicated above, the received view is that the report of the President's Commission, Deciding to Forego Life-Sustaining Treatment, was very successful in shaping the current consensus about decisions to limit life prolonging treatment. My argument will be that this claim is much too simplistic, and that once the factors of context and role are taken into account, a much more complex picture emerges. In particular, we shall see (a) that most of the elements of the consensus were prominently present in the public debate before the appearance of that report; (b) that the report organized and added one crucial element to, offered a sound foundation for, and placed an official imprimatur on, a very new consensus that had just emerged; (c) that the report raised many crucial issues that were to become central to the later debate, and adopted positions, often quite ambiguous, on these issues. This ambiguity was possible because the report was not designed to lead to any specific legislation or hospital policy. None of this is to say that the report was unsuccessful. It is rather to say that its success needs to be understood in terms of its context and its role.



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