by competent adults? (4) Do the special features of PVS patients mean that decision making to limit life-prolonging therapy for them is different from decision making to limit such therapy for other patients? (5) Can physicians unilaterally limit futile care? (6) To what extent, and by what process, can life-prolonging therapy be limited because of economic considerations? Let us briefly analyze the contribution of the Commission's report on each of these issues.

In the last ten years, there has been a considerable debate about the respective merits of two major forms of advance directives, living wills and durable powers of attorney.17 No consensus has emerged on this question. The concern today about living wills is their lack of specificity. The concern today about the durable power of attorney is whether the surrogate decision maker really knows what the patient would have wanted. At the time of the Commission's report, the concerns about the living will statutes then in existence were that they were too narrowly drawn and lacking in assurances that they would be honored, while the concern about the durable power of attorney statutes then in existence was that they had not been drafted for use in a medical setting and did not have appropriate safeguards for that setting. As far as I can see, the report was the first to raise the issue of the merits and demerits of these two approaches. Moreover, while summary conclusion (9c) states that durable powers of attorney are preferable, the text of the report (pp. 136-53) offers a much more balanced account, emphasizing the problems as well as the strengths of both, and the need for legislation to deal with potential problems with both. But since no specific legislation is proposed as a model statute, akin to the model statute for brain death proposed in another report by the Commission, the issue of preferability and of emphasis in legislation is never really resolved in the text of the report.

Are there any limitations on the right of surrogate decision makers to refuse life-prolonging therapy for those for whom they make decisions which extend beyond the limitations on the right of competent adults to refuse life-prolonging therapy for themselves? While the report discusses that issue at two points, once (p. 133) in connection with surrogate decision making for incompetent adults and once (pp. 217-23) in connection with surrogate decision making for severely ill newborns, the more substantial discussion is in the second context. The continuing controversy on this issue, both before and after the passage of the current Baby Doe law,18 testifies to the fact that there is no consensus on this issue. The report of the Commission clearly limits the right of parents, acting as surrogates for their severely ill newborn child, to refuse life-prolonging therapy which is in the best interests of the infant; such therapy can be refused only when the child's handicaps "are so severe that continued existence would not be a net benefit to the infant" (p. 218). An important footnote (footnote 79



The National Academies | 500 Fifth St. N.W. | Washington, D.C. 20001
Copyright © National Academy of Sciences. All rights reserved.
Terms of Use and Privacy Statement