End of Life Issues

Question: Regarding end-of-life issues, which of the following statements is most accurate?

A. All persons may forgo life-sustaining treatment including artificial nutrition and hydration.

B. A doctor may administer increasing doses of morphine to treat pain, even if this may cause respiratory depression and hasten death.

C. By exercising the right of autonomy, a patient may legally request physician-assisted suicide.

D. If a patient lacks medical decision–making capacity and there is no next of kin to give consent, then two doctors can together provide treatment in the patient’s best interest.

E. Just as there is a fundamental right to stop treatment, there also is a fundamental right to insist on continuing treatment.

Answer: B. Only an adult of "sound mind" can make decisions to accept or reject medical treatment, but this does not extend to physician-assisted suicide, which is illegal in all states except Oregon and Washington. Choices A & C are therefore incorrect. Where a patient lacks mental capacity and there is no surrogate decision-maker available, the doctor is obligated, except in an emergency situation, to apply to the court for a guardian ad litem. Simply having two (or more) physicians agree to a course of treatment is inappropriate. The best choice is B; it speaks to the ethical principle of "double effect," in which the intent is to confer a benefit such as pain relief, notwithstanding knowledge of an adverse consequence including hastening the patient’s demise. E is incorrect as there is no right to futile treatment.

In the 1976 landmark case of Karen Ann Quinlan, the New Jersey court underscored the fundamental right of a young woman in a persistent vegetative state to forgo life-sustaining support with a mechanical ventilator. Furthermore, the court allowed the right to be exercised by her parents on her behalf, and recommended the formation of hospital ethics committees to decide such matters.

This right was extended to cover artificial feeding by a unanimous U.S. Supreme Court decision in Cruzan v. Director, Missouri Department of Health. There, the court reasoned that whether or not the techniques used to pass food and water into the patient’s alimentary tract were termed "medical treatment," it was clear they all involved some degree of intrusion and restraint. Requiring a competent adult to endure such procedures against her will burdens the patient’s liberty, dignity, and freedom to determine the course of her own treatment. The Court held that the liberty guaranteed by the Due Process Clause must protect an individual’s deeply personal decision to reject medical treatment, including the artificial delivery of food and water.

However, where a patient’s wishes are not clear and convincing, a court will be reluctant to order cessation of treatment. In a 6-0 decision, the California Supreme Court ruled in Wendland v. Wendland, that a patient’s tube feedings could not be discontinued under the circumstances of the case. Robert Wendland regained consciousness after 14 months in a coma but was left hemiparetic and incontinent and could not feed by mouth or dress, and bathe and communicate consistently. His wife Rose refused to authorize reinsertion of a dislodged feeding tube, believing that Robert would not have wanted it replaced. The decision was supported by his daughter and brother, the hospital’s ethics committee, county ombudsman, and a court-appointed counsel. But the patient’s mother, Florence, went to court to block the action. Robert did not have an advance directive but had made statements to the effect he would not want to live in a vegetative state.

The court determined that Robert’s statements were not clear and convincing because they did not address his current condition, were not sufficiently specific, and were not necessarily intended to direct his medical care. Further, the patient’s spouse had failed to provide sufficient evidence that her decision was in her husband’s best interests.

A contentious end-of-life issue is that of medical futility, which basically denotes treatment that cannot confer an overall benefit on the whole person even if it can restore some physiologic variable. The stickiest scenario is where a family member insists on futile treatment against the advice of the attending doctors. In earlier cases, the courts had avoided addressing this issue directly, but in a 1995 trial, Gilgunn v. Massachusetts General Hospital, a jury returned a resounding verdict for the defendant hospital that directed the unilateral withholding of futile treatment against the wishes of the patient’s daughter.

Finally, there is the issue of physician-assisted suicide and active euthanasia that achieved public notoriety with the criminal conviction of Dr. Jack Kevorkian. In Vacco v. Quill, the U.S. Supreme Court reasoned that the important, logical, and rational distinction between assisting suicide and withdrawing life-sustaining treatment comports with fundamental legal principles of causation and intent. First, when a patient refuses life-sustaining medical treatment, he dies from an underlying fatal disease or pathology; but if a patient ingests lethal medication prescribed by a physician, he is killed by that medication.

Furthermore, a physician who withdraws, or honors a patient’s refusal to begin life-sustaining medical treatment purposefully intends, or may so intend, only to respect his patient’s wishes and to cease doing useless and futile or degrading things to the patient when the patient no longer stands to benefit from them. The same is true when a doctor provides aggressive palliative care; in some cases, painkilling drugs may hasten a patient’s death, but the physician’s purpose and intent is, or may be, to ease his patient’s pain only.

A doctor who assists a suicide, however, "must, necessarily, and indubitably, intend primarily that the patient be made dead." Similarly, a patient who commits suicide with a doctor’s aid necessarily has the specific intent to end his or her own life, while a patient who refuses or discontinues treatment might not. In holding that there is no fundamental right to physician-assisted suicide, the U.S. Supreme Court nonetheless left open to the individual states the continuing debate over this contentious matter. Legalizing physician-assisted suicide and/or euthanasia is opposed by most professional organizations including the American Medical Association.

Dr. Tan is emeritus professor of medicine at the University of Hawaii and director of the St. Francis International Center for Healthcare Ethics. This article is meant to be educational and does not constitute medical, ethical or legal advice. It is adapted from the author’s book, "Medical Malpractice: Understanding the Law, Managing the Risk" (2006). For additional information, readers may contact the author a

Question: Regarding end-of-life issues, which of the following statements is most accurate?

A. All persons may forgo life-sustaining treatment including artificial nutrition and hydration.

B. A doctor may administer increasing doses of morphine to treat pain, even if this may cause respiratory depression and hasten death.

C. By exercising the right of autonomy, a patient may legally request physician-assisted suicide.

D. If a patient lacks medical decision–making capacity and there is no next of kin to give consent, then two doctors can together provide treatment in the patient’s best interest.

E. Just as there is a fundamental right to stop treatment, there also is a fundamental right to insist on continuing treatment.

Answer: B. Only an adult of "sound mind" can make decisions to accept or reject medical treatment, but this does not extend to physician-assisted suicide, which is illegal in all states except Oregon and Washington. Choices A & C are therefore incorrect. Where a patient lacks mental capacity and there is no surrogate decision-maker available, the doctor is obligated, except in an emergency situation, to apply to the court for a guardian ad litem. Simply having two (or more) physicians agree to a course of treatment is inappropriate. The best choice is B; it speaks to the ethical principle of "double effect," in which the intent is to confer a benefit such as pain relief, notwithstanding knowledge of an adverse consequence including hastening the patient’s demise. E is incorrect as there is no right to futile treatment.

In the 1976 landmark case of Karen Ann Quinlan, the New Jersey court underscored the fundamental right of a young woman in a persistent vegetative state to forgo life-sustaining support with a mechanical ventilator. Furthermore, the court allowed the right to be exercised by her parents on her behalf, and recommended the formation of hospital ethics committees to decide such matters.

This right was extended to cover artificial feeding by a unanimous U.S. Supreme Court decision in Cruzan v. Director, Missouri Department of Health. There, the court reasoned that whether or not the techniques used to pass food and water into the patient’s alimentary tract were termed "medical treatment," it was clear they all involved some degree of intrusion and restraint. Requiring a competent adult to endure such procedures against her will burdens the patient’s liberty, dignity, and freedom to determine the course of her own treatment. The Court held that the liberty guaranteed by the Due Process Clause must protect an individual’s deeply personal decision to reject medical treatment, including the artificial delivery of food and water.

However, where a patient’s wishes are not clear and convincing, a court will be reluctant to order cessation of treatment. In a 6-0 decision, the California Supreme Court ruled in Wendland v. Wendland, that a patient’s tube feedings could not be discontinued under the circumstances of the case. Robert Wendland regained consciousness after 14 months in a coma but was left hemiparetic and incontinent and could not feed by mouth or dress, and bathe and communicate consistently. His wife Rose refused to authorize reinsertion of a dislodged feeding tube, believing that Robert would not have wanted it replaced. The decision was supported by his daughter and brother, the hospital’s ethics committee, county ombudsman, and a court-appointed counsel. But the patient’s mother, Florence, went to court to block the action. Robert did not have an advance directive but had made statements to the effect he would not want to live in a vegetative state.

The court determined that Robert’s statements were not clear and convincing because they did not address his current condition, were not sufficiently specific, and were not necessarily intended to direct his medical care. Further, the patient’s spouse had failed to provide sufficient evidence that her decision was in her husband’s best interests.

A contentious end-of-life issue is that of medical futility, which basically denotes treatment that cannot confer an overall benefit on the whole person even if it can restore some physiologic variable. The stickiest scenario is where a family member insists on futile treatment against the advice of the attending doctors. In earlier cases, the courts had avoided addressing this issue directly, but in a 1995 trial, Gilgunn v. Massachusetts General Hospital, a jury returned a resounding verdict for the defendant hospital that directed the unilateral withholding of futile treatment against the wishes of the patient’s daughter.

Finally, there is the issue of physician-assisted suicide and active euthanasia that achieved public notoriety with the criminal conviction of Dr. Jack Kevorkian. In Vacco v. Quill, the U.S. Supreme Court reasoned that the important, logical, and rational distinction between assisting suicide and withdrawing life-sustaining treatment comports with fundamental legal principles of causation and intent. First, when a patient refuses life-sustaining medical treatment, he dies from an underlying fatal disease or pathology; but if a patient ingests lethal medication prescribed by a physician, he is killed by that medication.

Furthermore, a physician who withdraws, or honors a patient’s refusal to begin life-sustaining medical treatment purposefully intends, or may so intend, only to respect his patient’s wishes and to cease doing useless and futile or degrading things to the patient when the patient no longer stands to benefit from them. The same is true when a doctor provides aggressive palliative care; in some cases, painkilling drugs may hasten a patient’s death, but the physician’s purpose and intent is, or may be, to ease his patient’s pain only.

A doctor who assists a suicide, however, "must, necessarily, and indubitably, intend primarily that the patient be made dead." Similarly, a patient who commits suicide with a doctor’s aid necessarily has the specific intent to end his or her own life, while a patient who refuses or discontinues treatment might not. In holding that there is no fundamental right to physician-assisted suicide, the U.S. Supreme Court nonetheless left open to the individual states the continuing debate over this contentious matter. Legalizing physician-assisted suicide and/or euthanasia is opposed by most professional organizations including the American Medical Association.

Dr. Tan is emeritus professor of medicine at the University of Hawaii and director of the St. Francis International Center for Healthcare Ethics. This article is meant to be educational and does not constitute medical, ethical or legal advice. It is adapted from the author’s book, "Medical Malpractice: Understanding the Law, Managing the Risk" (2006). For additional information, readers may contact the author a

Question: Regarding end-of-life issues, which of the following statements is most accurate?

A. All persons may forgo life-sustaining treatment including artificial nutrition and hydration.

B. A doctor may administer increasing doses of morphine to treat pain, even if this may cause respiratory depression and hasten death.

C. By exercising the right of autonomy, a patient may legally request physician-assisted suicide.

D. If a patient lacks medical decision–making capacity and there is no next of kin to give consent, then two doctors can together provide treatment in the patient’s best interest.

E. Just as there is a fundamental right to stop treatment, there also is a fundamental right to insist on continuing treatment.

Answer: B. Only an adult of "sound mind" can make decisions to accept or reject medical treatment, but this does not extend to physician-assisted suicide, which is illegal in all states except Oregon and Washington. Choices A & C are therefore incorrect. Where a patient lacks mental capacity and there is no surrogate decision-maker available, the doctor is obligated, except in an emergency situation, to apply to the court for a guardian ad litem. Simply having two (or more) physicians agree to a course of treatment is inappropriate. The best choice is B; it speaks to the ethical principle of "double effect," in which the intent is to confer a benefit such as pain relief, notwithstanding knowledge of an adverse consequence including hastening the patient’s demise. E is incorrect as there is no right to futile treatment.

In the 1976 landmark case of Karen Ann Quinlan, the New Jersey court underscored the fundamental right of a young woman in a persistent vegetative state to forgo life-sustaining support with a mechanical ventilator. Furthermore, the court allowed the right to be exercised by her parents on her behalf, and recommended the formation of hospital ethics committees to decide such matters.

This right was extended to cover artificial feeding by a unanimous U.S. Supreme Court decision in Cruzan v. Director, Missouri Department of Health. There, the court reasoned that whether or not the techniques used to pass food and water into the patient’s alimentary tract were termed "medical treatment," it was clear they all involved some degree of intrusion and restraint. Requiring a competent adult to endure such procedures against her will burdens the patient’s liberty, dignity, and freedom to determine the course of her own treatment. The Court held that the liberty guaranteed by the Due Process Clause must protect an individual’s deeply personal decision to reject medical treatment, including the artificial delivery of food and water.

However, where a patient’s wishes are not clear and convincing, a court will be reluctant to order cessation of treatment. In a 6-0 decision, the California Supreme Court ruled in Wendland v. Wendland, that a patient’s tube feedings could not be discontinued under the circumstances of the case. Robert Wendland regained consciousness after 14 months in a coma but was left hemiparetic and incontinent and could not feed by mouth or dress, and bathe and communicate consistently. His wife Rose refused to authorize reinsertion of a dislodged feeding tube, believing that Robert would not have wanted it replaced. The decision was supported by his daughter and brother, the hospital’s ethics committee, county ombudsman, and a court-appointed counsel. But the patient’s mother, Florence, went to court to block the action. Robert did not have an advance directive but had made statements to the effect he would not want to live in a vegetative state.

The court determined that Robert’s statements were not clear and convincing because they did not address his current condition, were not sufficiently specific, and were not necessarily intended to direct his medical care. Further, the patient’s spouse had failed to provide sufficient evidence that her decision was in her husband’s best interests.

A contentious end-of-life issue is that of medical futility, which basically denotes treatment that cannot confer an overall benefit on the whole person even if it can restore some physiologic variable. The stickiest scenario is where a family member insists on futile treatment against the advice of the attending doctors. In earlier cases, the courts had avoided addressing this issue directly, but in a 1995 trial, Gilgunn v. Massachusetts General Hospital, a jury returned a resounding verdict for the defendant hospital that directed the unilateral withholding of futile treatment against the wishes of the patient’s daughter.

Finally, there is the issue of physician-assisted suicide and active euthanasia that achieved public notoriety with the criminal conviction of Dr. Jack Kevorkian. In Vacco v. Quill, the U.S. Supreme Court reasoned that the important, logical, and rational distinction between assisting suicide and withdrawing life-sustaining treatment comports with fundamental legal principles of causation and intent. First, when a patient refuses life-sustaining medical treatment, he dies from an underlying fatal disease or pathology; but if a patient ingests lethal medication prescribed by a physician, he is killed by that medication.

Furthermore, a physician who withdraws, or honors a patient’s refusal to begin life-sustaining medical treatment purposefully intends, or may so intend, only to respect his patient’s wishes and to cease doing useless and futile or degrading things to the patient when the patient no longer stands to benefit from them. The same is true when a doctor provides aggressive palliative care; in some cases, painkilling drugs may hasten a patient’s death, but the physician’s purpose and intent is, or may be, to ease his patient’s pain only.

A doctor who assists a suicide, however, "must, necessarily, and indubitably, intend primarily that the patient be made dead." Similarly, a patient who commits suicide with a doctor’s aid necessarily has the specific intent to end his or her own life, while a patient who refuses or discontinues treatment might not. In holding that there is no fundamental right to physician-assisted suicide, the U.S. Supreme Court nonetheless left open to the individual states the continuing debate over this contentious matter. Legalizing physician-assisted suicide and/or euthanasia is opposed by most professional organizations including the American Medical Association.

Dr. Tan is emeritus professor of medicine at the University of Hawaii and director of the St. Francis International Center for Healthcare Ethics. This article is meant to be educational and does not constitute medical, ethical or legal advice. It is adapted from the author’s book, "Medical Malpractice: Understanding the Law, Managing the Risk" (2006). For additional information, readers may contact the author a