observed that doctors often hesitated to make difficult medical decisions because of the perceived threat of legal action against them. She suggested that an institutional sharing of responsibility for morally charged treatment decisions might make it easier for physicians to take appropriate action. Teel recommended that multidisciplinary committees analyze treatment options for deformed infants in light of their legal, ethical, and social aspects, and support physicians in their implementation.

In 1976 the New Jersey Supreme Court cited Teel's work in its ruling In re Quinlan (3). Although the Court assumed jurisdiction over the issue of surrogate decision making and awarded Karen Ann Quinlan's father guardianship for the express purpose of consenting to the withdrawal of her ventilator, it contended that the court was not the proper site for such decisions. Instead, it declared that the authority of an incompetent patient's guardian included decisions to limit or refuse life support, and that such decisions should be made in consultation with an "ethics committee," as described by Teel, or a "reasonable counterpart." The Court understood the committee's role more in terms of assessing the patient's prognosis than resolving the ethical dilemmas of treatment, and mistakenly assumed from Teel's comments that hospitals commonly had such committees. The state then issued guidelines for such prognostic bodies, consisting of physicians from varied specialties, and for their role in decisions to withdraw life support (4). In 1977, the Hastings Center held a conference on the actual and potential roles and responsibilities of IECs. Participants' experience of the roles and constitution of such bodies differed, but they generally agreed that multidisciplinary committees, well versed in the ethical issues of medicine, could serve in a valuable advisory capacity to physicians and families confronted with difficult treatment decisions (5).

In 1983, the President's Commission for the Study of Ethical Issues in Medicine and Biomedical and Behavioral Research issued its report on the ethical, medical, and legal issues in decisions to forego life-sustaining treatment (6). The report focused on the creation of procedures for such decisions, and examined the role of public and private organizations in establishing and governing the process. The Commission recommended that hospitals formulate specific policies on withholding and withdrawing life support for competent and incompetent adults, and children and infants. In evaluating procedures for surrogate decision making, they rejected the practice of seeking formal judicial review as too cumbersome, too adversarial, too expensive, too public, and too harmful to the process of patient care (6, 159). They concluded that institutions should establish institutional procedures to "promote effective decision making for incapacitated individuals" (6, 160), including neonates (6, 227); one such procedure was review by a hospital ethics committee (6, 439-442).



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