religious bioethics literature, but I believe that the evidence already presented is sufficient. What then was the role of that report in the development of the current consensus?

I believe that the report of the Commission played four roles in the development of the current consensus: (1) It summarized in one well organized and authoritative statement the consensus whose elements had emerged in the years just before its work. It needs to be remembered that all of the material we analyzed was from the last ten years before the publication of its report. There is some even earlier material, but it is neither very extensive nor very authoritative. Moreover, no one other document contained all of the elements of the consensus. The report of the Commission was needed to give very authoritative approval to, and advocacy of, the full consensus that had just emerged. (2) It offered valuable criticisms (pp. 159-60) explicitly directed at the Massachusetts view about the need for judicial approval, suggesting ethics committees as an alternative, and it offered a valuable defense (pp. 132-6) of the substituted judgment/ best interests approach, thereby implicitly criticizing the New York decision in In re Storar. In these ways, it defended the new consensus against some alternatives. (3) It also placed great emphasis on durable powers of attorney for health care decision making, a tool that had not received enough attention before the report of the Commission. (4) Finally, the report made it very clear that the organizing theme for the new consensus was the patient's right to refuse treatment based upon the patient's perception of what was in the patient's best interest. Although much of the legal material we examined contained that theme, this was not as true of the professional material. There was a real need then for this emphasis. In all four of these ways, then, the report of the President's Commission made a valuable contribution to the emergence of the current consensus, even if its outline and most of its elements were widely accepted before the appearance of the report.

I believe that there was another contribution made by the report, a contribution that has not been adequately noticed. On a considerable number of issues, the President's Commission took positions that went beyond the consensus then and even the consensus now. Some of the positions were not clearly articulated, but this ambiguity was possible because the report was not advocating some specific legislation or some specific hospital policy. Despite these ambiguities, the report was often the starting point for further discussions about limiting life-prolonging therapy, discussions that still continue today. The issues were: (1) What is the best form of advance directives, living wills or durable powers of attorney? (2) What are the limits of surrogate decision making, both in the case of newborns and in the case of incapacitated adults? (3) Can society legitimately prohibit active euthanasia and/or assisted suicide when requested



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