PAGE 1 An Ethtcal Analysts or Wtthdrawal From Ltf e-SUStalnlng Tedlnologtes and Assisted Death A Report for the Off Ice or Technology Assessment James f. 01tlcnss tmtvntty Yta,Jnia PAGE 2 '.) ,, 11 V \. ..) ~, ,. lntrarb:ttan HI T111t 1:,.,...,...flthlDtsttnctklAllangTypes-WttllllllldlngllllWlttltng Llfl-,Sultllntng Ta:bnDlaglll I A. Dlflntttan-and Dlllrtpttan Typas fl Wttllhaldlng and Wtlh-cnwtng Llfl-SUllllntng TldlnDlagles I 1. WltNIDldlngllldWtthnwtngTrlllmlntl 2 2. Dtnct 1111 lrdnct Effects 4 3. Lltttng D111111 ICllllng 6 4. V 111d Extr1111111 V 1111111 10 I. _. llllllllnLlnl-DratngAlnangLMls IIIIKlndllflTNlllblltnt 13 I.,_. 0'imldrll1alll In a TYIIOIGrf flWlthhDldlnlllld Wltld-IIILllt-btllntngW Trlltmlnt 20 C. Dlflntttan fl&dctdlllll lllltPllllltlan taC..-E1drlV Plapll Aatv1ng Llfe-SUltltntng TldHllaglll 22 D. Milylts C.. to lllultrltl Dllttncttant and Clltilrtll 27 E. Narlllittw lmpllelllanl fl 111111 Dtsttnctlanl 27 Ta. 2: Dlllrtpttan fl Important Etlltad Trldltlllll AIIMnt to WtthhDldlng er Wltlltwtng Llftt-SUltltntng Tldndagtll endlar Sulctdl 28 t 3: ,._ SpactftcDIIIC11SUtctdlAlnangtllldrly 43 ss S& I. Qapattbntty of ltlltlttng D11111 wttb Pralllllanll S6 0.andPractbl &a D. lnflune fl lnstttuttcnl Setting 1111 Sa:111 cant.ext 62 CII Alllltld Death -t -' \ PAGE 3 . l 't I T S: Qn:lustanl A. Splctal S91iflanca of theNxttl I-far U. EJdlrly 66 I. Fatbntty and Dlslrlb111ty rl 8utdllfn11 66 D. Prtcrtttll far PUbltcAttlnt1an RIii ding SUtctdlAmang tlll EldrlV tn Rlllttan ta Llfe-SUltltntng Tecllnalagill 68 E. t11Jcr. Poltcv Qattn 69 ....... ...... I. U.S. TCDIPapullltanSutcldlAltllpr I00,0001r,'F~Y11r#98raupl~ 1933-61 II. SUfcldl Al1II pr I 00,00 11v Flw-Yer /tgl lraupl, a.lar, and S., "' I 972 Ill. U.S. Wllttlt1111Sutctd1Rltllpr 100,000 llyflVI-Yl4118raupl, 19&lSI IY. SUfcldl Al1II tn 1111 W tn Rallttan flAal 1111 RD~ i 974 1--pp.2-3 ---p.6 --p.14 --pp.1+.-11 &--p.19 6 --pp. 22-23 -p.24 --pp. 21-26 CJ-p.&2 10--p.S! 11--p.&4 ti - PAGE 4 Introduction This report ts dlltpd to offer an eth1ca1 nJysts of mctstons to wtthhold end to wtthcnw ltfe-sustatntna technologies from patients In m:ard with thetr wishes and interests. Few dlbltll tn aur sactety hlwe been mnpltcated r canfUlld dlbltls about lifeaustetntng tachnolagtes the last ten ta fifteen yers. Thus, It was not surprising that the Prestmnts eommtsstan fer the Stuctf of Ethtcal Problems tn Medtctne end B1amed1cal em BlhlYtcnl Rl9III ch unmrtmc m1 mmtnattm of e:tsions to rorv, llfe-sustatntno trllllmMt--whtch WII not part al its crtgtnal lllJislalive mandate-- natura1 owth of ffl studlll m tnfarmed cannt, the dlftntttan of dmth, end 1C011SS ta health ere, and a Wflf tD dlll wtth .,. at the mast tmpar11nt and traub11ng llh1c:11 and legal (Jlllltans tn mamrn lllldlclne. HawMr, the chairman, Mcrrts Abram, noted when he submtttad the resulting ~l Dec1d!111 to EW ttt1:Se,.,,,,01rv Jcw,tment, the cammtsstan cancludld "thlt thl cw ta.Ill tnwlYI true ethtml cHfflcultill are menv fewer thin cammanly be11evld and that the perc:epttan of dlfftculttes ca:an prtmartly balm of mtsundrstlndtngs about the dictates a, law Sid et111cs C Presidlnt's 0Jnmtsstan. 1983). Whlthlr real ar anly app1rent, llhtcaldlfflculties, dlllmfflll, quandr1, or problems n generated by percetYld canfltcts 111N11g ethical principles end_ values. Thus, it ts essential ta IXlffltne um pr1nctplls and vel1111, espectally thlV are m1a:tld 1n re11gtous and human1st1c trldlt1ans, legts11t1Ye actians, Judlctal dlctstans, and mdls and pra:ttces of prafessillal anu:t. -Wtthaut dlnying different emphllll and pasttianl, tt ts pallible to tdantify SMral ethical prtnctples tl1d values that re mnmonly tnvaked to all end raolve such ethtcel dtfftcultfes. SMra1 or these principles--especially beneficence, nanmaleffcence, ut111ty, autonomy, and Justa--n 1dent1f1MI and explicated in Task 1 ; thlV m not presuppose~ p,rticular -111-:) I' '! ; _j --~ .\ PAGE 5 J ,.._ r--". / ( :,/ ....... '. v ... lthicll ttmy but are compatible with and can be driYed from sewra1 different re11gtous and humanistic ethtce1 theories. In short, U..,, represent ethical considerations that re widely m:eptld, Mn ttmr proponents frequently differ about thetr and about thetr_ tmpltcattans fer particular cases. Haw thell ethical principlm end values are applied to parttcu.-CISIS often d1p1ndl an tntlrmedtlll principles, rul, and dtsttncttans, such as the dlsttncttans between kt11tng and letting die, betwan direct and Indirect effects of a1ans, and between crd1nery Md atraardtnary means of treatment, an discussed Uldr Task 1. One mejcr tmk or ethical nlysts ts ta 1X11Dlne end IS98SI these dtsttnctians tn lt~t of the ganeral prtnctpl and values and the realtttes of particular Hfe-sustelntng technolagtes, such as ml dialysis, antibiotics, rttflctll nutrtt1an and ,,,...tan, resu!Cltatton, and mecftlntcal venttllttm, tn treatment of the eldrly. SUch an analysts wfll tnvolvl careful acruttnv ti repra,tattve ~iticm, t~Judtng thl arguments fer and against UIOII pastttans. Ethtcal w)vsts am trwolYes c:maptual analysts, since same of the av cmapts ere aftln In dtsputa. Fer example, S1M1ral trdttons hold that sutctdl Is wroog, but accept sne acts that result In one's own deeth while dlnytng that theV are acts fl sutctm. Other tnlfttions mav hold that those eta re Justtftable acts of sutcida. Thus, It ts rd to know whether a .. trdttan accepts or rejects autctdl, but aJao hGw it dfstfngutshes sutcfdl rram other ects such ref'UIII ct llfe-sustatntng tlchnologtes undr same candltknl. Slmtlrtly there are dablteS lbaut thl caucept ti misted death. well maut the mcnl suptabntty of m:ts that fall IRlr thts cmapl Ethical analysts ts often interwMn with other kinds of analysis, such es scientific, poltt1cal, iegal, and eca1~tc ~lysts. Hence, m1 etht~I analysts or po11cy options regarding Hfe-sustatntng technologies wm ineYitablv incorporate scienUffc mta end presuppose political tv- PAGE 6 canatratnts, IUCh Ule systllft within which the legtslattan llft-utatntng tldlnalagles. This ffrst dlsttncttan, which aim ftQures at least tmpltcttly in 111111 auwr dlsttncttans, ts aftln !Ill bV and au.rs ta bl wrv tmpartent, Mn tJm11 It ts hard to dlfend tn terms of various ethtcal trtlltttons, whether relf. humanistic, er lllldlcl1. C... 1 indicates haw this dtstfnctim hes an intuitive appeal to same professionals 2 - PAGE 9 . .I and athn. An attending phvsician asked me to aarve ., ethics amultant far the staff caring far an eldr)v man, who was suffering fram several mejcr medlcel problems, Including tanntnal an:r, w1th no reaaaulble chlra ol lTJNflY. Thi patient wm clearly lrmnpetent andcauld nat mmmuntaa wttb othrs; hi hlll no ftlv ta ww proxy dlctston-mlkers. Thi lllllllbn of the staff crtng far thl patilnt hid tlV and qutclcly .,_. e111 no mdl. tr m nat rtllUICttata (DNR) arar. They felt mnfartmle with thts mctstcn .,. of the pat11nt's awnn anfttm and ..,.,_ts and balm nat resusc1tat1rv.1 thl patient In the event or cm ,tic arrest maid be vtewed wttbhaldlng ( nat sbrttng) rathlr thin wtthrawing (slapping) trlltmlnt. 1111 patilnt wa being maintained bV tntrMnaus nutrttkll and tr,,ratkll n1 anttbtattcs ta fldd tan. Sewu al mnbn ti the tan ~t that 111 medical trllbnlnll, lncltdng artfflctll llltrlttan and--... ant1btattcs, shauld bl stappld, but othrs, 1111 hips a meJcrttv, ~t tlllt It wauld nat bl rfdlt ta U.. trlllrnmts. HawMr, whln III IV 11111 inftltraild, maf the lattlr ,-aup canarred that It WII td abltgllary ta strt the Hne IIPICIIIIV If ft tnvalWld I cut-am., blcll tt could bl vtewed 111 ltr!Jm nlthllthin cmtJPllfll I trllbnlnl HawMr, othrs sblrply a-1t1ctZld this Ull fl \ tbl dlst1ncttan bltwlln wtthhD end wtthlnwt~ trelbnents, an the rGllldl that tt was If dlClpttw retianlltattan er IIIIC 1111 y aaphlltry TIii canmptual and narmatwe raats the dlsttncttan betw wtthholdtng and wtttd'awtng treltmlnts are tlnglld. P hlpS thl maat plauslble erg1111111t ts that In blgtnntng 1 ltfl-lllltltntng trlltmlnt I pntia1111 lllltll a pranaill, crlltll an Implied ardract rr CIMllllllt, er Q11ldll I apectattn, which, an 9'Gllldl fl fldlllty ar JGyalty to the patient, require that the treatment nat be slapped. However, athn contend that the fundamental pralll ts to act In a:ard wtth the patient's wtshls and Interests ( tftl prtnctples or beneficence a respect far persans), whtc:h cen nulltfy tr OY11Ttdl the premise ta the patfenl Furthermcn, llllnV lrQUI" this dtstincttan betweln withholding and withchwfng treatments is often -3 - PAGE 10 . (\ \ marenv pnlctu. aw1au11y tt mav lead to OY1rtreatment, but tt mav 11ao Jeed to llldrtreltment, stnce w prctesstnls hlwl repcrtedly been reluctent to start treatments in mdralnstlral rcr ,_ ,_ bltng kl:ted tn ta thltr cmt1nuat1cn HawMr, It ts anen 1111: a 111 'I ta strt Uftt-sustlfntng treatments in anir ta gain ttrne and tnfcrmattan fer a better -prag1mts, and dlctstan. Thus, It plutble to erp, the Preskllnt's Cmnmtsstan ( 1983) as, that the blrdln pnd ftUld be htghr far withholding Um fa-wtthlhwtng ti lllbnlnt ~nm JUdrJMnt lbaut thl llttr muld preunab)y bl relChld an mare soltd And Ital 9111111 rnaral prtnctplll are relfflllt to and an:Justve fer dlctstcn to withhold er to wtthlnw 11fl-lUltltntng ti IMllllntt "whltMr mmtdrattrm Jlilttfy nat starting shauld Justtfy ._tng well. Tim tbl OIRalllltan cancludll thlt neither law nar public poltcv lllauld lllark dlfftr'IID ~,. maral --bltWllrl -Ing and nat starting treatment CPresidlnt'sCUnuntsstan, 1983, p. 77). 2. Thi appHClltan -the dlsttncttan bltwlln dlc&t ( lntllldld) and tndlm;t (111tnll11dldbut ftl IHIH) lfll:taQf &tlanl flalmcafltrMI sill There al .,-elllllflt Um, ind tbn ts annl m:eptara fl acttans tblt rellM pain and suffering Mn Ulaudl tlwf -, hlltln dlllth, If thlv are In acard wttb I plttent's wtshll RI tntlrllts. This dllttnctfan tm aftln beln used In the Ramin catholtc trdttan, but In other trdttans and cantllta well, 1D lhaW tlllt 111111 ect1arll Ullt 11M I hrlllful lffllct, SUCh dlltll, m nat always flll lldl' such manl pnmtbtttans a autctdl er mtrdlr blr:IIIII the hrmful direct ts Indirect, 111tntlndld, ar IDlrllV fer 1111n and, such, ts Justified bV other flltlnl the act and its CllllfJIPIICII. Trdttanenv this dtlttncttan between direct and indirect effects his Involved four anttttans: (I) Thlactbl In Itself must blpdcr at least mcnlly Indifferent; (2) thlagent must tntend cnly the gxxt effect and not the evil effect; C 3) the evil effect cannot be a JmlllS to the pt lfflCl; tlll pd and wn effects must folla# tmmedtately fnm the same action ( otherwl the 4 -: .i.. ~. PAGE 11 I I ') ---4 ,. J '-' .. .i -... :. .. wn wauld bl lntendld 11111n1 to the pd end) i ( 4) Thn must be praparttanaltty between the pd end r,11 effects rl the ectlan, that ts, a praporttanotely ,-ave er serious reman fer 111awtng the wn efflCt ta amr. Thi wn lfflct ts allowed, not saudlt: It Is ran nan. not tntaldld. (Fcreunmr,af thlruleafmublelffect.Manaan, 1~9: Bavle, 1980: 111111:hanpandQltlchll, 1983). t1Glt aftln thl rule af able efflCt Is invaad when Uwl Is I canfl~ betweln ab11Qlt1ana cr YIIUII and It 1s not paastbll to fflllt cr to ratllZI 111 rl tblm at th!lt time In the sttuatm. Fcr 111111pl1, In u. an af trmtnenv m patients. the prtnctple fl rmneleftcence lltlblilhll I Glly nat ta hrm er ldll thl patflnts, but the prtnctplll ti bnftclra and rapect fir Pll' lltlblllh I m,ty to -*8 U. pettent mnfartable 11V reltwtng pain end tnlb:tng slllp tf till patllnt dlstrta ......_., In 111111 sttullttans It 1111V bl -bll 1D dllr.fttl 91 thl 1lttllr cmly Iv be~ tn cttans tblt hldln 1111 pattents dlltlL Wltrl thl fair mdttans af the rule fl cblb11 lffa:t n met, ft -, bl Justtfllbll to 111g11g1 In acttans that can bl r 111Yllbly prtdlctld to hldln u. pettents dlltht such ICttansm nat aud vtalattans af thl prtnctple af nanmallftala er tmlctdl. laadl(I ta Ula Etlllcll and RelfQtaUI DlrectMII ftr ClthDltc Hllltll Factltttes, tt ts nat IUtblnllll ta QM I ltftng psw lldllM11 and 11111g1stcs far tbl llllvtlltan af pain, whln IUCb I,_.. 11 Judgld MCIIIIYV, Mn Ulaufl IM\ U/ dlpriw the patient af the" ..... er 9hal tin hts 1111 ( aim Sacred OIV91Q1l1arl, I 980, ftr 1 st1111r Slltlmlnt). Thi rull af mubll efflct thus dlsttngubllls bltw1111 reltwtng petn at the rtst bringing lbaut dlltll and rellwing pain IPf bringing about dlltlL Thi dlsttnctkll bltwlln direct and lrdrect effects cannot cil Ill thl maral wart that 1111 tobe fDlt ( 1 ) Nat Ill ecttans that fal 11111bly result tn dllth re Just1ftable, and ( 2) DII ecttans that lntenttanany result tn dllUI -, be Justtfllble--e.g., remcwtng a resptratar urar some circumstances. Thi Judtcfal Cmn:11 Uw American Medlcll Aaactettan ( 1982) holds that that the ptp;stctan should not s - PAGE 12 () ..;, ; ,.: J l (, tntanttanenv C1U11 dllUI. Just lftlrt caradtng that tt ts lthtcal to CIIII er amtt trtetment to let a tarmtnenv 111 patient die. HaweYr, amtsstans mav tnwlYe the tntenttanel c:amttan of death, Mn 11 uw, m nat alW/1 result tn dllUI (I.e., the patient mav SUrY1ve dlsptte the tntentmal mntlltan). km ding tD m crtttcs ti the dlsttncttan, the tan ts nat whether au, ts r FI Im ftr m:ludlng Sine 11111111 fl bringing about dllth, MIi If there is .,-~ent amang 111 the prt111, tncludtng the patent, that hi er n wauld be blttr arr dllld. 3llne men or bringing about dllUI, such potaanlng er stmttng the patient, mav be ruled out. an alhr thin thl rull-cblbll lfflCl HIia, the crtticlJ quattan as nat mm n primary and 11111dl y tntlnttans er w prtnry end S11Ddry,--ar direct and trdrect--effects, but the 111111111 dlllll, prtlculrly tlll dllt1nctlan lln= ttlllng Sid 1ltt1ng die. 3. ; etttmcfllntkfJJtm lnnsttuattan (CIII 2) Mr. R, 62venold, WII lmpfflltad fer llllllltlttc amr ti U. mlan. Wllln It bll:IIIII cllr thllt hi wauld nat lltllv blnlftt fnll etthr ctanalhll aw er rdlttan, Mr. R Mlfmld llbal atary taD, ant1btat1cs, trnftlstans, nl Whtie aaptlng pain lllldlClll1an, tllDJ!llr1c sucttm. and tntrMnaul fluidl. Fmr dlt/S llllr hi lllklll mctm s ta ..... up bis dlltll, 1111.,.... 11' his pain and dlalllfart and mare bal hi muld nat INin tlll ltifng Pl ac 111 anv 1angr 81d did nat Wint 1D Jeap11..na his ftntly's ltmltld flnenctal ,....,_ in this ... Lo Sid Jamin ( I 980) wrttl, ,,. haull Slaff QIWI mlbltlnt11I cmes ti rnarphtne and dllfllPIIII, wtth the ag--..nt fl t1111pat11nt and f81tly. This CIII cannal bl bnuJlt 1lldlr tbl rule fl muble effect far aw111 c111t111 ; the mldlclttan WII nat gtwn ta relteYI petn at tbe risk ti hlstlntng dllth. It WII nat. CIII" letting the patient die but rather one" directly Sid acttwly ktlltng the pat1ent at hts request. Samettmes the dtsttncttcra between ktntng and letting die ts dtacussed undr other hldngs, such amllltan and action er passive and active, blcll111 tt ts argued that mare 6 PAGE 13 I I dllcrtpttve terms are rad to rep la "ktntr,t, which mast tend to view wrong, and etttng ct1e, which mast tend to view as rt;ll Thus, the Presklllnt's Comm lsste11 ( 1983) med the dllcrtpttw trma 11:ttans thlt 11111 ta dllth and amlsstans that lead ta math. WhltMr terms are npb,111, the 1ssllll are tbl SIIIII. Mall etbtc:al trldltlans prohibit the direct, s:ttve lct111ng fl pattlntl 1 rull, w Ulall;I thly dillll about U. fcudlttans of that rule. Smne hold that tt ts tntrtnstm11v wrong ta 1cm tnnacent PIii ... auws hDld tt11t tt ts nat 1ntr1ns1ca11y and lblDlutely wrong tom m, far mmpll, When thl SUff'lrtng pettent requests -mercy tmtng, but tllll I rule prahibtttna mercy tnllna ts nee a HI v tn ordr to prwt bid amequeras fer fubn patilntl and ultlfflltllv far till aactety~ Thus, manv whD dlnV that acts ti ttntng Innocent 1111 are elw/9 wrong att11 auppart I rull pncttm that prahtbltl auch ects tn pert bal af 1111 dfl1g11 s lf .... 11111 af trusn11twa pnttanall n pat1lrlts, n sulMI sfarl fl tlll aacletal mnmttment tD tlll Pl 1Jtlcttan ti tunan ltfl-- VII stan rl tbl WIIIDI er slippery 111111111 ta tlll dlsttncttan bltweat1 ttlltng md lltttng die faCIII ma claims lbaut the tntrtnstc WMlll!fJIHI af k111tng YlnUI letttng die; alhn fcall CII tbl appl1cllttan af thl dlstlnct1an ( far II arplllltl, W, 1980). Same crtttcs hD1d thlt thn 11 no tntr1natc maral dlff1rm bltw1111 k1111ng and lilting diet whllhr thre ts I mara1 dltfarm wtll dlpend cm the ctrc:IIIISllnces fl thl aa Thul, tn 1 W1dl1V dlc.l n 1 art1c11, Jllnll Rll:hlls ( 197S) cmtaldl thlt the ,.. dlff.-m bltwmn 11:11 .i ktlltng and a:ts (atsstans) fl lilting die 11 nat tn 1tlllf I mannv relMnt dlff.-aa, hi 1111111 fer hts tr, mtdltng two C1111 thll differ m.)v tn tlllt cm lnYolYII k1111ng, while tlllathr tnw1asallawtngtodle,andllklwhlthr wewau1d make different mcnl juct,nents lbaut thl cas. In thall cmm--k1111ng I stx-yer-okt CDIS1n r letting htm die tn ordr to gain I llrga 1nhr1taa--bat.II acts are IIPl11V repreh1ustbll because of the agent's mattves, ... and acttans er nanacttan& But thall raprehlnltble e1111 m., ablcure the signtftcance -7 I) \ ,,' l. PAGE 14 fl the dlsltncttan tn alhlr cas where 11J11ts re trying to berwiit ( rather than harm) patients and whlre thly re elm an:ernid about the bnmr 90Cial amequences of rules that permit or pralltbtt sucb s:t1ans er am1ss1anl. EYIII thl dlst1nct1e11 mat1 not be important 1n 90IIII mntaxts. tt-, bl important in oUln blcll rl alhlr moral principles and rules. It Nf be tlll bllt mnpranatll IIIIGIIII c:arnpating mcnl mllidlraticnt respecting a patilnl's wilhll, ra111ring 1111 pstttnts pain and suffering, and pratecttng the sactety's mnmttment nat ta let 1111m11t paaple bl ktlled. Thi pralltbtttan al direct, actiYI k111tng of IMDnt petSIIS ts built into the legal ... WIil tnto PNlanll c:adll and relfQtaul and humlntsttc tradlttana. ArQuments to chll1g1 ttlts rule aftln appal ta C1111 b 11111, tntrectlble petn and auffrtng, U11U111y f~ e slaw dlltll frcn mm Amrdlng ta a-lt1Cl rl tlll rull, 1 remn ta 1cm 1111 p1t11nt In tl1DII clraanstaas, wllln tbl pattent plam fer ~, ts cruel and tnhulllanl. SMral respmms bMbllnafflNld. Flrlt, tt ts nat cler that tllre n manv CIIIS-11rmtrol1eble pain end sutrertng, tn tlll lllldlml 91tt1ng ( perhllpl In mill llt to the blttWleld ar an ~tdllnt) patn can usually be mntrollld, Mn If re1W t1111t1111 dllUI .C whtcll ts aeptable am ding tD the rule~ muble lfflct). (Fer III mmtlllttan rl thlll matters, Prllldlnt's 0111mtsstan, 1983, pp. 73, 19-20, 275-97.) Sll:and, the crtng srar-11111 nuld take mare srtausly the aDltgatiml to relteYe n1 auffrina 1111 prav1c11 lllldk:llianl thlt wm bl effecttve, warrytng less about amttcttml 1111 stdl-lfflcts In terminal cas (Angal1, 1982). Thtrd, permitting ffllraf ld111ng wtn dtvrt attenttan from finding methods short of ttntng and tnstltut1Gnll and aactal cantexts such hoSplce that can rab:I the pain and suffering to tolerable leYels. 8 - PAGE 15 ,' I I ') I ,--, .:' / l ,;_:, ,Fartb, In vtew ti the unartaln ftlld to changl the rule In ordlr to press beneficence ( relfM pain and suffering) and In view of the dm9I s to the aactetv thraUljl abuse, mcltne of trust wtthln medk:111 relet1anlhtps, nl the tlnlt to the prtnctple fl nanmaleflan:I thit prahtbtts ttntng, thn a rmt IIIOllr to bl sufflctent r 111 to chlllQI the rule. Same argue tlllt the INrdln ti pnd lhmlld bl an thall who would lllllntatn a rule that tnfrtnga the prtnctple ti autmany. HawMr, It Is plulble to argue that the paltcv and practk:e fl prahtbtttng ktlltng whtle aa:epttng ... cam at allawed dllths 1111 sYld the aactety wen, t,nat prfectJv, and u.t 1111 INrdln fl praaf should rest an ttae who argue fer ~ng It; ftrthlrmare, manv cantlnd, tlllt INrdln 1111 nat blln fflll 8lfare thl atety undrtlal a llljr 11111 lltan ti thll rule, It nllds llrang wldlncl thll thl dlll1g11 are really lllldril ID Mid ,.,. ........ blnlffll ftr paltenta ... Ullt tlllgal lfflctl wtll ---the bid lfflCts far al1 prt111, tnclldng U. atety (BIIUClanp and CJltlchll, 1983). Ftftll, thn n w_. ta aapt 111111 mapttanll Cllll fl_ IIIIRV ld11fng wtthaut clllllgltag tlllarrent 1lgll andaactal prahtbtttan--e.g.,~ dlll:rettan,J..-y ftntlngs ,nat guttty bV raan ti tlmprary t111111ttv, and nm,1tttan rt -.....CV- ftlCllr thlt mttiglta .....-IWIII t,tt-, nat ea:u thlagant. Ewn wttb U.. tnfarmal aapttana, u. rule mav .... a YIIUlbll rwntndr ti thl tmpartna rl thl prtnctple of rmnaWbncl c nrst fl 111 ar at llllt m no 11rrn) 1111V prwtdl I velulble ceuttanry natl. -argue that a regulltary llDIDl wttll prGClllrlS ta mate sn thlt tlll pettent r1111y wants fDdll wauld 11111111.t abulll; hDwMr, tbl farmeltzattan ti the pa ,ass -IGUld IIIMI Its awn CDIII .._ tt wau1d tnvolw thl IDClely pa,-pectiYl)y and dlrectJv tn dlctdlng tmpllmenttng mercv ktntng. Ewn If the dlsttncticll bltwlln ktntng and letting die ts aa:eptad ma sactal and legal rule far atrtnstc ralhr thin Intrinsic rn1mm, thn n stm debates 8baut where the Une -9 - PAGE 16 . ', l ~-fl' .. ,. ... \. t' '-. / .. \.. ~-} 118111 lhauld bl crawn bltwlln ktntng and letting dte. It Is nat sufffc1ent to point to the Cllfl9'lr Ill of ecttve and pmlve er acttan end amtsslan. Har ta It simply a matter of Identifying 1111 CUI rA dlltll- 11tt1rw.1 dll lnvalYtng "nlbnl CllUIII such the undlrly1ng disease m IIQllllld bv the 1IIIQUIGI ti nabnt dlith--ftr ldlntt~ -U. cue tn maral legal lllttngl 11 tn prt I narmattw wll 111 Plrtml llllttr. It htng11 an prier JudlJnlnts lbautwhltwt11auatC11U111(Prmldllntsemnmtsslan, 1983). Andpeaplecanbe NIIPllll1D11--marenv end 11g111v WIii C1US1l1V--far mntsstlllS rar camtss1c111. Whltl1r mntsstana wm count cues ti dlllh wm dlpend In part e11 whlUllr there ts a mcral er 1IQII rapanstbntty toutatn ltfl, wlltcb ls the tan that thl dlsttncttan ii IGffllttmes ...... ta remlvl. n.ewtll alftI blw btgutty and 11111 talntv lbaut the ltne INllW tt111ng 1-1ngc11, nmlllllth an 11llandaawswm cnw tt tn dlffll d plal, In tlllmnfllctl tn CIII 1 lbM. tDIMr, tlllrl n 111111 clllr C1111 ti dlrlat, -~ ttntng, I~ Cia 2 lbawl, 1111 It II nat Wai lHml'lbll tD llllintlln tbllr. 111 mtlltttan Mn the aaclltV cantftllll ta ... whn the 11111 allauld blcrawn, rar IXIIIIPII, l'IIJll'dlfl rtfflctal rurttm n tr,,nltan. TIii Prldllfs a.mtsetan C 1983, p. 72) '11111 lllllfflttan an tndlYtul lf-clltlrmlnlttan tD bl an acceptable mst ti mrtng the g1n1r1I pratacttan fl~ ltfl lffardld 1ri 1111 prahtbfflan fl dlra:t kt111ng. 4. ctdlrw:v CIIIPVecnD11 M1Wa( fnnlmeat Ortgtnelly fcrmulltld fn Ramin Cltlloltc IINNI tlmlarf, th1I dllt1ncl1CII, whtdl 11 ,xpr HIid tn IMl'l1 dlffll ant tlrlllS SUCh a "raultnl. and ,.'Ole, ts,.. wtdl1V IClaptal In allllr llhtcal trdttans win tn 11g111 the intanttanal tlrmtlllltm al tlll life ti Clll lunan being by anathr, the Amrialn Medtc:a1 1' 11 ac11t1an Haull ti DIIIQllll 1n 1973 held thlt the pll11nt and/ar his 1mmldlltl femtly can dlcldl lbaut u. ca111t1an fl atceannccv m-,, ta prolcllg the life at the bGtf when there ts trrafutlble IVldlra that biolagtcal dllth 11 imminent Similar distinctions hM been tnvokld 10 -' PAGE 17 i I tn alhr pralelltanel axlll and legal dlctlianl. Al dMlaped t,f Raman cath01tcs to dlll with prabllml of Uf111Y prtar to thl dtmr.wy of anttaepsts and anestheste, the dtst1ncl1CII was used ta dltlrm1nt wllllhlr I pat11nt's l'lfulll fl trlllmlnt stlauld bl clalsfflld su1ctdl ( far the dMlapment ti 1111 dlsttnct1cll, Md'Artlll,f. 1980). Refusal ti cn1t,wy 11111111 of 11 llblllill WII Y1Nld a lUtcldl, whir rafulll of ..,. .. dlnrt 11111111 WII nat v11W1d IUtcldl; wtWlDldlng cr wttbrhlwtng ardlnlry 11111111 fram plltlnt WII haln_tc:ldlt, whrels wtu..-ldlng er w1Ud'IW1ng extrardlnary men W11 nat cmstdnd hamtc1dl. Amrdlng to 8nld Kenv ( 1951 ), one of the mast dlsttngutshld and tnfluenttel tntrpretn of the dllttncttan, -onnnn ... are 111 mldlclnis, 11 ....,., and apnttans, whtc:h offer r 1111tible--blnlflt far tlll pettent and which CIII be ibtllnld and Ulld wttflaut IXCIISM pain, er alhr INDIWlltlnra ti I aat I .. ~are 111.-tMS, ti-, Md apnttans, Wblcll cannat blabtltlllller Ulldwtt11aut ac111hl111111. pet~. er auwr 1IIDIIMllllra, er which, tf 1111111, wauld nat affr r111nbll haplaf bnflt M dlMllaped lrf Kelly, till dllttncttan dall nat rdr 1D III q1111 till~ lllldlcll practice ar ti the llchnDlaglll UlllnllMlli tt rlllllr htllgll CII two a11rla W...,_ lllf prttculr lllldlml ti tlbnlnt affln I r 111 mmll ctaa rl blnlflt and wtlltl1lr Its ll'Gblble bnftts autWlldl Its III Ullble lNrdlnl, tncludlng .... and pain. HawMr, It ts now aftln Ulld tn marel dlaDalnl In and lbaut medlc:al ere, the _.. fl ardlnr, n atrm..nnery 1111111111 IUbjlCt tD thlcrtttctsm that tt tlllds to faclll atlnttan CII aatallllry lllldlCII pract1cl 1111 tlcllnolagtll thin an tlle llldrlytng prtnctp111 and VII thlt thl dlsttnctkrl sllau1d apr tn prttculr 1W. Hanel llchnDlagtm n IIIINltt11111 vtlwld ardtnary ,f It ts ..,.1 er custamary far phystcim to ua them ftr artatn dlHHH r prablllns end .. extr ... dlnr;' er "herotc. If not. Thi patient person aftln-pers fram vtew. SMral athr crttrte hM been tnvated to dtsttngutsh ordinary frmn artraardlnary ffllllll fl treatment: their stmp11ctty (stmple/mmplll), thltr naturalness 11 ') .': r--1 ~-' PAGE 18 ' (\ "\ : (' '(: "-'' 1.: : I -~-:_. (lllbn1/artiflctll), thltr ..... ( tnapens1Ye/cmt)V), tllltr tlMIIMIIIII ( m,trwasive/ llrdlnl (prapartllnlll/~tanltl). It ts alllgld tllll I tlcbnalarf ttlll 1111111 thl first ar 1111 palrld tlrtna ts car ta ardlnary, while a that 111111111119IIDld fl VII paired terms ts claar 1Dlldrdlnll"y. Salll llhtclltl (I.I,, Rlnlllf, 1978; Vllldl, 1976) Pl apa11 ta rep1a the terms an1nmy 1111 -wttll GUllr tarms tlllt are 1111 mtsleldlng. ~nary cauld bl recanstructld ta 1111111 mcrallv abltgatary, mandlkrV, 1'8"1nd, ar lmprattYI, whtle actr ,a..-y cauld bl bl NIIXllllructld ta 1111111 mannv apttanal, 1111:tlVI, ar mcp11ldlb1& Sucla ..,.111mlblv rlfllct U. paint fltbldkdlncttan mareclllr)v Um tlllarrent WM lat tflll~-----bn lsltfll tlll-tanlDGUt wlltcllfltllllblwe rt11rtacr GUllr aitartacan dlst-,dlh Gbl..-Y hn aptianll tnlbnMts In prttculrctrallltlnalL lftllllblWlcrfflrtanrelMnt--indw-,blrelMnt-It tam1V,.._U.V-.. ~pr .. Vlhlll.u:llacttngtnaantwtt111 palllnt's wtlhll ( 1h11 prtnctpllfl autmmy) 111d In aa:rrd wttb a pattenrs fntnltl ( the \ prtnclplll fl blnlftalll:I and IIIIIIIIIHlftl:). Far .. pie, If III Millbll ti lllmlnt ts simple 111d nabnl but nat In aard wttb I paUanr1 wllhlland tnltl tt II hard to whv tt should Ill hlllllllll dHI' dlV thin 111111hr lrllllnlnt lhlt II mnplmc and rttflctel. Flrthrmare, 11111Vfltlllcrttr11n111:11r. la:a11ng tanstult(mrdl:lldlftr thl natnl dlllh act WII --1111 In C11tfarnte, '*'9tcllnl In tblll stlll-ellyvtewld rmptratn, dlltvsts, nt ........... arttflclll, but apllt """IV an lntrMnaul riedlng, while two-thirds lwld lmulfn, anttblt;lttcs, llldclllnalhll lPV nat1n1 (Rldlelf, et al., 1979). Othr a-ttrte, IUdl 1111--~ IIMIIMIIIIII ( rmtlMlliw/lnvmlYI) and mst ( expensive/ cmt)V), mav be morally relMnt tn vtew flu. patient's CMrln mndlttan, Interests, and 111 lflrellCIIL Thi main amtdntlan rar manv llhlca1 traditions ts consistent with what Kelly -12 - PAGE 19 [',,' i -~. ;, ( 1 1) praprat and with whit 11 IIIW aftln Pl 1111d bV the crttrtan ti pniparUanallty (Smnd OI tglllan, I 980): It na:111 y In 111 clrcunstaras to hive recaurse ta an ..... radii? In u. palt, marallltl repllld thll GIii ta,._ abl1Qld to UII J ') \ .. ,, \.J r \.' _/ _j,_ '.} 'lldrlndt'( 111111111. Thtl rlPlvwlltcb pr-1111111 hDIIIIGlld, ts 1111 hips llllclllr 1'1111111 fl U. laaprlCtllan 4' 1111 llrm 11111111 rapid pra, Mil In U. lrllbnlnt ti n:lu 111 Tu 111111 peapll pn(r fD ... ,,, ~Pl apartlanlW and 'dllpl apar(1anltl' IINIIIII. In ,., cma, tt wm bll tD llllkl arrst JWOIWllt to tlll 11111111 bV stult/tna thl type,_ tnlbnlnt tD bl Ulld, fts c.,,. ti mnplllttv tr rtst, Its cmt 1111 U. passtbtllttas fl ustng It, llllmraprlng 1111111 ..... wtlll tlll rlllllt tblt CIII blapstad~ tllctng lntomlll the atatl ,_t11111ct1111 llllllllrllr_.....nlmaralr---. In 1111 al.-111111 II dlltlncttanl- wttllbDldlngl wttllttng; dlnl:t 1111 Indirect lfflcts, tt11tng nl lltttng dll; 1111 Cllll1111 y and edrlardlnlry ~--- nat Pl wtdl ..... lltllaudl-., rtflllt tmpartant marel caneldllrlllan& WhlUIII tlllll dllllnlttn art VIIIUllbll wtll -111 tlllll wllllhr U., dlrlat mr attenttan ta 1111 tlhntnll8 r dlltllrt VII rellMnt maral mllldwatlanl, prttcullrtv 1111 pr111:tplll a Y1l1a1 tllll hM IUlfCII trdttanl, 1111 rellvlnt maral caldrllklnl n tlll pattant'1 wllhll and tntlrlltl, in l"'91 fl llllcr hr anlttan, and In.,.. -U. wen anr:lltll allaclttan fl,....... and 1111 111t111ttv-S111alllllru,M11tblpralllltttan,-ttlllng,taprwtlllll.....-. s. Nr Jlnt:-,.. n k1Dlsa( JcwNDI In vtlw tithe ._ dlltlnctlanl 1111 Ulltr llldrlytng prtnclplll 1111 YIIUII, ft II fmpartant to tin to 1Mls and tfndl at tlltlllagtll toan rr patflntt, fnckdng ta austmn their 11-. An rttcle bV W., It II. ( 1984) dll:rt~ IMrll 1111 II 1'Mtls of an: ( I) lllllrglllY resuscftal1ani (2) tntanslwcn and lltlllad ltfe support, tncludlng mechanical venttlltfan; ( 3) gnnl llldlcll aint, tncllllng anttbtattcs, dtllysla, and rttflcfel _tr,,ntlan and nutrittan; and ( 4) -13 - PAGE 20 .~\~?t~t~'"' ...... "' .. ,..,...,. __ ........................ ,_ .... ... ,,_. .. ... .... (~;' ,~ ; I) t'' "' 7_. _' :j ,., :~ gnnJ rifting en Including petn re1W and t,,,ntton n nutrtttan fer patient camfarl It ts evtdlnt that UM 11Ye1s ermnpms the _,..,1 types of technakvf that OTA pin to axpkre, and It ts tmpar tlllt to analya the arguments ftr end egatnst wtthhaldlng ar wtthlnWtng these leYels fl an In SIDI stutittans such tn the follawlng two mses. In CIII I, Mrs. X, 111V111ty-nt111,wr old wtmw, hid bean a r11kllnt of I nursing 11111111 far IIMNI .,..-a. In U. pat ft hid mcperterad repeatad ti lent tstmtc attas. ..... ,, Pl,. mlYI crgantc brltn svnrnme. Shi hid last IIIGlt,, hr mental lbtltttll and,.. bllXlne .tlsrllntlll Shi IIID Im aptaadls ti tlnmbaphllbltts well CD-1YI hart fllllft Hr cllud*r ind ~Hehn Yllttld hr ~ly and Gbvtausly laved hr dllply. fflltad, llldtlll__,.11 wa11-.111lw*'*8. 3111_.,. naMrY, ranetntng abtllldld 111d IIIIMl'bll, but a mnttlull 1Dmantfllt a wttla'_. racttan to patnful stlmult llllm IU'Plllltul blhwtm-s. Mn. X nfulllll tDlllaw I na-tc tube 1D bl pllCld In hr IIIIINdl; at 1111:h altlllpt a t11. 1111111 lbaut vtollntlv 11111 pu111111 u. tube..,_ Mir u. tube .. n11111v plat, Nrs. x pu11111aut., ramwnts ... _.,..to, .... tt Afllr .... _., tlr lY st111 wn llhlUltld. tan rr thl stiff was whlthlr tam ftrthr lltrlardlnlry er ....-ate ..... 11 matntatn fluid awl nutrtttanal ftr this eldrly petllnt who hid 1111111 M rtaHflY fram I INBIM strake end who W111arglly UNIWll 9 and lfflllPGIIIM. Mir -Dllldll -.,1111 and dllculltan wttll Ula 111'911 e11 thl naar and wtth tlll ..... r.nv. u. _... tn c:111111 dlctdld Id ta prwtdl rw111r IVs, cut-mwns, er a t'lldlng tube, and 1D allaw f1rs. X to dta. SIi hid mtntI cnl Intake and died CJJiltlV the follawtng wiek. [This C111 1111 been a11pt111 rram ane pr111nted lrf Dr. Mrttn P. Albert, Cllr1attmv111e, YA) In CIII 4, Dr. Ht1f1ur C 1983) reports being called at 3:00 AM bV the nurse at tlll nursing hame where Mrs T, an 119'tv-thrte yw old waman, hid bean c:anflnad since her -14 - PAGE 21 .. .') 'It ,' ;; .:. llratlthrelya"lerltar. Mr& T tsnaw blrlctlllnendaphastc, wetpanly691bs., ahas dlcubltus ulcn an hr blck and htp, and the nurse reparts that she his a fever, hasn't been a111g mucb thl lllt few dlVI, and 11111 llttle CDUl1L Dr. Htlfltr ps ta the nurstng haml where hi ... ,. Mrs. T whD pars at htffl fram behind hr blank ra. Hts tentative cltegnasts Is ~ ..a hi ab thl 11r11 to can the tlchntan aut fl bid far a chllt x-rav nt 1111 ~ ..-1111 cultln Dr. Htlfttr .., the 111r11 natl that _Mrs. rs antv friend tn the nurstng lllnlwha pnm111y tnaws blttlr thln.__.elSIWhlt Mrs. T. _wauldwent hlltd thlt shl ,_ Vin waulcn't bl.,, hlrotcs ff Mrs. T -sick IQlin.. But the m,ly rellltve ( I distant ntawhl Hwa ftr IMtf) hid Clllld ta rlqUlit thll ..-ythtng palltble bl mr11 far hr aunt Dr. Htfflkr Nlf1ectl, '11111'1 tn tlll mtcalll rl "8 ntc,lt I cmllfdlr 'ming MrYUltng pmstble' fer l1r& T: tra.rer 1Dt111halpffl1, lntrM1ail11nllfar ..,.atanllldantW1cl, llllrllary 111d x-ny Mlllll1an, twtatdllllV rmnll to be m tlllt a ts rlCIMlftng. mare lmdc anttb_taltm,. 1111 MIi trallflr to regtanal halptta1 far Mlulttan and en IP/ 1 IPICll'lfll Nalll tt II w 11111:nlble, and anaUlr ntc,lt I mtc,lt chaall just am mna. But -. rrrv IUnln _.._. 111wtt11 rn. T 1111 wtlll I parallW fir dlltrl ta dll. .. In.,, MIit i dll:ldl-1111. the llnlcs. lut I c:an't lllll m natlltng, ettllr. My 1rltmng 11111 lllclVGllld n tm 11rang. 1 nat 111aw IIIYll1f to blmlltlllnt n just aa ham& campramtatng (1111 ulttfflltlly llllktng I dlclstan thlt llllkll III lllldlm1 ar llhtcl1 111111 at 111), I wrttl ardlrs 1nltrUct1ng t111 stiff to mntntstr ltqutd pantc1111n, ta nauraga nutd 1ntlkl, and ti--~ wttb 111V afflm ID Ulll I C111 r-1111 Mrs. T tn 36 Ian In e111 thl flly _.. staff dlctdld ta lit Mrs. X die Mn tllaudl thlV muld hM prolangld hr ltfl far 9111111 tt1111 tflra.VI llldlcll nutrltfan and -.1an. In ca Dr. Htlflbr dlctdld ta ermnga nutd tntate end to mntntstr ltqutd pentctmn but nat ta prcwtdl lnb MnDUS Hnes ftr -.1m and mttbtatfcl. HI mnaldld that his anpramt ma no c11 ar lthicll -at 111. NMrthelell, tt clelrly reprea,ts ane Wfl/ to craw 11nes tn -15 - PAGE 22 ' wtttal-llllwtthrnltng trlllllllntl. Al baUI e1111..-, an1 majcr 1ssl.ll 1n nwing lines is whlthlr 111 medical 11 lllnl1lltl, dllplndlng an tlll ctrcunllaas, can be canstrUld ,-.o1c ar atraardlnary raUllr 1111n an1111ry er apt1an11 ra1111r tt1111 m11g11ary baule cut at praparticm wtth 1111 patanr1 wtlhll llll 1nllrlll& Tllte 11111111n .. 1111r1 tn IMrl1 llll)cr aart dll:lllarllllld wi111V dia.JISld In 1111 lttnbn tn the 1lllt twa ar Uni~( Lynn and Cbtlnll, 1983; Cllllllln, 1983, Clpr111, 1984; Cllllll, 1984; It el.) tn effarts ta dltlrmtne ...._ lllldlcll llltrtttan and tr,,nttan bV par1pbn1 er Cllllnl 1ntrMnaus 111111, nm~lllrtc tubll, er .............. stmtllr to auw lllldlal11rllllnlntl, am NIPII .... ar llll'IMtllr ta 1111 prorislan flfaad..a _... lrt mautll; whllhll-U.V n 111111111 cmrm t ndlllllY w w111n u., ... maranv apt1an11 tr 1111 prolanglUan" 1111, llllwlllUIII' .,,.,.taanllllCDD11lan tlllll IDwtlllbD1dcr IDwtll* 111111 wmld tlr ... UllfalnllUan fl ..... ..Sr.,.,,..l lllllbl anllldulttllltllV llldltll II~ &ttan. If llllrtttan 1111 tr,,nttan ...... llllllall 11111111 ta relMnt)V lllllt~ ta allllr lllllllm1 ti-, tlllll UIICIII bl~~ ti 1111 a-fllr11dllal1Hd 1111M. Crltbti Uda _tan, whtdl I IIM cllfllllld (Lynn 1111 adlnll, 1983; aatlcnll, 1911), ... __. ............ C. II thll lllldk:II llllrtttcll and lr,*at1an n 8"dflan1V !lflll ant frlli1 alhr lllldlal1 trlllblllnll .._ U., nlllllllltll fer mnfart n _._ .. If .nnat .... 111 far lffl-prolangllUan. HDMrtlr, aae 11111111, IUCll ae 111llrll lY, 1Mlvl MIU,_, .. 1111111 _,, NIQU1rl 1lllt 1111 pli1lnt bl lllrl*allv Cllllllrll1111L In dlltall, tlln fl wtdlla tllll paltlnls wtll n l11awld to dll wttllaut rtfftc111 lr,*lltan INff die_.. camfartlbly ttllll patilntl whD ralve MIi llylNttan (Zlrwlkll, 1983). A 911D111argllnlllt ts thlt 1n wttla'IW1ng lllldlcl1 nulrttlan llld tr,nlbl thltnflndl ar alms at the patient's cBIUI U11illlndr, 1984). Haweva-, dllcllSlld lier, this lntlnttan-, bl pr111nl tn alhr c:1111, ab ranovtng the rmptrakr, and 11Ntf not bl 16 - PAGE 23 \-. t lnlPIII aprilll In 111 cw. Third, whit II prablbly the ffMiar crtttclsm streas the symbol le sf91tflcance of m1dlclll lldrtttan-a,,a-il11rn, tlllt the stmtlrttlll anang 111 cts fl pravtdlng llllrtttan llld lrt*attal are lllll ft ts tm-bll ID dllltngutab Ull1r CICIDilP (&g., PIUllfnll allln) or tllllr ....,.,,. (ag., -CllbllVfnln nar~ flldlng). SUch &'IIIN nat e11t, 1111111 tot111, llldl ti 9Ullllntng ltfe ..a prawtdlngmnfart; UW, 111D express ....,,_ ..a exprtlling care whln tlwl Yio1* thl plltlnt's lnllreits (1111 the ...-11111 blnlitclra, IIIIIIDl1lflmnm, and autananrf). Thtl mn1 mllty II particularly ldlnt tn_. whll'I _.... lllrt llllmnttrut 1ntra1111111 l1nll but at arall tlllt wt11 ..... n tndllP,1nttanawwt1111(NtC11Uc11,it11., 1983); tt 11...-11tofo11awt11t11PP1Gldl mtv IP/ fllltng ta anNlldDI bl 1111 Pilat wtn b1a1ne 4llt,1ntlll 11111 lllf/llnllll'1I ~111 UIIIYl1111lllllnlllnl1ftcltannl1111111111.-.. Ffnlllv, mm n lbaut .,.a.Ito aat111111111111111 .-11 crtttm to hD1d thll acmptaa ti wttlnldlng llldwtlld"awtng llllllcl1 Nllrfttm 11111 IP,1nl1111, Mn tn 11g1t1mltlcm11, wtn 111111D tllrrtbll Fer _11, ar:ardlng ta Nark Stigler llldAlln W ...... d ( 1981), "CalllpIIDIID Cllll tr wflldwtng f1utdl tn I fN llatld Cllll blr thl adl al patantta1 ebllll ... eantflldng flutdl, Mn ta ct,tng paltlnts, praridll an tmpartlnt cltntcal, ...._., IIIIBIII 1111 rtr VIit lllaUld Ill rllllllld. Fen lbaut tlll rllllGVII ti thts 1111 r lalle111.......t ar tltdlfnll &tlana 1n aa:ard wttll VII pa1ent's inwlltl lo aatta.a tn aa:ardwttll 1111 taellly's lntlrllll, fnll VII pattants quality ft 1tf1 to thl plltent's wlUl tr -=-tv, fran ct,tng pllilntl to mntflnl pattenta, frcn lllttng die to ktlltng, from Clllll1an ti arttflc111 flldtng ta Clllll1an ti nlbnl flldlng, lb:. Wh111111111 ft thlll firs are ......... 111111ft Um 11M to be taan .-tausiv blcllJII f1 the 111W thrells of LIIQC-,.,., ... result ti caat-mntatnnmll wns tn mdralt to thl erlilr thrlllls of 17 ') .-. .' ) PAGE 24 fl .... -' (; :_,, =.1 ,:~ "':t NI h eel!Dl't lbntsadlnglr tlllt t111 r1;tt todle Mf bemnethl tMytodle, Mn ..,_ thl pattents awn w1lhls 1111 tntlrests C Cl11ahln, 1983). But tt 11 natc1er that thts dlngr can Ill Mldld an)V t,; Mmltng artfflclll nutrtttan nJ tt,,nl1cll 1n 111 CIIII, thlt 11, lrf mtlng III lltlrml 1111~ to U. ltmfll Ill IP/ 1111 princlplls blck af and crfflril tnvoMld in abllgltary llllapltanal ---tnlbnlnl le Clllll 1, 2, 11114 --~ In llllttan ta .,mbo1~ acttans, analhll-lllljar 18J1 ,11nl cttna 111111 m1..:t1cll ff JIIIQiiihts 111aut n lMI ti an r IINlll a tlchnD'lf to J-...... lbaut allllft TIits 18JI ts IVillnt In dll.all lbaut pollclll reardlw.a ardloPlllall V NIIIIICttlUan, wbtcll n parttculir)V tmpartant blal ardllc ll'l'lll a:an ll tlll "1nl prac 111 ,i fllfll'Y (Pnlldl11t'1 CDnuntlstan. 1983). HIia, tt -DI .... 11 ta OR tn III attapt 11 prola11g, 1111t.llrWIV, t11111 11G1t pllttents wlllcll tn llllpttll& Altllal9t dlllll 11a. 11 aatntsllrld prcnpt)V, thn ts dlllllllbaut wlllUIII-Ulltua:1I1- cnw an nlaalls, ual1Y bltwlln 8Ddand,._ ltf1, an U. bind, andardlnlry rellttanlhtps, en thlathr. Manv of 1hlll nlagtlll lnvolw Pl ap111 ty relltD'lllltps (e.g., Hie ts gift er lalll rram &xi) ..Vrr pm sanel ar roll relltfnhtps (&g., lunln blfngs are emrs cfltllhn, Ylftts er sentlnels). Thell are -28 - PAGE 35 !l :; el: ,J ,:' ) ~J i..,, IIIIIIIUmll Cllllbtllld wltll nlllnl llw lrglllllllts, In Ramin CllhDHctsm. In gannl, It ts fair tD-, tblt 111111 tine rellglaul trldlttans rule aut aulctdl ( In mast ctranallncls) end elao a:ttw ........ ar ~tt11tng(tnlllGltclrcLIIStlncll) (LIMII, 1981). Fer, ... 1111 dllculltan fl autctdl and euthlnllll, and mapttana rt gat 11ft end dlllb, IIUll III plad tn 1111 atllt fl 1ft IDIIVI, wt111ng dllty'1 relattan to tbl warld and 1111 ..... llllftll wtthtn tl lfllllft llfl raM11 lts'lllul fralll lad, wllDrantl Ile a gift and whD llanl CIII tltl It flllfl/ ( Sllgll, 1979). Tllraulll Its rejlettan fl sutctdl, JudllStl -.mrms Its htdlY111Btanflltf1111dttsbllWtnt11111M1retgllylfthlCrlllm' 1111t fnll 81111111 9: I, wldcll praldbttatllllhldllngtillllllll blaad...,11111111 bltnalncrlllllll lnthllnlO flllll Thi TlllludbDldl tllll U.flltyta pratstluiln 1tfefall pradlramapt wtwe ..,.. a&Ull .._..lltty ( I.a, fnCllt ar dlltlry), er tdD'8lry wau1d a. ""1nd tn ardr to prata:t 1l lndlld, u. to prallct 11fl-prtartty w GUIii' reltglauScMa u:11 ..-u. Mbllll la:ardlnD to ... Rlbbtntc ats, Seurs adcldl was umr111c1n tn IDMldprafllllltanafa.t(Sllgll, 1979). SllltlrlV, llll'tyrcbl llaaptablllldr m clrcumltlnall, an lfflrllllltan ti flttll tn rllllr thin dllntel ti 8ad. Thi rulll fer rfllllll ff IIIGll'lllng 1111 tntlrlllllllt llCludl tlll 11111' WIID 111111 camm1ltld su1ctdl. HawMr, tn alllr tndltlanl, Vil crtt1c11,111ttan ts wbtdl a:tl n CDlllld acts ti sutctdl, rea1 IUlaldl& n.-, crllartan tawQJOrt ,111111111 trdttan lllldMlapldlUdl &lltltlldruatl evtdlnal fer wtlfu11nllll "Ulll fer 111 prsttml INl'PGIII IIIIIClll 111 IUtcldll n treltld 111d1MII wllD dlllrcJ;lll llmllMll 'IIIW111funv (Sllgll, 1979) .... n acm did the UIUII rffll far the dlld. In effect, DII dllUls tblt n,ld allwwt be cauntld sutctms are 29 - PAGE 36 \-' .. r1111M1d fram tllllt Glllp y IIIIB fl tlll la af sufflctlnt ev1dlnce of wtllfulnm, since there 111 pr111111pt.-u.t no ane wauld wtnfullv. cammtt autctdl nl dlnv Garrs SM1 ef9aty, the INrdln .-praaf ta llllbltlll sutcldl Is blfll. VIII thl rr 011 a fl fer fl petn and suffering, rcr ...... .,, be sufflcllnt wt11fU1181"" nae u. bV renwtna u. mndn. llllllly 1lbll fl IUtctdli a,, mnb at, Mldlla mtrdr. _.. lmmcnltty, ar lmlatry muld llldc tlll lDt rl autcldlL In 1111111'11, thlJlwtlh trldlttan 1111 rulldaut_lllllW tt11tnge11 thlllffll~ llltcldl; t1at111C11tdls wrall, itl whD kills, wlllthr [ the Y1ctl111) bl llllltlP/ pnan er a stet PII 111111 aaabtng dlllb, ar w I pattlnt ail'llltf tn htl dlllb-thrall, 1nltld a apttal crtalnll (.,.._. tnJlallarill, 1978). TIii tndlttan 11111111 blld thlt It ts llll permilslble to -,111ng tblt m._ lllllllldllll, IIUt It llil prmfflldNIIIMl ft-,tlltng tlllt tfd lrtlftelllt, ll'allllll ct,tng, I.&, 11 Mid 111 fnll clllllrttlia -clng thl ct,tng para (111111), wlllllldllll 11 tllaulld fl bl tm1nlnt (wttbtn tlnl mrdlng fD-llllllarfttll), ... tndlttan ... required tllll ab--Ill b .... a ltvtng Ill" In all NIIIICl9 llldtllll nalhlng 111 ... tllll tfd-11111111 htsdllll, ag., cmtng Ill lllltanrs.,,. er rlllllrtq 1 ,..._. ptllaw fnlll lllllr 1111 hlld Aftr IBhllna 11111W tt11tng, 1-,.. tllt In 1h11 trdttan _,. fl thl ct,tng patllnt: -SHI yau-, nat put It an his ....... him 111 langr. It lllllnatll tlllt tt I 1111'1111 ll~and---near his .... llcllapplngwaad tlllll 1111811 amat ~. tllll C111 stlauld r1111av11111 (waad) cbaDllr frlll 111n <~ 1972; ..... d, 1979). T1w tmpartant dllttncttan Is bltwlln ICttVIIV hlltlldng dlllll, which 11 pralllbltld, and rtmlMng tlllpdments to dllth, which ts prmlttld (WIIIINI d, 1979). Of cmne, It alwlr,9 blln _,, to extend the prtnctples and rules alladllll tn thl tr1111t1an ta naw candlttn acmsllnd IPf 111:hnalaglcal mvelapments, such the raptratar and art1flcte1 nutrtttan and tr,,nttan. Thi IX1lnstan his m:urred nl~cal -30 ?: ,., ._:. j ( PAGE 37 ,.;, / 'l ) : r" ~' ,. '-' :_i ~) I tlllrendllllllll tbaut IPPI qrflll wtlhll"-1 end wtthholdlng ti llfe-austalntng treatment -lllnnllllll 11r-,.111111ntent 1nt1111'ltlttans. GI U.lralllds,.thllllllCttty" ltfe, w rlblltntceutllarttlll "wtll nat lllaw.,, relllltlantl ~arts. IDIMr .rttflcll and ulttlllllllv bap1l111, ID II olang ltfe (Jlkablrltll, lt71, p. 80 I); llhn allaw wltllholdlng~ wttlllta,tng,. olc ....._ .. VIit IV prob11ct,tng. In 111 II, U. tradltlan app1111 to 1M strang_.i tovtewtngrmptratarshntellldr111111ctralnstaral, but thnnmcn dlnllll lbaut anttabfalb 11111 arttftctel lldrttbl and IP,,hltcn. Same tntrpreln hold tbat the prtnclplll, rulll, 1111 pradlldl In tblJawtih trlllttan parmtt tnatlllltan fl anttbtattcs tn wctrcaatllaa, but n laue lbaut rttftnll llltrittan and .-1an, which, WbDld, mtdlt lllcllttngu11111Dllfnll Cldlnlry, lllbnl --flMllla(Jl!!aDrltts, 1978;Wlllblrd, 1979l A,_ allllr polntl wtll ~Illa tlll IDlln cantan a( Jll'1III Ulaudlt and practbcm thlll aattlt9. First, tlllOrtlwdlc,Olm vlltw, andAlfal aJlllrtlll trlllltlanldlfflr In prt m111ng1D tllllr apprCldl ID tblJIWtlb tndlt1an, tbl Qrtlmlc mantrat1ng III ttll rulel, thl ~......,.,,tllll U.111111111' tntll III llllkln tltlll ru attlntkll ta the prtnclplll ar w11111 ba ti tlll ru-, 111111111 Rlfarm trdtm tlll prtnctplll or ...... IUCh ,wpect far 1111 tr autmmy, ralllr U.. thl rule& CIIVlaullV, thltr IPIIIOldillDtllllllljr rulllllllprtnclpllldlleu111d1bMwtlldlfflraccardlnGIY-Smid, tlllrln, U.I. 1111 rudlallllfl ti 1cancaptkll rl I gaad dllUI a a tllll rmn tn aard with tllldlvtlll wt11 ... 11klll Sia U.Jlllrtlll trldlttan 1111 nat plllltad 1..,, dllttnctlan bltwllll aptrtt llld bait/, It 1111 nat blln flmpted to vtew auffrtng pastttw ar ta Y1lw lllldlcll en -nvtng In tlll fa fl prwtdlncl (Jltablvtts, I 978, p. 793). Thn 1s I mtv to pro1ang life, but nat ta prolang ctftng, C or aane, u..e are cllttes ta arpa, but not llltlll to prolang 1111 flllCttantng fl Its badlly parts; IDIMr, dllpua lbaut the wing and crttrllfldlllb ... ..,,... thl~~ tblsnparl) -31 - PAGE 38 n. 8nDID QdboJtc tndlttan 1111 allD prahtbtfld autctdl, ustng bath 1n1laglcll arp1111ts llldlllllnl-1-lrQllllldl. Farmmpte, Thamm'1qut11111(ET, 1981) arp,11t1111 trets8ad's gift ID 111111, 111d 11 IUbja:t tD Hts pawer, WbD k11111111 llltls ta 11. SUtctdl II "lllartll stn .... tt II "antr y to 1111 tncltnllllan ti lllbn and to clllr.lty wlllrll,f M1Y 111111 should lave llflllllf. FlnlllV. thl eat fl autctdi t111 agant lnj1n1 thl canunmtty fl whtcll hi ar shl lleprt. Tlut,1Utctdtllanaff11111lglllllltthllllf,nabre,111CiltV,andGad. lngmII, -- canvtct1c11 cnwn hi 1111 NIW Tlltlnlmt thlt tt 11 nMr rtflt tom w11 tlllt pd 111"'9t rault, afflclll Cllntl tll:htnas and CllhDHc ,_.. thlDlaglans m nal Jmtt~ acts rl IUtctdlL ........ tnJudlllll. tlwtt11dlffll'111C1bltlaalllld1..,,,.,. r....-, Ill rellglaul-lllNI ......,_Ian fl 11:tsfl IUtcldtcllll nat trlnNlll lntD an lllqlllllflld llllglllM ... 11 ,_...lftlr 11111111 llll:tlrlllllctdl, tnprtm..-f6111nltldPIIUIIII r11111111tbt1tty. tin llc,ltflalnt)V fnll I IIINI atlHdpalnt, 1111 Cllllallc Cllntl 1111 IINIIIQIII 1D on11adlll ... Gllfltctstbatlanl,nat..._aamtnglglldl(U.l)llllllllr11P11)cr Jllltlfflnl 111tctdl, 11Ut t1nU1J1 clrtnmttan fl flll 111111ttng ,_ 1111 pralltbltlan ft acts ti sulctdl tlllt It._ nat tncludlwlllf--=rfflDIII as tlllt n lnltllalrlchlrttvcr neld*r a1& Hllm, -ll:tl Ulll Wllaltllntllapp1112 tabla:llrl sutctdln hl1d nat ta fell anllr Ill 111btttw rule. Tlltl r....ta acanfltct lltulltan ts r.-n fnlD the cb:trtne fl muble lffll:l (dlllll111~ lr11f1V llllllr TIit 1 >, 11111 dlllll to tll1I cb:tr1nl, 19Dldlll9 WIID falls an a ..... tlllWlldlaarldlliiii b 1111m tW. hlrolc, ar clllrfflbllact raUlr 1111111 llllcldl, .... tl1I dtan ftllif ( fllltng CII 1111.-1111111> ta 1111r111y pd cr nlUlnJ, U. avtl lfflCl (n's awn dlllh) 11 fcr1111n but nal dlrectlV tntlndml, the eril effect (ane's awn dlllh) ts nat I ffllllll ta thlpd lffect (91V1ng thl IMS ti alhlrs), 11111 thn ts sufflctent raan (91V1ng tlll 11vlll rl alllrs) ta lllaw tbl evil effect ( as awn cmlll) ta acar. This cb:trine of muble lffll:l 11111111n a-tttclzld bath lnstdl and aulltdl Aalllln CIUID1tc ttaau;d. Several moral 32 - PAGE 39 -;,. l > .~ r! r; -~ ,~. ,_ .. : -~) : _; llllllagllnlhMnpladtt l,f 1atrt111flprapart1anlllr1a11, but ttstm hakll.., tn afflall1 Cllnh lllchtngL Wlllln IUlcldl 11 Ytewed tntrfristcal~ IV11 and the cb:trtne of_muble lfflat 11-wr,flwCIIIIICIUIII' tllln 111111ynbn end9111f-m-fflcta1 a:llwauldeape 1111 llrGldldttan llllllllt sutctdl; artatnlV kt11tna e111111f ta stap pain 1111 lllffertna fram tlrllllllll. 11111111, ID Mid I paar quality fl Hfe, ar to rtDICI 1111 blrdln to alhlrl, wauld nal qualtff Jlllltflld eapttana .. tD 1111 rul& TIIICllhDltcCIU'ch 1111 tntndad GUIii' dlst1ncttml, 111111 ft wlltcb hM perllllltld publtc CIIIICiaulnlll and poltcv, to PIMltl ICUGHS tlllll llltdlt ..... It first aim ta bl ruled aul IPI 1111 prtllClpll ti ttll r:ttly ft 111111111111 cnwn frall mwtc:ttans GIit a.r, rMl'lld wlll 1111111 lllllnl 1111. Ftnt, Mii .._Wlca 1111 prlllld lUfflrtng far 111 ldualttve lllltptrflllll _..U.Judlllll 1111, indw It 1111raca111tatt111t lllllllry ... atanfl.t111tiPllnktlln-,111C1111CD11111m:1111anwtt11artsraad'flrt11111, tt . llllplalzlllthll it wauldlll .....,.._ to 1....-1111ra1c-.,t11Dttnga1gnnl ru11 (lllndQaij:agittan, 1980). Thi rullft cblbll lfflct 1111PINlfll11111111 fl lllldlal\lanl to reltM 11111 lllfflrtng Mn wlllll tllllr 1111 wtll lmtln dlllll, 1 tcr1I11n bUt 111tnllrdld C1111111111111D ( 1111 dlaulllall llldr Tllk 1 ). Sand, Wfc tbtnursdlvllapld 1111 dllttni:Uan bltl11n ~nary lrll lltrllrdlnmy 1111111111nllmlnt to tndlCltl the 1111fll ti U.ab1tgattan ta pralang life; tf I pattent as nat 1111 1111 v-attrllllnlnt, ll1lllllr rafulll 11 nat tlntlmalllt tasutcldl, and 111 ,....._. er 1flll11V mablr wttllllDldlcr wttllnnlldrardlnlry 111111111n mrdwttll 1 CIIIIPlllnt palilnrl wtlllll 111 ft8lllllllnl pal11nt'I llllt tntlrllll, tt 11 nat ffllrCV k1111ng (11111111111111a). It 11 nat ab1.-V far pat1lldl to ecmpt ar far praftanall and ftltes ta offer 1111 prcwtdl_all 1111111 ft trlllnNlnt VIit mtdll IUllltn ltfl It lat brteny: Min that are futne ar 1111111111 er 1hlt pnlb:e blrdlns that aulWlldl tbltr blnlffls .-, atraan1tory er "heroic, 11111 tllllr ta apttanll, nat llllndllary (ICl11V, 1960; 1951 ; SIINd ra,,egatbl, 1980 ). 33 - PAGE 40 TIIII, U.Wtc IIIGNI trldltlan parmfll withholding er wttlllhwing lffe-lUllalntng tr .... ltl, IUCII 1111 raplrllar In 1111 Quinlin c:111. Thi dlclatClfl mav be medl l,f the patient btlllllf/hlrlllf tr IPf I pray a llllg a 1111-111111 ,_ thl rd1Mry/ atrardlnery dllltllttan nfal11111111 M w ltr ( 1111111' Tat I), tbn II cantl 'Ml 9/ lbaut thlll gutdllt1111, prttculrly lbaut whit -, Ill tncludil 1111111' tho calcul111 fl III aparttanallty, thl calculus fl .. anttct ,-tty rl thl pattanra ltfl-, canatttuta IUCb I Hmttld blnlftt to ma flrtllll-11 lllllllapttmlll Ml.,.._ tllf ltfemuldblllllfllnld lndlftnatatv (f1cCarllllck, 1971). In part Ill ... II...,_ tlllClltlp Ill an 1111111111111 tD tllllllwtlln nat tmVlrlll1Y*1nll. Tlln llllmdlllllllllaut wlllllW 111 llllbl tnlbnlnll lllltutlln Hflan Ill..,._ 1111111' u.-.. y~atmdlnlry 1111111flll dlplnlngan 1111 petllnr1 11111Y, but bV m 1111111 Ill, CIUIDllcGIIIDlllltltllr bDld wttllJalln KIIIV ( I 9S I) tllll Mn lllldlml llltrft1ml ....... -, bl.uanal llldr-clralnstlral (NcCan11ck, 1981). (Far flrthlr llll1ylts rl tlll dllltncttan bltw crdlnary and lltrllrdlnary 11111111 ti It II -ta ti ta thllll 1111 dlsltnctlmll bltW dlrlct and tldrlct rl ....... bit ... y ........... y ............ not 1DJattt1 llllllr sutctdl er ..-o, ldlltng, but ta-thlt m 11:11 Ulll 1PP111 to flll llldr U. prahtbtttan fl U. ttlltng-111 lnnaca11t PII SIi ( whim rulls aut bath autcldl and 1D1raf ttllfng) re In fact CIMll'ld bV u... EUU.mll, 11m stmd m action er an allltan whteh fl Itself er bV ~lan--dllUI, In ardr thlt all suffering-, 1n this.., be 1H1111nltld, ts tntrtnllcllly wranga the direct ttlllngfl III ln.mnl Pll 1111 (SlcredQlngllglttan, 1980). -34 -, n ~' ,. ., 'j[ PAGE 41 i .') :' .. I ,J j .,/ '-J: .!. Alang wttll autctdl It II wrang ..... fl Its lntlnttllll and methadl. A ._. math In the CIUIDllc canflllt fl Uu a u.t lntantlan and methadl ii In ecmrd with the divtne wm .... 1111 f In a:r1ptn 1111 In 1111 nlbnl law. Fr IIIGlt peapll It wtll bl I math thlt Is hi llllllfllll ti Plln 11111 urr1na. art r1 acttvl tmtna; 11aMMr. rar 11111 people whD .... ,,_._, In __,.wttll Cllrtlr1.,,,..lngl. It-, lrwllvlmlaul .-...:ttan Pll'*llln. It llnat dllllll ff It IIMMll ldlllng, wllllUIII !Ir Glllllllf or bV atllrsi auch ttlllng --. IIICl'tll sin. EYIII thaurJI Cllthol1cllll Is mare dMnl thin ft WII Vallall 11, It Is still mare llltfarm, ll 1llllt In 111 afflctll tlll:lllngl, 1111n ettllr Judltlll ar Pralllltlntllln. It II rarely On U.wllDII, Pratlltlnts find_, Im, mare lldvtulllttc 1P11N111:11 tDdl:tllanl lbaut lffl nl dllllll tllln lltllr CIIIIIIIICI er Jllf& Evan Prallltlnll wllD --rulll .._. fram artptwe(NMIIIIII lllrlltty) nafllll111Plctallfltlll tlndrl dltltlldcautstry tlllt u.r In CIUIDltcm cr\UIIIIII. -Pralllltalll rar tlllt .,..._ cautstry paapll-, b111M tllll U.,am Mldaln 1111 blllllllrtc,dlaul lllltlllltfl r-..tztng tllll -are tnwltlblV llnful 111d IINlll aapt 8ad'1 ,.._..... (Juatfflalttan 1rt' flltll). HID, wttll uh mapttn Paul Ranay( 1970i 1971), Fralllllran 1111 Hatv fDdlwelap lhlsrts"dltllled dllltnalllllltllltlPPIII lnCIUIDltcm IIIIJallm Alal dlnlautcldl, ... Prallltln1acallllll Ulll It II wrong ..... It vtolltll btbllcll ru tlllt .... tbtt ttlllngt.,... (ag., ICrl llr1II n1 Dlllrldl ....,,_.) bald thlt tt II wrang bltllllll It dllpl9jl I llct fl trust In llld flltllfu.,_ d 8ad. HawMr, In g11111r1I, Prdlltlntl n lal llDIV to lnltl 1111 pralltblttan fl sutcldl llmlute tllln are Jaws and CIUIDltcs. ffl' SIii Prallltlnts It_... s ta be prime flc1e ratllr Ulan abmlutely wrong, Its .... wr11111111 -dng CII vriaul ctrc&lllltln:ls. Far IXIIIIPII, ref11cttng the dlbltl about 35 - PAGE 42 ' t) ..... ,: .... _, ._/ ,_" ) ':t ,:..__; tlll Yin Duin' joint IUtcldl (111CIII), a patara1 llttr ti the PNJIIIVtlrY fl Nlw Ycrt CftV In 1976 cancludld that ~It Is clllr tlllt fer aame artsttens, as a lest resrt In the gravest fl altult1arll, llltcldl-, 111111 ICt fl tllllr artst11n mnactence C Battin 1111 rw,,,, 1980 ). Twafl tlll lllGll tnflullnttel 1111 anHftc Prallltlnt wrttn tn btmnldlcll lllla re ~Flltdw(1954; 1967; 1979)111dPaulRllllal'/(1970, 1978). Flltdlrdlf .. both lutcldlllll ICtMllltllllmtl, but,...., rejects bath fl tblm while ~tng I will rengl tr"llllnlnt ,..,._II lllllttld bV tlll ttndl fl cmlltdlrattans that appar tn thl lltholtc mctr1~ ti mubll lfflct and fl'dtnry/ 1111' dlnary 111t11111 fl trllbllnt In llts erlllr writings Fletchlr blllllbllwgllllllltrlUtctdllllda:tlvl....._an ..... mandlladwhtchactknl ,......, .... para& In 1111 lltr wrlttngllllblllll 1111.,.....m uttlltrtanllnl llldllkld wtdcll ICltalllwald ... talUMn Wllftn. !ipllctt U.laglcll ..,.._ pl(anly 1 lllllllt rall In his 1lbr wrt. wtdcll lllD ..,.._ rttrta fl ttv ft ltfellitlll ta 1lrma By aantrlll, Paul Alllllt" rulll aut balh IUtcldl 11111111NV lctl1tng-tllaufi hi lPlm S 1DrlalJIIZl-mapttanil bardrH111C11111. P.llmllvlfflnnsartatn 1111111111 tlllra._. ti llfl-MtllnlnD ti 1111n11nt IP/ PDrewd ...-. 1111 tnd1Urs wtn aa nat "'-9 trtumrm, 1111 r11111ttc idlrvlntklnln -11111JU1ttflld ta Pl atlCt 1111 pettanrs bllt tntll esta. In ....... IINIUt ,..,...,, p1H1nfl, R111111r Will II 111 JID)iwnts .tbclUt qualtty Hfe; ftr 11111 Wllll II llllpm tint In tlllardlrlryllllr dlllll '/ dlltlnctllll C111 Ill-....... llmcllt wtthlllt tflallt r .. tndr ta I lllldlcll lndtlttans polk:(' CRlnlllv. 1978, p. SS). Tim, 1D dllll 111nll wlltcb tr-t II abllgllary and which apttanll far lnmnpetent pllilntl, It II IUfflctlnt tu dltlr'natne which 1rlllmlnt ts lllldlclllly lndlCltld end which la not. Far the ikia1 pattlnt, 1111 relMnt ChDtc8s n bltw Rrthr pel11atl'II treatments and no ti -eatments. far wmmmctaus er tnmn-mt mmdna pet11nts, regrd1ess ti their cpsllty fl ltfe, thn ts an allltgaltan ta UII the trlltmlnt thll II lllldlcllly tndlcltld. Almllv' ,_ Is that WI are slldlng 36 - PAGE 43 -~-........ .. .... ~ ......... ..................... ... .. ,,.. ,, ................................ ,,. ........ ........ .... .... ........... -...... ....... ... _._,.,,.........,_.,,.._ ... ...,.._ ....... ......... ,,, -....................... ... ........ ,. pattn& Agalnlt uh palky, Ill 1111rm111 mtnflhldabHgatlan nrst fl an to SM ure ... II Ullmnl lnlblnel, ta U11 pallllltw tlllbnlntlwbn ., ... (1978, p. 165). Nae 111,111,.._.,,,.11bt:ac:-JvaJ-.....blclltlwfvtolaU.prtnctpllctmUbt,_ 11111111 IIVII, chMI rr. 8rlt1Crtlilan fl lulNln bltflll In bte IIIIIQI and his lndllcrtmlMII .,.farlll ,,.._.. Pratastlnt tftlolagtln, Ar1b1r Dyck ( 1977) rejects IUthlnllll an the~ u.t lllftY ar ktlDIIII tnctudll batb nit lllmtna Ct111tng) and blnlfltttna au.rs and tlllt nat lllrlltng1lal prtarttvovr bnfttttngalbn. Agatnat.,...... rcr blnlf1clnt IIIUlllllltl IPt' lllalllllnlntlltlrinb111at'llrtn1Cabl( .... >,l>t1*111qn111mllblctJI ............. wlltcll wauld lltlllll tbl follalltng tnllfl an tD patllntl wballdlllb II llllllnlnt relWrl peln llldlUffrtna, NIIPICl ftr U. rtdlt to rlfUll trllllnlnt, and pnw,tam fl 11111111 an wttllaut ngard far lbtltty ta Plfl. Same wauld .... ,.,. .,.,., tllll dllUI II nal elweys I mt ,.,. Mn tf It 11.-. ,.,. 11111 tlllt ttlltng Mf ... lllrCV 11'11 ttld1111 tn prttculr ctralnltlncll, IIUt wciu.. llllalblrs flnd.,...._agatlllt euthnlltlmwtnctng If th& nlllllll In Wllllfl adll-111stlcl ralblr tlllll lCll tlllt are alwls wrang. Stlll a1br Pratlltlnta faa.11 CII thl ctslCllr II IIJIIMI and rajlCt baUI IUtctdl and......._ bala ti wllll U.,---1111 nl 11111 lbaut IIJIIMI, ettlllr lldtdulllcr cmn1nmttlll (Hurwal, 1911). llfcn tntno to au.r rellQlaul and m,lr paalttans, tt lhauld a. rmd thll while llatctdl 1tg11 Illy prahtbttau,,111 tlnlllllJar strwldlrlU.JudllD-Ortsttan tradlttan, tbltr 111111 entt 11M different ntm autcldl. At 1ellt stnm E. Dcrkhltms ( 1897; ET 1961) ,__ llllt/-lUtckll In U. 1ltl ntnatllntb mntury It 1111 been obalrYed that e11 the whale Prallltlntl tllMI I ht;.r rate ti sutcfda thin Cltholk:s, who In llrn hM a.htpr rate of IUtctdl Um JeW& Tbll pattern 11111 holds ( f1111r, 1979), Its p1ntlan ts camp la since It I 37 - PAGE 44 ._ nal m lithlr U. prabtbtttan rl aufctdl er IIIIClfanl 1g11inst sutckll ( ag., 1 martal sin) but ralllr, Dlrthllll argued, an the.__ of tnteratim fl lndlYiulls Into the -tty. Praflltlntla tlndl tD Ill mare tndlvtcllll11ttc tllln either Clthollc1sm er Jumtlm. laullDrillltnl fGCUlldan tlll---tntnttytllll:III ~Ian. hlpetd lalSattanttan ti tlll tldYtlUlra..,.ltmlnt to WIii a thlcmnttnt fl NI ... LWWs; 911111 rant atudlll 111111_,lrlllltan ti bllllllllml tndlnblll wllD lllllre ID 111111 reltglaul trdt&nt (lllltdlllll, 1976). Olllr-(~ .. 1982) --tlllt reltglaul bllWS-, structure tllljulttftclltanl tbll ,..1ew111a111111tt s111ctd1afftr In thllr nalll ta antwrs, prttcu.llrlV tn ardr ID ralvl u. a,abtlttttan d11Utcldl 111d -~ 1111.-tbntty fl IIIPPV lftrltf& a..~ ..................... 1tt ...... ,..1c1ra ..... ~. 111111111-,Prafllllla,IIIIUIIIIWlcl, ilUl _llm....,.talllrollf'IIIV.,11 per1r1III fun, tnchdntlllllnlllllllfltlllreltglmtlll(Nlnllrlllllrulb, 1911)). It ......... blUllful .. bMllldlltflwrtltlanl In rlfulll fl 1111-IUllltntng trllllllld a11111 tbllllllrlllfl thllltrllll'.lan& 111m tlll prlnDlplll...._ In thlll ; 1, trlllttanl IPPIV -~. WIii to petllllll, It II ... pmdle .... thllr apact e11111 ..._, practtca In lstultf tblt W11 anll:tld 1n 1970-71 bllarl 111111 mejar ,' fl .. 1! -r '' ~ 1.'' ) '-..( "'%: .._ hldllllfflll tn publlc pallctll lawll d U.wfll*-1 rl Hfe-lUllllnlng lrllbnlnt, DtllllCra ( 1978) ftlnl tllll llllnl Pratlltlnt pbyllcln wn tlll llllt lncltnld ta be ICUYtlll, L&, to llldl .. ,.__,_ta prolallg pat1lntl' IIWI, WIIIIIJawswn the mast tncllnldtl lllaattvlll& SIii lllnl tllll tlllll tlllllln:III ISslltldW anang Pll'111whD r tdlldlftllll 111111 tndlltanl but w11D WI nat Yfl'Y reltgtau& TIit mJr tnlfflkm" 1tbrtlrten11nt and hllnlntam reject u. thltsttc cantat t111t llrucbnl IIIUCh ti tllltrglllllnt lfJltlllt IUtcldl and 1111rcy k1111ng and far CIMltn 11lawed dllUII tn Jew1lb anrn21rtsttan reltgtans, and they tlnd ta reject the kinds of dlsl1ncltans that M1vld tn thGII relfglaus tradltianl to expr111 VII ltmtts of the abligllltan ta pro1ang Hf& Thi 38 - PAGE 45 (. ,, !'. .,. -11, ., '1. :. ', 'l \ ,!' ,.~ ...... ,_., ... 1 c .... 11 -1tflllll1111-dlllllw.t111XP1 U.. bvm1D ,p1lttill 1Jlll thiee91CU1ar tradtttans --In pII, 11111rt1r .. reaveanl.rllPICl a praan's autanamaus choices la,g nat IWII allln; tball cllDlall M/ llglt1nlltl1V tnclUdl sutctdl 111d mercy k1111ng wtt11l'lfulllllciltfl----tr~ L ..... .., ...... flr 11tmtnaUna tlll llgll-prdltlltttanl_tll ...... lldctdl (Enga1tllrtl, 1911; Englllllrdl llllt11111y, 1912).. Rtddllltlal IDIIII .... who NV..-ci U. e UW,chlml lalig thlym nat Ylllllltlllr-au.per .... Hulllntsta tlnd ta tncludl but mav nat rely camplltlly an 1111 I liberty and lllfrlany a ltlNrtlrtlnl. Wllll'm ltbrtrllnlvflW rllPICl far..,...,. chDICIII (1111rty) U.IV ..,..a1111g111111, llulllnlltaaftln ,_..1at.,.._ar mercy aDltgltlan, nal IIIIV ..... -""ICttan. ., .. ...., ... l1lrY1n Kahl ( I t74i 1977), I lunlnlll pbllalapbr ,.,,.. tllll blnlflcllltlldtllllll1e(petnla 1 .......... rlqutct ,_lttng In blnlflt far U. ractpllnt) 111 prta 11:11 abltgattan IIICII tndlYtcblll and IIIDllttll ._, prllll flDllabllgllttan II trlllt peaple ttnlV 1111 blew blnlftcllnt ......... ts ttnd. llnlflClnt euthllta ts nat llaftld 1D CIIII tlllt Involve a pattenrs rlQUllt far er m11111t ta ........ tbl lmllffllllDrl dllUI, 1111 tbl Pl HIJQ '1 pain. The pattenrs quality ti life is I ............ 1111y tball w11o .... uttlttrlln ethlcll --lltarll, ffllft' .,. wttll ICalll Car Mn lllllrtlr~ aum Engalblnl) aut prttcullr m. reject adl _. 11,,cuce" sutctdlar mercy tmtng, Mn ta bnnt and ID reapect patients who J.1 II I J. wtll bl wars1 If IDCflly ....,11 ..... IU1ctdl ..Ur ffllrGV t111tng thin If It melntll111 tta rvl8 egatnst Um. Such an ....- the ltDlrtlrlln and IUnlnlst caldlratlanl In a brOldlr m:tel setting with prttcullr lltlntm to u. s fl abllll and of the slippery slope < Beauchllmp and Cldllhll, 1983). 39 - PAGE 46 ::., 11na1.....-1P1reltglaultbtnknnnatnec1111rtlyrelfglaulllwypotnt, -reltglaul thllara 1111,,..._-11111e flwham mlfll bl dllcrtbed re11gtaus lnln11111t1".._ NCDIJlta tlllvaltdltyaf tllls srt af .,.....t llJllnst a rule permitting llllllaulcldlnlCllvlllltlllllllll, lflllr In llllltlan 1Dar In plaflflcalJv religbll .....-., lndllllt, iucb 111111r ~naftln Ulld In plcnlllttcaacllly, whltw ..... ,.... .,.._,, ... ,..aapparttngrulll_.lllldmtcldlntaattw llltllllllltl, IUab mnvtcttans about tlll lntrtnstc rl 1111 sll tn tan. It ts rn1V ,-a,111D argue dlncllV fnln mwtcttan tbll III act ts a stn ( t.e., .. aff1n11 to Gad) to I ,_._llllltllll Ir I prdllbtttvl poltcy. ~. .. !l ") ,... ... l __ i ., ._: ) l_., lalalllll-Nllglaul trldlttamn nala IIIIPIIMlftl ....-ally In 1111 UM 1111 GIIII ........ .. 1 ...._. ..... ._... 11111111-prt---Onltltllllll 11 ..... wlddl 1111 _,, lfflldttll wttll J11111111 CJrllttlnltV, llllrtna In~~ thlcrm,ttan rl lrtnalmnt, 11:lM, wtlltngdldty, Wbllll wtn IIUll III fl11lwlrl Wflll JudNn 1111 Cllrtlttlntty, 1111 ICnn .. thll it II nat glvln ta-, ..,1 IDdll, IM IPf U. 1-1 ti ctll, ll ....... Ulll.(qualldlnSllflbllllPerltn, 1971). Tbllgnralprtnclp!9hll111PPC111dl pralltbtttan llJllftll lUtcldl, 11111111 tndttlll tllll the Prapblt Mubmnalld rlfUlld tatuy 1 1111 1111 who 111d cmmtttld IUtctdL Thtl prtnclpll 111D suppartl I prab1btttan al IIIIN:f ttlltng. lal allllllllfltarl bald tllll ft ti ,...111111 fl all'dlr 11 Jlldm the dlllll ft I paltlnt MIi wlllll 111.,...frall .... le ...... (Alall-Rlllf, 1978), IIUtstaU.VIIIDrafl1Zlthlt tt ti ........... MIi abl1gltary to relllwl It 11natclllr ........ hM111rtnctple ...... tDmublllfflGL AJUlau"911111'1 ...... aut 1111 prapar fntlrprlllltan ti u.111-tc tndlttan, a11 Mu11t111 hold thll ,,. rttflclll pro1anglttan of 1111 lffe of I terminal patient wllD 1111 Pll'Mlllll)V 1ml CDIIClaulnlll II mareny llljust1ftabll (AIDJ~-Rauf, 1978 ). M wttb Jlnll and artsttan apprGIClm, u. m about a pd er appraprfltl math focuses an tlll dlvtnlwfll a IXPI 1111d tn cammadlllllts and prwtdlnt111 acttcnL 40 - PAGE 47 .:. '~ ; f\ .: ,....; .J \_' _. -..:. Gftln lltllntlrprelld and dlltartld IPf Wtatarn thtnkart putting little val111 an ltfe tn 11111 warld, 1111 Ellllrn reltgtaus trldltln hM camp la attftudls tawtrd 9Uicldlt. Early lndlan NI-trlllltaRI Gllllllld lUtcldl, but 1ltr Htrdl1mn nut Cll)V penntttld but MIi CDIIMldld tllllllralcartftcafltllllll)V Pll'D(IIII_,.), UIUIIIVIP/ 1111111, sur:II cllllh W IIDIUc rlfulll IDlll, l1IUllr 1111111 IPi a:ltYI ... (Smttb 111d PrHn, 1971). SUtctdl 11V I wtdlw (lllltll) .. ...._ In lndl& ElrlV lndlln Bldlltlll prahibffllllUtcldl, but 1ltr ........ r1C11111211J 1111 llntc l'lilllCllt1anGf 1tf1 tllraufl IJIIIM lllllliL It 11 fltr ta-, 1lllt -Sldlltlll cllll nal flV prab1btt sutcldl, but ICID ding to lldlltsl sar:red tats lldaldl11wtng1. tr a.,r-,ttngtDIUtcldlannataveaftllllfhn thlatlnbll llllldlttlnlf-lldllll(cr 1rm.,.uan>: urM(ICltllll) _.....,.... ar11P11VIPll'D-IIIIG1111flldlUll:ldlM111ftmrldldllUl(Nlltaln, 1971). In lllllrll, fer baUI Hlnlllllll 11111 ludllla, VII lltttudll--tn ICltan and 111111:ltan and tllllr trfflCII rtblrtb lfll ulttlllll N11111 ll'lcrtttmnv 1llpartlnt tn tlllcanmpttan ti a pd dllllL Tlllllttludl tau.ant .... Ing NIIIIII-11111n tufflrtng ttlllf 11 CllllrlL (bll far ti IUll:ldltar llanar 11mwm111111 llllllparttcullrlV 1n.-, wlllfrlhlrlktrt ar IIIPPUkll hll lllln dlllln Ml' .............. ....... blln wrtl1ln lbaut Hkdl 1111 ...._ alt1tudll tawtrc1...,,, t1n1ng, 11111ttttu1111111nrc1 Nfull1 "ltfHultllntnt trllllllnt ftllt11 tn Mluttan tllllll trldlttanl Cll"lfrant 1111 w prabllml GCCllilllll IPI ----In an:lullan, 11111n rellglaul trldltfanl tn tbl 111111 ta GPINIII direct ttntna, wllllhlr tnlUtcldlaractlvl .......... Hanvr, tt.f rlCIIIJIIZlmaapttane(aften not mllldll tdautcldll) enddlltingutlll lUll:ldl and actlvl-. fr trlltmlnt refUllls er WIid'_., whldl n 1CD1Ptlbll In ..,, ctrallllllnl:II. In an,11, u.e reltgtu trllllttanl, aftln Joined by lunlnlsts wen, dlfn the 1IQl1 prabtbtttan rl lslld sutckll end llttwlldblnllll balfl U.tr warrlll lbaut U. negattw .......permitting them, 41 - PAGE 48 "i?I, -,1. i j o !1: -I~ {'' ',.) :_' "j 0 but U., IIIDauppart 11n tlllt Ila Glnpltant tndlYIMls to rtfull Hfe-sustetnlng tratments Ir....._ 111d far tnmnpetent plltents, Wldr w ctrcunstnas ( they frequently ..... lllaut t111111111.-.. c1rct1n1111m). Tlwf U..11:cipt a llQII r._. tadllllll ta let dll, 11ut UIUlltv ..-1 1lall rldlt to tm n to bl tlllld. .._.., stc,atflclnt 111tnartty \1111a tn 1111 reltglaul trllltlanl 1111 ....,. ... tnllll lunlnlltlc trllllttane IUPPGM IID ......... tufctdl ... acttvellltlllllllllandmlll thlt prntlt u... Thell ..... 111 be dllll 111d 1n nn dltlll tn T 4, Whtdl racu111 an preyetllng arapts rl latld dllUI. But wtlll I trldlttan .-lbaut auictdlcr refUIII fl lrlltmlnt fram tlll llln$alnt fl lltlllr 1111 lldvtMl ar pullltc PDltcv-, nat lllllbll CD111 ta predict lfff tndlYtMl's IDllmllf'lllldllllsulcldlcrNlfulll-fnlltawll rm..,,a1111rrac11n,lldlat111 n 1111111111, DIMlculrlV fl llll' 1111 lttttlldll tn 11111 tndltlanl 1111 fl m r.-.S bllwa Nltglaul IIIIW.1111 practlall, an 1111 bind, 111111:11 fl IUlcldlllld nfullll fl 11,._Mtllntng tr .... lll,e11tlilalllr. lnlddlttan, lbdllnllllllllllfltlll lllparlreltglaulllllW.1111 praatlall m fatllll 111d prafl11lalllll WIID IIIUlt dlctdl wllllhr tawttNIDldcr wtthnw lttll-ulllalnD 11 .... 11 tn1111.....-1t,att11111.. In ffff stultf, tt 11 tlftt tocnldll trldlttn Y1lwld 1111 IMld bV tbltr pnattttann. Fr ... pll, In IIIIPf pullllcdlmllltarll l ....... tng trlllllllntl In Ramin Clhlllcllm, whtcb II wtdlly vlewld pro-Hf& lut tllll llttta fllll wttbln tlll """" --al1Md lri tb1Cllllp-11s thlt hM .... dlNllapad In tll11 trdtlan mt thlt wwedllcil111, lblrM. -42 :" PAGE 49 ' -~ J ; .... ~-.... -.. ') ... ~-' V ._' / i (-;_,.,: .,. .. 60 lllloldr repr 111nt I a.s PII mat ti 11111a11m w papullttan, but cammtt 210 Dllalll ti 111 IUll:tdll ( '1111111', 1979, p. I). Dlllptll such stallmlllll, tlln n er dlfflaulUII tn cMllnfnl .... llld hllplal lllllltlcl aut VII tncldllm ti lllictdl--and 111D fl Nlfulll ti llfl.... 111 ta 111111nt--111G1111 tlll papullttan at Jarga and IIPll:1ellv emana the lldrlV. CN 1111rc1 fl dltnculty tlllt II mnunali to 111 IIJI t'QUPI 11 cancaptull: exstly whtch a:llauat ststl IU1ctdl? M w lw, dlftnlttans fl 9Utctdl tlnd to 1ncludl 1111 aaant's : lnlllllan-wltll tlllnabnllllctru11tll-fl UIIICl Sinai IUlctdl II nat a ttmylllllnl ............. wllllGllllllIDlfllldcldlwr hi tlllarytattmy ... ....,.,.,. tDvifult..a;,11112 A1111111t1;a,......aawr111111tcrlldlreparttng IUICtdll,tltllr( 1979) ldlntfflllfmr ....... wv .... tlllt: ( 1) nat wenttngtolltpatla arvtvan, (2) ll1Ntng11r1M1"1 toCIIIICI rgr ltfl lnllnnclllllllflll; (3) nat bltng_,. fl UlldlClllltr, fntlntlant...,.. t111 t1Vcr frllllll..,,,_cr hldautctdl nalll; ( 4) Ult ..._fl ... car11 1 tlarttff adllllllautctdlan1Vwbln ,,..11111111111 fClnl (dllptte r1111rdl ftndln1II 1llll llllll lldcldllm nat 1-11111111). TIii 1111'11 appr*illl r-.. tllllcltllgll tolldcldl tn IIIGll Cllllllllll1t1I tn part ... tutcldllPPlll'11Dlllmaatfl._ lanlllalllrlar al ...t to9VlifVtlllflll1n ff alllll'a- llllltDtwldlfl'lrlllllfl'crll 11-Ullll 1111-ClllllittldlUtcldl. Ftrst, tlln 11a.lfflrt ta-tllll 1111-Wll r......,11 far htlCI' hr ICII; 1f 1111-W11 nat ......., cldnat llldntlndwtlll Iller 1111wa-. ar did nat lCl volllltrtlv, i.ar nwa llllr11P11llllllt,tndlalw lllldltlllaatr11111ttngfndllllll r11111blll IUtcldl, tt wnat flnlllV gl I( Wdcfdl TIits 1ntlrprltattan ........ tn reltgtaus mnm111tttes thlt apllW wtth Wm bllwllll maral and palllrel r11PG11111 to 9Utctdl, lfflrmtng mcranv tlllt 9Utctdl ts 43 - PAGE 50 ; (\ :\ f,A,- :, wrangllllaftln lfflrnltng plllara11y tllll thl llJllll WII nat r11panstble fer llillhlr IC\1 n thus did nat Clllfflit IUlcldl, I bl m IIP( act. Tlda tntlrprlllltml 11 suppartad tn prt by thl cama~ Pl',1:lltllrtc Yllw fl llltcldl 1111 ralt fl llllntll 111na. One t11pl1clltan ti Ul1s 11111'11111:11 II 11-tllll 11111Pll wlllattapt llltcldln ICltng rat--1,V. 1111 ftrlt lffart lllla: Hille lffll:tl an 1111 ...-., fl IUlctdl ltal11ttm, 1111 .... lffart 111111 ... tmpd llllt,'sl)V ..... tllllr reltlbtltty. It Midi 1111 llrll tllll ,...1t fnlll 1111111111 ti lUlcldl 1rt nat alllltng dlubtful c:1111 a ICII ti IUtctdl. far ....... -Clllllrilll 1ncludl ........ llltcldl In Ulllr slll1lt1cl, wldll aibars 11st ub ; -1111r1111ru1rt1:,._tldlllll1N1111111(1raau, 1974). Qr11dlfflrc,11tlyan 1111 amlllflwldlaNqlllrt11vw fl llllcldl;tr ...,11,allllllltanld -.-...... -... ---nall, Wlltcllllll11ta11VIPlllll' 1nilll 1lalll1ftitllldllUIIClfflllll1yClllllllltulcldllllldM11 llllfr1111a11t1VlnlUll:ldll11Vtlll lldlr.,. lnaulltful e1111. ft 11aftlll 1111111' 11111111 traulaltngtoauat U.dllUI :1111111t,,...ttmllltcldl.llll',llulllllldllllalllll..,,....n.aldlinll ..,..., IWUltlll frCII 1111 .tntanttan todllar to 1* ar CNlll I htdl r1* ti dllUI. ..... IUll:ldl 11 gllllll'lllV WIii lmdl P, rlUlr 1111n a I rt (t11111r, 1979,p. 11), ttm:ludlllull...,lcllananrmplfllawttb1~crdrl ...,., tlll 1111-lllldlClltalll er dllrtdll lllllllcll trllllnmt, whtdl may bl 11:ts ti sm ---....... llan l,f allpatlnt paapllwttll 111111 --111d vohlltrtlllll. 8anle ll:IIMII ea111111Pl1anfl llanl1 er *IIJlbllll.,, blllltcldll actswttllaut being ll:lltlllllakll(llug1, 197&). lalIClltl sutcldln1111Vv11wadICltYI rllhrtlm pa1tve--MIi thaufl thn n cllr maptialll--1a1111 Nlf11111s ti lffl-sustatntng 1l'lllmlnt, prttcullrly wtlln dllUl 11 tmm1nlnt, wauld nat bl muntld sutctm. Unfartulllllly, tblre n nat, ta 111V tnawledgl,.,, pd stlttsttca m refullla rt 11fe-sustatntng trllllln.nt, dlslt....,.. fram sutctdl. EYIII tJlaudl It 11 not difficult maptually to 44 _.tJ - PAGE 51 ') j--' ., .J ;' j t) .!. dllltnaullblUlcldlfrlll IClMlllllllnldl blcllU. flnll IIJlllll:f 1ldlffnnt, tt ts mare dlfflall todllttngutlll IUlcldl fl'III l'lfulll ti trllbnent tn 111 lldl:ldl,_r,11., ftalllVtllleldrlV.,.._ Ewn thGulll tllrtn ,... .... wttll lllttlttal, tllllllltlltl 1rt clllr 1111 Cll'llln IIIGUllt ti llllbltlh ... fl tllllr an lfllfflltala Al,_..., lldrlV piap1I wllD Clllltllft IU1cldl find nat to Clllllllllliclll llllr 1nalttml 1n IIMIICI ti' 1a 11M nalll; 1n lllllttan, U., tand ta bl tlftl llful (tttlllr, 1979). Dllptfl tllllr llllfflttanl, tllllVllllbll ltattat1cl mav bl Ullful, If llltlrPI 11111 ttll lfultflllllllllllauliv. ln ...... ~Nllllla 1111~1111,lllltlllrlllfllldcldlll .._ lrlldlrlV Alllrlal 1111ft Ir fllfalllr 111.-.. <.--, 11111r, 1979; a.11111, 1980). lttltmpartantlDnalltlllttlllntlfllldcldlaltapllllllllla.lldlrt,ta ,_.IV Ill- 1111ra11--.)1111111r .,.... taut tllll tllllldlrlV__,ll h_. NII (Ill ... 1977, p. 26): thllr atllllpt ....... llttan ratio II twa ID, wlllll U. ritto ts tllrfnlllllltdlllll rllllr .... tlCDllllllllalllwttllllltcantrol ..... WlllnlUlcldlratllpr 100,ooon-fnldlPffM-yw.,...frlll 1933-1968111111972(Applldla), llltna 1 tneutildlNltllapeapll..-oldr llcler. Thllla 1111 llnat tdlllyw, -. Ill _1961, lr_,II, brllllll 1111'1111 ta1g1SS-St,1dlell111thraul#I 7S,llld ..._ lla1111 Mr7S. for11111t,it111yarsGM1lll1Pftblllltlllltts, tlllllldllSlsutctdl NII II fGllld In tbll'GUP 7S and Mr. Fer tllall wr 65, 1111 sutcldl nll 1111 UIUllly been at 1llllt twllll llllllllmll Uni ttmll tbl lllllanll Ml far 111-9'111111 < Shrmln, 1980). (FarftrtblrbrlltlbmllVlrJl,Appllldlla) In 197S,rltbe27,063sutctdls ca ltflld lCl'Clll tbl UM, paaple 60 and o1dr mnmfttld 6,228 fl tllllll ( Mtlllr, 1979). 45 - PAGE 52 ~. n -'. t' ". ,./ V ,.,'' j a"'' ltllMr. In v1III ti llll trmnp1*nns "1111 stattsttcs and 1111 prablb11 llldrreparttng ti lllllr llllllllll lllll 10,000 (M1111r 1979) ... .... tnndllllau1d bl natlll ftrll. thlllllcldlrlllaang OIDP11Mr 65 Wf'IIIIIIIVfnll 19&0111970;ttllll1Mllldallcrdl:llnldlltdd1Vltra 1970. Tlllll'I lldllllllaul U.mu11tl tbtldllDllnl, prttculrlV ...... t111lldcldl,.. amang yamgr paap1lta1111dll 1111-UM AltllalOI llllll~ 1mnt1fy..-el _.,IICIIIIII "'*',..,,VII tllll 1111 prcntan fl tna 1111d mr:111 ....-t rtdd ts 1 _. fll:llr tn tlllclll:Jfnltl llllcldllllNIIIUII nlr)V (Ntlllr, 1979, P1L 2-3; ....... ING). land.bn1 arltlll ...... _,1111 tnllll ...... tlnlrlVINl' ... ,tlllrlta .... .. _1n_ ...... ., ..... 1VIWfcldll .............. 1nt111rlllP11' 100,000 lllllrlVIIII ... Tldrd.tlll1111'--cllldcldllwttlltnt1111atl11111blrtldllllllfar1anrt dia Jllll wttlllgl. EWlnU....U.lldcldlrllll1nlrllllwttblgl, tllldllltlrlllll,f 111CIIUIII 1111 ..... 11;; .... lldl:ldllCllllllflulle 1lrgll-.. ,.. uan ~1111111111 IUlblr ti dllUII far VII Y111111 U. tr tlllllllrtf (1-*llr. 1979). 1tt:111r'ala.a.ttc111111Ult111~1V.,..,t111flglrlltot1111ntausJv atllldngbllalllfJl&yfltltodllttngutlllncraupa1111111t11111dr1V. Ofprtta,1r lllpm IINlnthldlfflrlllllll ............ ,.. Thi lddl lldcldl l'IIIIIIINllllthlldrlV llrlllV llllllrtllulldlDwhtlllllla le Mflllr ( 1979) 1111111, -U 11Cll1Valllwllffl fflllll tllllll ...... ,. 11~ ..,..._ tlll ltflo,dl. Tblllltcldl '* far oldr wllffl 1111111 lllllllall far ttlnll ....... tlllll U. w 1111111 1 wllDII (Ntlllr, 1979). In gnn1, 11111111 lllllnpt IIGl'I IUfctdll, .... mnplltl mcn sutctdlL Thta gap tna HIH st,lfflcant)V IIINIIII 1111 eldlr)V: ,_. .,. 65-69, mnpletl fmr ta tNfX'Y ane far femalel; bV aga 85. 1111 f1'n ti twelYe 1D 1111 ('11111r, 1979, p. 3). Tll1I dlffll m bllweln e1dr1V melt 1111 -46 - PAGE 53 .. :.:, .' 'l ~, ... ~.' V ,_ .J :;j ~-' 1111 Ill lulcldll 1111 blln attrW to IMrll fackn, tnclldng 1111 parCIIYld dlclfnl In male ............. ..._ reltrlmlnt, 111 ... lall, c, but thll'I ta IIJCGl-lll.llabaut lllllflcllr& Wldllnan-wbfllllltctdlrllllnrcadltv-' totllllllflwb1111 lllltl o 35--1111-, MIi 111 .._ fer AIIIMcln lndllnl llld bllCts fNII IIJII IS-29 (t1H1r, 1979, pp. 4-S)-_.. 111 llllflntlll 11P lftll' Ullt paint (8111111111, I 980, p. 31 ). Same thlarlstslltributl tldldlffll a ti 1111.,..., ffllll1Yl Ylttan fl w, pawr, and tnnuenceexprterad bV .................. retll.Wlllftt,&,slnclblashlvlaprflladrlltlr .,, -lvlttanlll...,.. Ulllr IIVI& Tbn 11awevtdllatllll bias In tllllBMII ....................... lldr(lul1rllllllwtl, l973eNtllr, 8979). laullfltbl .. lfllllttad dlfflr bll\e1111IUtcldll 1P1wll ...... aaws. fflGlt .......... -...... Wllll n tlll Min cllrlCllrllttm fl lldr)v llllctdld In prtlculr, cit ffff CMrlDllrllUal NfllDt flDtal 111111 nllml9tftalnt In Nlfulll fl Hfe-lUltltntng tnllmlnt, MIi '*'*81111 ... 11111111r ttvt11tfe? first, lldrly aulcldll tllltnrll:Dfltad Mb tllll ID bl a11111tt1111 IP/ ICltvl and Ylllllt -tlllt IUPIJGrt cletms fl fntlntlanll lllhlwtar; typlcll ICla n lhaattng, JIIIIPlnl, hinging, and tNllffling ( 111111r, 1979, p. 18). lutctdl.,, ..... 111111 llllt OIIIIIIGft. aand, tlllrl tldlllllllllaut thlwhlllllr llllldll and/er p11ystc1111111111 ts an llltadlnt ...... flctr In lldrlV IUtcldlL --- tndlcltld trltr, -Ulll 111111111 lllnlll 111 prtlllry ,. tn 1111nV tldrlV IUtctdll ( Balchllar, 1957 i t1t11r, 1979, p. 31; Rablnl, 1911). Yet thn n ._ 11111 llld vlpaul dlbllll ebaut the wtng and crftlrll fl lllfttll 111,... If a PIii 111, II llllldll)V 111, It II UIUll)y amldlred 1PP1 aprtete \o lntlrVII ta-Ille altlmptld sutctdl; tf I peraan ts nat lllllltally 111 ( and llltsftes athlr -47 - PAGE 54 ., ., J ,,, I, anllttll), It-, 111 .... dlfflallt ta jlllltfv tnllrventlan ta wlllt mtdlt bl mnstdred a ~:--., Nltallll lUll:ldl bV Cllllpellnl ,..a eattng wttb wen111 and valuntartl'IIIII. Ptr,llalltnlllllllaftlnMe11fflld;WtnlUtcldl;wtlllhlrtt111GlllllWts _..cllfflcultfldltll'lnl--1.& ...... IIIIPll'Dalllmfflldllltcldlblallllfltlllphystcal 111Bl(lr .... 1nw111c11 ""'*'1111IIIIIIPPll'lnl1V p ..... roll, C..). TIii--llllll lllllllll'tad: ,-.,i thl tnftrmtntl felt thll 111,_ hid papartlllt l'OIII; allllrl fllt tlllll 111111 p11t,11d an)V a1nt rolll; stt11 a1111r1 wn lllClrtltn tt1111r1V1tt1a1a(Aabtnl.1981). ln-.llddY-fMIJll'Cllllfttlllpeapllcw eo wti. ... tltldllltcldl 11111ar1a111 pl"*8I n111111ait 1111u.r111111r at111(Darpat, II, 1961;tllllfldlnAnfkllllQlnlr, 1970). 111111111:r, -....1111111ao..,.1111u. ... 11r111,ia..-11M1M11111rt1nltnn11111 lllllbdllnrlllblallllU., flll lDclllttngutlh tlll p: p .af I dl11 frCIII _,,,,,.. ti 1111 dllllll nl baUI frmn flE ti I ~ wlllcll laf &I'-, nal bl 11'3111d ,r UDIIIL And,.._111 af Ula.., YSy --llld)V 11111.,, nat Mn lllarrllltld WIIII t111sm:1111 ,c t[c In l'llrmpactlVllbdll, .._ rardl P1M1tl 1'Mlll_.11D ldllntHy IClull dl111111 -,,-,,.,. flClarl but nat nacnnrt'IV alllll r&tuis. Saall r1111Tdllr1 hM fGlnl tllll apprmdlnltlJv 711 ,-u.. whDmnmtttld llltcldl hid blln ....-tlllanol I plr,llclln lhartlV blfare tllllr act (f11111r, 1979, p. 69), llut 111111 IIIAI -.1an 11 nat bllpfUI w1Ulaut CIUW lnftrllllltan nl mnpr11an w1th pw.911,-the ~-wllldld nat Clllllllt IUlcldl. Tlln 11-.vtdllm thll paaple tlnd to cammtt autctdl whln thlv find their sttuatlanl ....., .... (f1111r, 1979), tllll ta, whln U.Vexprtlra lall, which mldlt bl phystcll, ........... Pl 111nt,r Mn(l.&,anttct-), andwlllr1 U.VIXIIIMthat U.VhM 11111flrnlt1Yes er aptklls C Perlin, I 985). Fer 111111ple, tn ane m C Pfrltn, 1985), an 48 - PAGE 55 r lldlr)VMIIIIII cmunlttldautcldllftr bltng tald Ulll ft hid tlrminll canar, that no treat-111111111 wre Mlllbll, tllal hr antv relaltve, 1 llltlr, caukl nat en rcr hr, and thet Uwe was 11N1-we1t Witting 11st Ir 1111 _. .... 11111V prtfatmllll 11111 __..tlllt anti- llllnla -111 IIIIINllliltl MIi If 1111 nen. Ullt ts gtwn 1D 1111 pattlllt--... tlrnllnll 111111111111,. aptlanl--wauld nlbnnv 111d to dlpl lant lllldlclllan -, bl helpful Mn tf tllldlpl kll ltrallanll lnv1111raf thlbldnewsand._maf apttans(Pr11n, 198&). Thn 11111111 IVtdlnal thll thl lnltttutlanll 91tttng alltll I dlfflra In repcrtld llt1tudls ti lldlrly pettents ta an1II ( Prltn, 1985); ftr mmple, pllllntl 1n balpttals are mare : lllrllV ta npart Ulll tlllV Wlftt tD IIVI tllln palllnll In mntng halnl& It fl men difficult 1D CII rlllll tltltudll wltll partlculr ltfHultllnlng lr .... 111. Stlllll In tlll 1111 1960a and IV 1970t ..,11111 Ullt tna 1111d autnll ralll ( nat 111rett nana tlll lldllrlV) tlndld 10 bl lftltaa,attan rl a lang, lfnglll lngcllllll lllllr thlCIIMl'Ol ti Ill ... I tn 1llpll Ill 1nltflutlanl wtlll wr1alll tullll llll -11111, 111 ginrlltng tlll lfflllltl llllplHlft HI 111d 1all ti alltrol, 11111111 ... eldrlV paap1ltaC111111tt lldcldl, Mn tllaudl tlln re III llllpful sllltlttcs 1D tndllllll 1111,.......al 1111 prabllll. ~clllr c:111 thlll 11111 blln widlly dllcu111d tnvoMII tlll Ytn .,._ (a..a.. 10>. In ..... fl tllldllttnC.ttan tntrarmld lter, lldl 9ll1ctdll IINrf llllllllll lnllnlnlntll llldaprllllM. TIii rollff reltglaulCIIW'k:t1anland pncl1all 1n lldrly ......... 11lblllmtlr to ffl rollalblr IUicldlt Thnn .. 11111119Utctdl ratllnang JIii. Wb, 1111 Prallltlntl tr r111n dlcnnd ltar (t11111r, 1979). Wllll lbaut ,,,,,,,, tui:kllr IIPICilllv nang 111111drly? t1111r ( 1979) cantlndl that ._,, arfllr'= tutcldll aculd nat be acmmpltst111tw1111aut the mtstance ti maperll1vl 11111111 tbnMI', bat.Ill lllistlnce aMrt manv actians and nana:lians, tt ts Mn men 49 - PAGE 56 ~r{{-... tft~' dlfflaln ta dltlrmlnl tts roll thin ta _,.t,. 1hlt I su1ctdl hll blln cmmlttld. Inn sblt/ ti 11111 IMI 9Utcldll ( IIIUl11v WMI llltlttng hulblndl balm GT thl 1ergr number fl ..-IVNIIIUtcldll), 1'1111r ( 1979) ldlntfflldtlnlmetn pattarns: ( 1) spaulll rmtntr-~ In t11111-bulllll.-... dnglUtctdlldllpflalma.,.._nat1mbllallltlllVIDPl'Md tlllldl talliddMltlltng 111n 11111 ( C. 1 1); (2) IPIIIIII flllln ta tau lltf appraprilll aattan lffll' dlawlrtng IUtcldl nalll ( er bllng told lrf 1111 tiulblnd) pr1ar ta the acttans ...U .,.. .,.., IIIIIM llllt 1111 na111 (er arel CDIIIIIIIIII) wn wtaus; (3) -tn lllktng hl1p lftll' a. but --~dlllltl lllllamrnd. AU tltlla tnvolve111tsdan rathr 11111n Cllllllllltlll, nanlntlMIIUan ralblr thin nt11 Vllltlan. ThlV fell lhart rl alhr lcnllfl a. MIi 111 avlllng tbl 1111111d 111lcldl, naat11 wtdllncl lbaut alllr 1111111f'lllllia. w 1a tlllWlcll dlt& WlalSI Id slllllttcll dllllbaut tlll llllbtllalPiprtlllalllrtl\lntpmJIII &g,,physlciall. Ill aanclullan, tlllrl II 1111111 Ir dltlanll and relllbll llallltk:11 dat& Nat an)V ii ltpralllllllelhlt tlll IN:ldlla~lulctdlalllllltllleldrly 11 .. )VllldllrlttpCrtal, but WI 1ICk llllptal lnfarlllltllln lllaut refulll rl ltfl-9Ultllnfng trtlblltnl Rlgll,llng sutctdl, It wauld bl 1111Dtal 1D bM blttr lbdllft tblYlrtaulanllttcllll, Mb mental and ""'8tml 111nm, thlt -,,lll.,.ldlldractm'sntlbdlltudllllmt111whllhrU.VldltIIDblC1U11lfeclars. In lllllttan, tt ..,Id bl bllptal ta hMarrelltlanl wttb alllattt,.,. ihl traabnlnt fl 1111111111, U:11 ..... lmpfflll, 1111 llnlng ,_; andwflll Ulla --ID 1rlllt ltfl..111 11t1ntng tnn 11111 It II snblllll Ullt tn _,, tf nat IIIGll caa sutctdl wm mnttu to ..,. ,_MIIIIGllanll andlllllll flnn:111 rlPlf'~ far 11r1twrs; ffff r1111rch lbauld be dlltpd ta Mid CIUltng hlnn while 111 llfng neeraJ lnfarmltlan. lnfarmattan lbaut 1111.,,. and tfnd ft IIS1stlncl bV athrs wauld also bl helpful bUt perhaps tmpasstble to lllllll, IIIPICfll1V In Yilw the Unit fl legal lllbtllty. 50 - PAGE 57 :,,i, Algll,lng refulll ti Hfe-lllllltntng m~I treatmant, r1111rdl ahauld be dlltpd to prwtdl thl lctnd ti fnfarmltkll Just ldlnttflld rcr aufctdl. It wtn bl important to tdlntify ,Ctzn!II WIii 111 -,P1J ...,_.. (Just It Is Important tD tdlnttty attnptld well m uc111ful IU1ctdls). Qullttane n rnlv ra1lld lbaut a pettenrs campetaa ta can1111t to 1n11nN1it ff hi er n 1CC11P111111 trlllbnlnt; but whln I patilnt 1'11111111 lnllmlnt that thl ---bllilvllahauldbl11D1Ptllt,thlnquattant~C111----11 ; () ;:\ --" :\j .. PAGE 61 . ( ') \ ., .. ',J ._ .' \.J TIit 4. D......_ II PNVIIHng Clllapts of Alllltld Death 1'111 pllr t11Jdlllll" CIMlrl ........ palltbtlltilltl aallan and lnaattan. Lit UI lllrt W11II thlm111,-acttw t1111'1 thll tnva1 baUI tbl pattlnt ---~ party--1111111111Utctd1 andvohlltlry act1YI .......... Tllllldltrr IV IPI vtrtuaflwllD flnallv acts, tlllpaltlnt.- ...... 1111 u.c1n. ... 11 tllllClllfl ..,. ... t1ndtl ...... Thi a111m.-....-11111-1111a111 .............. 1tratn1"""'8ac ......... -wflll lUlcldl. 11111 II. 1\1. 11 tlll laltan ar lllttng, prwlllCII rl 11111' lllll1an lbaut 1111 .... rt llrtnglng lbaut dllltb, provtatan fl tlll 1111111 ......_, wltblllldlnllar wtll*tng Hfl-lultllntng tnlblllltl, Clllfarttng 1111 pattlnt 1n tlll 1111}( 111 -fflnl, & TIIII ranga II aufflcllllt tD 1rdai thl 111111111 uttlttvfl111tmt111111t111dlllll: tt tstmbraldtoblllelpful tndllllflllbaut oallctllar IDtlan& n. .. ldlntlflld ... ... IIMMll tlll II awfltan lnfarllllttan ...... ( thl Rallln ca 6, pp. 22 23), 111PP11M 11111 llllllll'lgllll Cu. Ramin cma 8. pp. 25 26), the prcr,tatan ,t111 IIK9ft fl lldng ID llang wttll 1111 trlllllnn ( illl BIMIIV Cllrt e111 7, p. 24), llllllVlllltan(I 1,p.54). SanllafU..nmatn,-stal. Farmmple, It ts nat clllr 11111111 _... whD OM lrnlv C1ri thl tav ta brn alf 1111 par ta hta rttftctll hllrt Wlllld 11M blln vilwld a lllllltlng hta satcldl If hi hid Ulld tt (and tlln are dlblflll lbaut wllllbr his acttan would 11M been 1 "sutcfdl). fm-tlllrmcn, cw fl nantntrwnttan, IUCb 11 are prttcularly prabllmlttc, blcue It ts not clear whlthlr letting die a,, nat fntw Ylfllng ahauld aud llllltld dllllh, er, n this cmtmct, tsted sutckll. 55 - PAGE 62 ~' _:' /" .. .., ,: ; \) ,:._, S..WlllldWQUlthlt It 11 Mddlllll, nat llltstlddlllth. HawlMI", lndlcatld In TIit 3, 11n Ntlllr ( 1979) v1lwl IIVWII typas ti nanfntlrwnttan ...... 111tcldl and Ollltlndl tlllt IIIIPI grtllrtcsutcldlln nat pmstbll wtumt thl tstmtl auws. In -II. allltan er nantntll w11ttan nuld CDllt lltlra anly wbn tlln ts 111111 marel er roll Nllltanlldp bltNn tlll prt111 ( ag., tt wauld bl add to-, tblt p 1111r by whD did nat lltlllpt ID-..... train JIIIIPlnl fra I brtdrJI lllld" In 1111 pnan'i autctdl), but MIi wbn thin ts IUCII rellttanllltp, nantnlll Ylllttan nuld nat lwlt/l blCIIIIIMlld Ftrtlllrlnln, a.ave C1111. a-, lncludl bath ICCIPllbll .\lltat1nat111t1111rllylhnffldtolN,-.,W1PDfl1dlclllantlllthll._ 111111 ,_,.,ft-, acar Ill 1111 IMI fl dl;!lm-n ttlllf, La, wllltlw ta bring lbaut dllllr nal Alltltllall 1111 IMl fldlclllan-llllctng~111Dtncludlbalb_..lland nDDIP1lb11 a:11, ranging frCII IDllcltlttan, u:11 IIICIINIJlniflllllllltna, er mnlllllllng, ta llllllpulalall, 1111 tDdllcullllan tlcllrtfy 1111 pattenr1 aptfal11 (Fnn:11, I 980). TIii Gi-al llflil dlllll II nat wry hllptul blcll It 111C111P11111 tm 11111P1 llffa It llllllbt1fflll reardlnil wllo dlctdll and wllD ICts, WIii IIDII dlllb II ll"clGlt about (&I, IDltwlV ar PMIV) and*' tt II ll"clGlt about C e.g., wllllhlr to bnftt 1111 whall dllll 11..,.... about er albn). t1are III IClltan II required cm llCII ti tlllll patnta. I. Clllllllltbtllty If Alltlttng D11111 wttll rrot111111111 ca. 11111 Practlcll 1111, Hlppacrlttc 01th aprmly prahtbtts w ._. fl atsttng dllllh: wm neither Qlvl did'! rug to anybaltf If estld far It, nar wtll I mate 19UIJlllltma to this lfflcl. HawMr, atbr perts ti this aath ere naw VD 111, Including the ~tbttian of abarttm end S6 - PAGE 63 ~?}\;:? ~~\'..... !~ '( .'1' ,. J: f) \ ; 'I .. -, ,:.: u :.) U9IY a,, 1 Htppaa Ille pl,/llctln, and 111111 prtnctp111 bdld In thlaatb -ag., tbl m,ty ti blnlllt 1111 patllnt-llllalhn tlllt hM beln __... .. ,.. thin-a.g., the principle of IIPICl Ir Pl--muld 111d tD1dlllnnt polll,f In tlllmdlrt-ntcr dlvllaplllnts In. 1111 lldlDlaDIII ta 11 ,,1ana Hf& TIIIPrllmtplllrlW Ellllcl-tlllMlltlcln W f 11m:llltan nat dlrlctlV d ........... wlltdl ......... d'1111d .._ ....,Pl lllllanlnl1PPllcllt~ ti the ~-Fer .. pll, tn 1973, anr pralltlltttng "lnlrcV ttHtnt er t111 nt1nt1an11 I tnlllla1all fl tlll llflfl CN lulllll bllng lPf analbr UIIRIA Haullfl DI __ held Ulli c111 ,tm,. ltfe-lllitllnlng tnlllmMt IIIIINIIV Jlllltflld wllllt tlll patllnt nt/r 1111 pattants 111 IV. wffll ttllatmllllJudi 1111 t1t111...,,..., dlaldl 1DwtlNIDldcr to Ill fl -.1n11rc1n1ry-1D prola.1 llfl wllllt tbn II lrrlftltlilllwtdlra tlllt bto-1aglcll dlllll II flnlltnlnl TIii Qltnbll ti 1111 .alctl1 Qan:11 fl 1111 N\\ ( 1912) IIDld thlll tlll--nal 1ntlnltanl11V C11111dlllll I prallldttan 1llll acllllll llllrOf ktntng. t....., t111Gptn1an11111r-..111t111plrfllctln'1 c111a ettan to,_..tlllcanfltct llllwan tlll Cllllllflllllltl ta pralang 1111 lill 1D reltM lllfflrtna n., lllarl IIIJ 1111,Y lllldlcl1 trlll.. toa1llvtlllll'1paln ( ...... )VM11whln tt 111Vhlllllldlllll), nlU.,lllaw ~.., 11a11c1111111t11111 n 111111111 ltfl tuppart 1ar III trNV1111b1V CD1n11a11 tlriltnanv 111 pettant allllltlnl wttll tlll lllllntlla anfart and dlpty. hlll 11111.91 tlll ...... tn tlll lnllrlllttallll Qan:11.fl Nlrllll QIIII fer Nlr9II (Mw, 1973) 1111 tlle Mllrtaln Nlr9II' l 11 m.wtlan Qdl far Nlnll( 1976) CD nal apltcltly d' tllllf nprllfllt I lhtft.., frmn abdlla to thl _._. RI the tnstttuttan ID pral&ttan fl 1111 pattmt's tntlrllts md r1dlts. In practtce, 1111111 prtnctplll IPPIII' ta hM 111111 lms'prllld to autllrfZI lllttna pattents die llldr m circumstances but am to rule out .-.,,, tflltng ( tla.9I the Mdla lbaut mercv ttlltng ts tn part bad e11 the lack ti evtdlra -17- PAGE 64 ~itY" ~f\. .. \~}-}:'_ :,, Ir 11111ft _,,, fnll tlll trdlkllll prabtbtttan). HrMvm', bal'I tllllr clall n m111tant 111'11 IDttan wttll pat1lldl, 11n11 llllr req1lllll fer ICliYe and dlrlct eulhlnmtl men frapmtly .. ...,,,....(lram,). Ft11111v. 111 w, 11n .i Rtdlla.i uieAn11r1a1n t1a1ptta1 t 11rm:11t1an c 1973> lnc1udll b patlnt'1 .... tal'lfulltrllbnlnt111111 lldlnt pnltltlll.,, and to bl Wmlllllltltbllllllllll-fl11111Dlian.. In 1111111'11, tl'IIIIGIIIUllllltcadll ..._,. 1Cl111 tlllllln a1111l1tllll wttll u. llgll .... wlttcll praldbttl....,, ttntnglllllllllllll lUlcldl llut 1111 llgll -tnt1rpr1ldlan-wllll ............... 1n part alllmNry 11 &ttla INrtlntllV. 1111 ........ pralmlmlll ........ llrgllyw: INl~llllllllflwMlllbl&ttbdllnat aflr lllttn11crttvlf t11fCI lla1IIII tllll ialllldll(aw.. 1971). Odll1111ladff ll'atalllfllll Ill blldndchlllall In tlll prsl1all t11111111v& NMrtlllllll, tt 11acar8'1 to a,tllllt111Clllllllrull-aut-farlllfl .. ...... ,..t1au11r1Vttm1tllllnt11lgll, wllfllaapttng-alllr farlll tlllt _....,..11 Tllk I. Tllla:l fl IUlcldl hll bllll dlcr1111n1111111, but a autctdl ettanpt-Nlglll'dlell ti 1111 '1 IIIGUvlt--II I 1111111 far ICIM lntll v111ttan IPf publlc afflan 111d fer thl -1Ylt1an fl lllrty (...,.._ fflwllllltlry .-,,:lltllrtcDII Vlltanllll ti aa,t> (Pratdlnl'sCmn 1913, p. 37). Andlidlnglllllbltttngautcldl rllllll111 llllgal In mmt slatll--1111111 tnlll It a a ..... affllllli m bring It llldr hamtctdl statutls; and athn make It I farm .......,_tr ( francts, 1980). Oftln, bawlvr. thn Is uncllrtty about what c:aunts atcflng 1111 lbltttng sutctdl. In ane fllllCUI ca c PaJe y Rnbeds, 211 Mtdl. 187. 178 N. w. 690, 1920) wamen WII lm-tailn with IIMlald multlpll sllrasll and llkad her husband to put a -sa. PAGE 65 . n. .... ,,, ;_.. -~ :_. .: {; u cup tlpolllll lfi hlr bldm tllll 1111 Clllld kill hlrlllf. Whan 1111 taat the po1lan and dllll, hi WII ........ Ind canvlctld far anrdr an UIS,_. u.t hi hid ..... 1 aulcldl ( Francis, 1910i Rmll 111111, 1913). Fer I prtad TW did nat prahtbtt lll1lt1ng IUtctdl, and CIII stultf 1111 ..... tllll 1111'11lIV1dlla tllit lbl llldallllr bld,......_GCCIITld(EnQlltwdl llllt1111&,t, 1912). ~-..,,, t1111ng ta n11g11 in fNflY mercv 1cn11n are nat .,_. Nlllllltlll, lndlctld, er cm,tcllll fr aaapae, tlWf n aamett11111 ftlnl nat gutttv bV raan --V inlllntty, tn 1111 l,vnlntlk CIII tn New Jlrll,/ ( Mltdllll, 1976), 1111 tllltr ............. In 111, tlllll, 111ft n 1lgll pribtblttanl fl llllrCV tl11tng 1111 lltld IUtctdl, ............ tllll'ltlaftlndlllltl111Dutwllllwtl1Cllllttt11tnitnlttllr typefl ...... awtlll w111 caat-F ID,4llclllll111Mw 1111111r1111rar mercv ttntng, 1111 up to 1913u.twwfll11111111111 trtld hid ban acqutttld J1rt11 (Pr11111J11t'1 01111111tan, 1913, p. 31). TIii ranga af 1lgll N11111 111 tD flllltlV lllllldln IIWIMd In ... OI ttlltngs llllelrat/ blln lrdaad. Hawlwr, Ill fl 1111111 C11111 ft ta bl dlltlngutshld f'rllll caa fl wttllllDldlng er wttl*llflng trlllllNllll at U. petllnrs rlqllllt. TIii Pr11ldlnts Cllllltatan ( 1913) nalld tllll It 11111 -nat 1111111.,, llllflral In which a-11111111 er ctvfl ltllttltty ,_ llllln ....-...... 111111111111ma1111cr au.n (aucha f'llnl1V nmbln) rcr ICQldactna tn 1111tllllt"1 reftllll fl ltfHultllntnl .,......_ t11namlnMI till In rant ~lllllllllldlclltan--*lnglbaut !mm_, paltlntl, whDmuldnat ardldnatsPII* wltr far......_ In 1111 fartn D11adlrectlwl. In 1 1913 r.ltfarntacme1 supertcr mrt dllllltllllll anll'dlr cllll 911 agalnlt twa pllystctans wllD wttll thl prmtsskll the pettent's ..,_ dlantlluld I resptratar and tntrMnaus flldlng tubes fram a brltn-cllmlgld, mnatme paltmt(lldW:Y $p:tg:0,tg(t)lllfq:nte, 147CII.App. 3d 1006, 19SCII. Rptr. ( 1913)). -st- PAGE 66 J n ; ,, ,-. : ~-, N '.I \, ~ V V Nmnl dlllll r ltvtng wtn lall, wll1ch re,.. tn lffact tn at 1llllt thtrty-stx stalll lftlr 1 fhny-llgll1attve sttvtty tn thl 1llt few years ( the first ane wes pmllll tn Caltfcrnta tn i976), pnatt ..-11 .-IINICl dlncl1 ta l'lfull.111111 farms ti 11fe-9Ultltn1111i ~--ll llldr w clralnltnll, UIUl11v tn anllCltm wflll tarmtnal n~n, 1111 Thlll llllutlldllltngullh 1111 ~ l'lfulll rt ltft-utalntnlta:hnDJagill frmn IUfcfdl, and aattm W ,._.. In aardwttll.,.. dlnalMII fn111 ltdld lUtcldl and lllftV ktlltng. Tlwf \ lla-,t prllfllltalllll wtlD l'IIV m 111111 dlrlCttVII friln clv11 IIII a-1m11111 111b11tty fer wttllllDldlrigcr wttldwtnD 11fl-utllntng 1lcllilllaglll (Ralllirllan, 1983). ,... .. a:ttwa -,tmcmtl twa trlll: ( 1) a,dD dm g1 NIPcll, e.g., i m nat want to bl -IIMllldrXalNIIIDIIIII; cr(2) atm,-,.n,e.g., i dlltc,lltaYto WCIIDllllllfarff I blalllll......_ A._lllllnllbnl-cr ltvtngwtTIICII pnatt(2) aWIII( 1), (2) taela-bllllldrBIIUlbllpawrflatarnwstatua ( 1111&1:llty Ir 1111 Rtdll ID D11, 19&4, I 981). In anmttan with aFA's llltll Ill In prttculr tldlllDlaglll, It II tmpartant ta nata tla Mr 1111(,. tlll tlltrtv-stx lllbnl dlllll ar IMng wm acts m tll:hnDlal1tll fralll u. aa&nr111M11a dlrlcttw& Malt staba faCUI an lltlnl dlrlctlwll lbaut 1tfl-9Ultltntng fldlnDlagla, vrlaully dlftlllll. rt1ftclll t lltrardlnary I prolanglng thl IIIGllllnt fl dlllh, lie. lut Mr llllf .... mcn nc ........ m:ludl1r1111111:hnDJaglll. For .. ,11, Flartdl's llllufl lndlcltll tlllt Hftt-lllltltntng tlcllnDIGQtll -..11 ra tnclUdl the prwtstan fl Utlla fl' Ill lllltntltrlt1an -IDldlalttan ar perfarllm fl IIP/ lllldlCII praaldln -,w:1111 V ti prwtdl aamfart or ta 11 P.*L Thll ttatuta ref1lctl u. IIIGll camman 11Clunnt ..... .,_ ( athr statutes UII thl llngullJI af naarfshlnlnt, nutrtttan end ~Ian, faad and flutdl, faad and~) and pracldlnS to prwtdl camfcrt ( ere) and to alleYtate petn. It ts ble tlllt w or tbl statutes exc1udl sustenance beclla of the belief that ft is essential fer plttlnt cmnfcrl Same aim appear tD distinguish natural from artlflctal meens of nutrtttcm and -60I PAGE 67 ' .. r () ,:', :'' '; \.J ,. I ~) 11'1 flutdl, ... tlllQ-egarl stalull acludls u. UMI ... typical prcwtstan rl nutrfttan whldl In tlll lllldlml J...,._.t -tlll lttlldng _... a pettent can to11rat1 ( &ICtlty far UII Rtdlt fl Dl'I. 1984, 1 HS). To 111V trar nn fl U. aUllr tlctlnDlaglls being studied IIV OTA a, arcblalfra U. pettn'a .,._dlnalfvll bV f//P/ statuta Tlllfll fl llljar mrt call slllCI Odam In NIWJtlwf In 19761111 actendld the r111g1ct pr111111tbll dletslal llldact1anl to let pattents die. t :r mmp, wtltll tn11 Olo ca 11111111 tlli rlfflMI rl N1Pir11ar In w ctrmnst1111, tht I 98S Oma, lltan, elm tn NN ._,, alland tlll rlJIIIMII fl flldlng tube tn mclralnltlncll (lllllaugh nat In UII 0Dnrrtf ca1-Hlllf). """" tllllldlDtltanl Involve 11111 stng, llll~WI nsttll cmtnt Vlrltll, Pll'hlpsllllll:tlllV tllall lnval'ltflrttflctll lldrtttan llldtr,,ntm ta-thl ........ fl lntll'llt tDOTA In this nect 1111111111 tlll lUbJICt fl mrt dlListcnl, aftlll liut nat .,. tnvolvtng th111dlrly. SIIICI tlll llgll dlcta1anl n bltng lllllyadwlwt lPI OTA, I wtl1 m1tv lndlaa ....,._ cmrtl hM IUthartad wtthhDldlng er wftld-tng ,11tr,111 Inn 111 eldrly plt11nt (e.g., Sprtng); tlll reaptntar--Ill MJect fl mmt rl thl dlctltm (e.g., Qutnlln, Pr1llluttlr, Etctnr, Qdym-, LIICII, llrt1tng, Fcllflr, and T1111); anttbtat1cs (&g., S.a 111, I CIII tllll tncludld IMl'II fldlno1agtll but ml dtllysts and rtfftclll nutrfflan llld tr,,ntm); (a.g., Dir.I sllln,INISMr1t1); Wartfflclll nutrtttanand ---(&g., QmJf, lll'br and Nllll, nl HIii', wh1ch 11M11ed Sll'gry ta 1mrt the flllll~tlal). TtwallllllPIII n tntlrltld111Jy tomQlllll Ulll 111n1 llall dletskl11SUDPll't wflNIIDldlng r wtuawtng IIICh rl U. tlctlnDlaglll tn CJlllttan In aame ctrcumstnlli U.. .. .,, .... ,, hDwlvr, cm,.,,., mau.r tmra-tant disputes, prtfcularlv about in 61- PAGE 68 o. lnflUIIIICII of 1111tttut1an11 Setting 11111 Sactal cantat an Alllltld Dlltll Draat1c chll1g111 hM cmsfld In the lnet1tut1anll aetttng and thl m:111 mntaxt of dllllll tn tlllUM. Erltr In thllmnbry mast dlllblammldll lane, but 11111 U.,CXDr In tnltflut1anl.11p1cill1V lmpttlll and IIN1ng lml& In 1949, ftfty Plf'Clld fl thl dllllll WWI In lnltltutianli In 1968 that fllln climbed ta stxty-ane PIii cant, thin In 1977 tow ty parmlt, 11111,.. tt ta 1111 blpl tNr ltfllY 11111 mnt (Praldlnfs Qnmtsstan, 1983). In cantrllt ta tlll tw, 1111 lmpttll er using llllnl prcr,tdll I mare, ....... nl publtc e111111t far ct,tng. In ttan, dlllbl cm.r 111111111111 oldr papulatfan, ualJv fNn clnnlc aandltlanl tllll _.._ ... wtlllarltr.r, andtlllct,tngcmnMr 1angr prtad. Salle ti._ chlrlDllrllt1CI m1tar,artrY ctflnl n lV1dlnt In CIIII Pl lllntld ltr, IIPICIIIIV call 31111 4 (IL I+-16). Dlffslllt llllltltuttanll llltlngs nl aactel CDlltlltl lnflUIIICI U. llfl-lUllltntflg tr......_ tn II ..,., PIii tlculrly 1111 dlClltan to aapt ar ta wltlllllldlwtlbtt" IIIHultltnlnl ......... and thl lapllllllntattan fl thll dl:lllan. M natatwlter, tt 1111 Slllltlmll.llllll ll1Uld tlllt aactel support ftr u. eldlrly 1nf1lllal the ratlfl lll1cldl It 1111111 pllultb11 to bold tlllt thlll instttutlanll lllttngs fl tlll using Imler halpttal alllilnll IIMlkldlllb lPPIII mlltractwe thin life tooldr ..... In ldlllttan, 1111:h lnltttutlanll lllltlng 1111 mlltrltnts C11 dlctslanl and acttans far dllllll, lncludlng lltld dllUI. t11111 lnlt1tut1anll mlltrltnts tlll mnstntnts ldl11ttflld 11rlllr far WIPII, 1111 .._-, lllatlan fl N11D1.N11 far mid w1Ultn IIIIIUI an; u. ...,-1 r11111, including 1~ 1lgll ru111, u:h thl prdltbtttan fl IINftV killing and lstld 1Utctdl; and the CDdls "vrlaul Pl afmklnlls who practice within the t~ftuttans. But w1111tn thlllaactal contexts, dlfflnnt tnst1tut1ans hive thltr awn spectal canstretnts, anen Involving their distinctive purpasu, rules, and allacattans rl rmaurcm. Thus, fer exemple, a -62. \ ~. l PAGE 69 . .. i. ,~ ; ) .-, V '_.' \,) ;;_; pattalt's dlllre ta hM I ltfa-lUldllntng tll:hnolaff Ullld mav nat be Implemented blcal of tlll lllltlld number fl bldl In lntlltve an and the lnstttuttans 1l1acattan VJ11cles. --lffllltld wttll I rellgtaul a111111111tty ffllV reflect thllt cam11111tl\/S bllWS about the UII "ltfe-lUldllntng ......... It II ...-11 ta._ 8111 .._ dllttnctfanl aang tnstitutlanll lnflUIIICII. M the PNlldllnt's Cmnalllltan ( 1913) nallll, acute an hlllpttals hM I cllllilllllt pw ldllpasltlan ta pralmlglng llfli fining 11111111 tlM 1 111Jtr 1111 mare vr11b11 mmnllllllnt to prolanglng llfe; MIi 1111D1c11 nchlrlClrtad IPl ~rl dlllb. Paltcv-lllltn tldltdl and tnstdl ti.. lnlltbftn lllauld (1) blainfl UIIIII -IClll llllfl 1111 lllpltCllln fl tllllr poltcllllr dlalltmlllbaut ltfllllltdlllll, f~) Cllllldlr .... .. llnll In thl lfdll "_ thl llllrllprtnclp1llllllcll1ga:f11e11111111Slllr,llll(c)__..tlllllllllllldlllllflml1III ralw tllfarlna1an lbaut tllamlllratnts that UW, CIII blttlr" dltll mine u. 1111111'11'1 lnllfluttanll lllt1ng. OD I paUant II In III lnltttuttan, clllrldll lad IPf Clrtlln aalllrllntl, It IINrf bl clfflcult 1D --- wftbaut cl11nglng .Utng& NIMrtlllllll, lnltttutlanl CIII 1111 lhDuld bl 1111ft fllllbll tbln tlll ave dlltlnct1ans .__ T1111r dlctstll .. allauld bl gMrllll lrf 1111 ~lnctplll 1111 pnctiCII rl pd dlclsklt.. _,and nat cmly IPf tllllr lnltttuttnl lllpntMB ( Prllldlld's Cmulltastan, 1983). Ewn ._,. tllltr dJMlapmlnt taanpltmtldand nb...-, u:11 tnstttutlanll IIIIChlnlllls llllpffll ltbtcs mnmffllll a, pravtdl paaatlttltttll ta wtttnld er to wttld' ltftt-utatntng trllllllnt In aa:antwttb I pattllt's llll lntlr8111, tt1 tlll lnltttuttan's tllmM:V to lrllL Fllrtlllrnlarl, llidll-the tmpa:t fl caat-cantatftllllllt __,., inltttuttn may m,, bl IUbjlct .... .,., 11111ntrn11 PNaN1wm1tw. r1111r t11111martnd Henct, it.., Ill 111: 11 a I y ta mvelap meclmtsms to ensn Gqlllte traltment tn mrd with a pat1ents w111111 and tntarests. -63 - PAGE 70 It II nat _..11111 tlll blltl ti Mtllble studtls ta dlta mine U. actual tnflulra of clffll It part1111, ftlv and 11111111 an pnctlttaners, whme own dlctstans end acttans ...,__. wttlltn 1111-, 111 ltmttld bV tbltr tnst1tuttanal .Utng and aactal cantmct. 8aUI fllllllll 111111111111 an 111 &ttttannn tbllllllws 1nflulncld llV U. tndlttans tdllnttflld wltr tn tldl NPGM, I.I, reltglaul trait ... nl prafllltanll cadll. And thltr lltlla tn 1 lll(ltlnr1 whllMr In tlll dlcllian er In ~ts tapllmlntatfan, dDII nat tblliw aet paltll 111. (311tllldllclllllan 1n Ta 3 ,. ..... st11a, at~ tbraulll allltarl, In eldrtv IUtcldll.) : I In 1111 llllllla ti lllfltri:II Wtdlla lbaut 1111 tnflulra and ~attlll vrtaua prttll, It IIPlllltllllllqglll W/1111 which the 1nflulncllllltltll-, Illar lllauld be ltllfflll In mrdwttll.tlll llllrll prt-111 ---erlllr .. A Cllllllflnt Pllllnt lllauld bM tlll r1dlt to-er llr _,. dlClslan, In ...... II 1111 ttlnl, nat fD hNl llfl---tng talllDlaglll. lut tn lddlttan ta VII lntlrllll 1111ft thl ~ lncallp1lllm1 tDdl:tdl 1111 act tn walrallltam, tlllrtnlPlll'GII tllltlCtlrllll llatll,u:ha tlllallly'1111d 1h11 11"-lanl' prahtblttan '6 IIIIN:V tllllng .... lstld tctdl. Just lllcaltan paltclll lPf tlll IIICllty 111d 1111 tnstttuttan IIID111t 111111-apr1lllat1rI lltnttsCII patient end ftt; clmic:ls. Flnlllv, thl prtnclpll ti,..-far par tmpllll that tbl cltntclln II nat 1111r1 tml er tnlllNad fl tlll pitllftt's wllhll; fer ...,11, llllbnl dllllb acts 11 ally NICIVIIZII the ...... rtdlt ctC1111Cllntlaul renal tDlllllt dlllb. tbl pattlnt W-. ...,.. thl -64-... (\ t J;. ~) \_ PAGE 71 ~6i'-~ .... ,.J ... -.,.~'""" ,. ~ ,,~, ;. ., .. .,, .. o I' fl .i I V ._, '_/ I ...;._ TIit &. Caallualalll -rltllllblwl--lllwlPlll:tll 11911flclra far U.11dr)V, In prt balfl 1111 Ila llllngJv larga runbn fl eldartv peaple, the dMlapment rl tlr:IIIIDlagill that a11 IUlllln lffl lcllgll(e.g., blftn anttbtattcs ...-..11 wa vtlwld "tblold penan's rrtenr), tlll llUbltc, tnstttutlanll mntact o/ ct,tna llldr thl an fl s1r..,..,, the frequent klll ft ....... 1Pi eldrly pat1lrdl, and tllt llllttld ... lty fl Hfe tllll aftln Nllllltl frn thl llleldarlV, Mn thl stet eldlr)V, ecla, Whln tlWI n....,.. tnd1Y1cblll With vrtaus lntlrllllandwtlhlll tllll r,qutrerlllNIClnl llllla. Fer WIPII, It ts lllfllr 1DY11w 1111 lldrly 1c1lllft tndlYtull wllD n 11111111 to llllcl thltr awn dlalltanl, ..... fl thl wtdl wrtltlanl ..ang u. eldar)V. M-, "*, IIIIPf lldrlV paapll ... ._ny wlnrable bllalllrtthltr dlpntlla ... lllltlld autDnrllly and pawr. I. Flllilllltty 111d Dlltnltlllty II 8uldlll1111 TIii nmct t1n1 tar11111 c1111 wttb u. fllltbtuty f! autc11111111, and 1 .... thlt dlllrlbtllty, which II brGldll tlllll fllllbntty, abauld 111D bl d' 111111.. A m,cr -tan abaut -ltnllllwllllhrthlvlhauldblD111Mn! (I.a, lndlclllJdlllhaulddlctdlandact) ar e!bdnnf!YI (I.&, lndlcetl whit 1111 end-, nat be dlcldad and cble, prttculrly Jm dllth nNt/ bl braulllt lbaut). In plnltsttc Btety, VII tadl1LY ts ta .-.art to pra:dral "tdlltnes to lllacltl euthartty fer mctdlng and ding, and this tendlur:y ts eviint In the natural dalb~ acts thll QM paapll the authority to ma Olla dtNCttves before thlv ban lnmnpetent tlld -61- PAGE 72 f1 ,., ,'~} ...... f ,J ,;: : ) ...... ta dlctdl. HawMr' IUbltlntlve gutdlllnll n ... Important" It ii ftlCllllfY' If the lblMt ..,...ta are ca rect, ta maintain mme limits an dlclslans and ectfans -crtatn)y to pralltlltt ....-.:, 1cn11na-and perhaps, but 1111 clllrt,, to prdltblt ....... sutctdl, at 1111t In-fl 111 farm& 8aUI ltmttsn lratf tn pla In sta llallllttan and cmrt dlctstans, but, Inv fl 1111 la -111tfarllltty 1111 clrtty, It ldd bl Ullful to 9llt 111tfcrm 11gtsllttan tn 111111 .... TIii t,l1awtngtar11.-m 11lbltlnttw il11ltsan whit nw, bemne. I. eu1111111111 ta hllp dlsttngullll a,Jckll fnln auwr acts-wttllboldlng er wtu.nwtng 1ffe-lllllllntna1rllllnlnl lltdlltnll hMa~ 111111 gadnnevaMna tn llgla1alm fnll IUtcldl, nwttllllD111h~cr W1t11-cnr,1ng trllalllll fram lllltcldl. 111n ta --lbaut ....... fldnl CDl 11 lllldld, prttcullr)V 1n lw rl 1111 chmlltc tna 1111 1n 11111 lllbnl dlllll 11:1111111n aart dllclltGnl tllll flrlllll-dlftnl tlllcmalllflnl pet11nt rldd to Nlfa11Wllnllnt 11111111 ~-rtdd ta NUlll ti llbn1nt far 1rmn-' pa1lnta. Agdn cllrtty and 111flarllltty acra11 UII nattan bl dllltrlbll fer 111 111t111. 2. a.tdllt1111 ta hllp dllttnguilb __,.,,!I frmn we a mMIIJ ICtl fl wtthholdlng r wtll*tng Hfe-utetntng treabnlnl Slv 11 dlsttncttans dMlapld lftlr Tlllk I IWI a.lvld ta dlltl""1111 aa:aptabll fnlll IIIIIDIPtlbll ectl VIit r1111lt In GIIUI; lllfartlntlly, IIIIIIVtnl thlll dllttnctklll cllll nat mnplltl 1111 nnl lllt and 1111V Mn dlstart ll All rl Um MIit GIi mare f11Nllffllrltal prtnctplll and YIIUII thlt must bl e,pHld dlrectly to C1111. Ctl)y the dllttnctlan between !dlHng and Jetting die wm faund to be prtk:ularly ueeful far public policy tn tne-that It 11 appropriate ta prdllblt mercy tllltng ( not sutcldl), but the dlltfn:ttan mav be mts1edng tr It SlQlllts that an CIIIS rl letttng die are aa:aptable, fer clllrly U.V are nat. One b appraach ts to maintain the substlnttve Hmlt of the -66- PAGE 73 ~'1.-':4-.. V '. '.J ,._., pralltlltttan fl eutlllnllta er -CV ttntng ( and perlllps al llllstld sutcldl) and thin ta pwsue 1 praalllnl aoluttan: ( I) mmt potents, whD are lnfarmed end acting voluntrnv, mar Nlfllll.,,_ltfl-~tng trlllllmmtl If Ulllr dlctlkrll nt "Ctlcnl wauld nat harm athln, 1111 C 2) an-1 pn1eils-, NNll tlPI llfe-Mtatntng trlltments fr 1ncamt pettents IUbjlat rwtew bV plt/llcln, tapttll llhtcs anmtttlll~ llc., 1D mm an that the dlctlian ._ nat YIIIWl 1111 pettents lntll ata This prGCIDN1 ~tan el1aws cmnpetant patients wtclr lltttudl UIIII 111 rar tnmnpetant pet~ .... ft thl dlllQIII s fl mnfllcts fl lnfll tll _.ts fl u:h a paltcv wauld tncludl tllDII wtlD wm,ld llmtt mn.-pattants dlctllanl ID CIIII In wblcll U.V n tlrlllllllllV 111, lmlnlnt)V .,.Ill, etc. 3. lutdlllnll ta help 11dulklllla dltll mini~ Wf WJlll ndll In Isled dllth& WIIIIW ......... dMlapld rar ........... tt II tmpartant fDIIIIIW raam rcr GIIICtlntlaulabJecttan 1111 ntulll blla piap11nw 11n11at dlffcnnt p~ Far ~le. prafllllarllll lbauld nat bl ftnld tD prttct In whit u., bllllv9 ta bl an act~ autctdl, In tbl caafl Ellzlbllh lauvta In IINIIY lflllll U. lllbnl dllllll 11:ts ellaw phvltcllnl nat ta OIIITY aut u. patllnt'1 D11adlrlcttve but raqutre btm ar hr ID mete a gm ~ltll lffart ta trnftr tllepatllnt tathlanfl .... & Tbllt-,bl111111P1qrtltlmmpramt11. Thlauklllf1111 anappraprtarolllmuldlegltlmltllydllttnguilhthl\VPll-'llllllnl1dlnt1flldlllllrTa S, aaludlng llllraf ttlllng and pm hlpl Mn_... .,lctdl, while prlittttng prafllllanlls ta rllllMI pain and sufflrtng wttll IPPI q1 1111 fflldlclltcn Mn If It hllln dlltb and to retrain fnll pranlng llfl-utalntna trllllnllnll raflllld by mnpdant pettns and (wtt111nt11111111tts Ill a,, 1111 palflnt'1 bllt idlrllll) rafulld l,f praill fer trmnpetant plltlntl. In shart, thl gutdlltnll lhauld rlfllct 1111 flnllrnentll lthtml prtnctplll tdlnttfted erlter: profmstauels mev n lhrllld act tn aa:ard wttll thl campetant pllflnt's w1sllls ( autanamy) and 1ntlrests ( blnlf-1an:l/nanmellf1an:e/ utility), and thl trmnpetant patient's tntnsts, subject to the allllrltnts rl Just a11amltan al hlllth care rlllJUrCII (just1c:e) and sa:tetal rul to prevent bad 67 - PAGE 74 f :c \ I ,, lt >J .;, :J ,' ':t fl whD dlcldll, whD a:11, far whit r 1s1m ( why), ant haw. C. ,_ Tlllt MIid Addlt1anll Anllystl 1111d R1111rch a..,11 aptrtm1 ,_, .. fl lldlrt, IUtr:ldl nl Nlfull1 ,I 1nllmln( arrelltld wttll 11111111, m:1111111 tllllfllltfanll cmtat, 111d partbllr tlCIIIDlaglll 111111 ttrtllll lltlnttan--Dlll11alllr1V 11111111Pd fl 11:111 poltclll, ub a 111:111 IICll'ity, CII pa-CliVld quaHty fl ltfl 1111 aptlanl lllllr wriaul anlttanlt cm ft 1111 eldrly 1o 111D dlcllknl, ...-.11aanfllcllfl 1111111111 bltwdll:lllaNnlarlllldlldlrlV Plltlntlt 111111111rtt111 lldlrtfrltllllllllMltllllll'GVtdlllllP/llltlnl dlllllll:ll,1111 ...... 11 ..... ,, ... ., ..... tr mclllCllllbaut 111rmtnatan ti trllllmlnt; tlll pralllbll lffll:tl ,i lltlrltDII tn pj'aflallrill,111:111,andllgll ru111tllltarnnt1Vllrualurlpr1Ctlcllilll1GWllllllllltld dlllllt 1111 prablllll tlllflld II cmt mM allll 111111n1cn tblan ti tllllldlrt,. D. Prtartt111 far Pullllc Attlnttaa ,_..ding Sutctdl A11ana tb1 Eldrly In llallttan tD L tfe-lultllntng Taallnllagla ,,,.,.,,, ff Pll1111l tnwllll, wtlhll, n1 mntro1 ti dletltcnnlk1ng tn thl Cllltlxt r1 a:1111111 lllaltan ft rlllll'allmd ru111 ta prlWlll abllll 111d alhr bid-; CLECIDI md-!lk C ne t.o llltlly 1111 re1Mnt marel prtnctplll; and thl tlllYfflbtltty al m CPDDCIIDl:ln principles tn I warklble policy tn I pl1nltsttc aactety. AltlwJIVI sutctdl ts a prabllnl amangt11111dr1Y(T 4). 1t tsnatcler towtlllmdlnt 1t 1sana:tedwtth the 1111 ti 1tfe-91.11111ning tlchnalogtes, and mare .-..rc:11 11 r1lldld m this subject, well cm dlclltll ta rel1a1 ltf,-.sustatntng tlchna1agill that wauld nat bl cauntal sutctdl. 68 - PAGE 75 '4 ... 4. .. E. 111111' ,.,. Paltcv Opt1all S.wll-'1alll bM blln tdllnt1ftld In 1111 mra af tll1I repart, and e111Y I flw ft tlllln wt11 Cll)V bl lltdllfddld tin. ~ Far.aullltan ti tddll1nll ...8 abavl, wttll prttculr ..... an thl mnttud prabtbtttantl .-cy ldlltng 1111 parhlpl llliltld ~tcldl, 1111111 rtdlta-lrlllmlnt .,.,_. IP/mm_.patllntl(ettlllr tnlMIIClcr In thllltuatlcll), 111 tlllrand llattaaf lrllllN.t r11Ulll IP/ 11 fer tncamlllllnt llllllntsa and an U.apprapr1111 ralll ti proflllknlll In all dl:111111 111d 11:ltan& Attlnttan ta bail praaanl 111d mlllnttwatadrdl, 11 r11111-,.. ltbtml arVIIUll thlt nrellvlnt ta 111111 prabllnl, and -tan flWhllhll ftrlllll' cllrtty lllf111tftnltty.,.. t111muntry ndlllrlllllllld _..ll,prttculllr1Vrt11,lngwtllltsen,1cetbfnndfblewtf1tllrm_..1111 CJn tlllwhDII, tt cllll nat app111r ID llldlltrlbll fDlltllnpt fldlffnntllll lr1aul ltfl-... ntng 1ll:ftnDlaDIII. Onl ._ __. crtttclal rl tlll lndltlanll dllttncttan bltw m,llarf 111d axtrwdlmry ,-,t b lllllllnl lmePr111, 1978). C..11, t, -r1II Nlt1n rl Silffartngllll tlll bll rl WIii, HM Em J MIii, 306: 639-&41,1~ a.11n11, J. F., er1arm11 Ja ,,.,,.,. Etbi:I < Pbtiadalpbte Thi w.tmtnltlr Pra, 1911 > CJllllhll, J. F.' "Wblil II It Naranv Julttfllbll to Dllcantt,u Faad and w ... ,. to bl publllhld In 11 ..... IQl fl 1canfnra CII arttflctll nutrtuan 1111 lr,1nttan, Jalnnl Lynn, Ill ( llmatngtan, Ind.: lndllnl UIIMntty Prlll, I 985) e11111rt. J. )YbQ """' nrzm ,_,,,,,. a Hlftllb on< New Yart: Odard ~tvnttv Prlll, 1912). Crall., D. f Ibl :,p;ttty p( :S,,1 Ll(t PC1ID Il'MlaNMd ,I Q:tttcalbf IJJ PMJlntl ( New Ycrt: Ruall Slgl Fallldltkll, 1975). Darpal, T. L, MIii W. F., end Rtp-,, H. 'S., -Yhl Relattanshtp rl PIIV*ll lllnm tD SUtcldl, .,. ,Sutctc19J llfhlvtcr= om ""tJarmrwn&, H. L a. Rllntt, .. c Bastan: Ltttll, Brawn and QL, 1968). Dlrthetm II t, :,U1cldl; A SbAC '" :o:tame. J. A. Spaulding and 8. Slmpmn, trans. ( 8lnal, 111.: ,,_ Prell, 198 I). l>,a,A. 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Bllttn Ind D. J. ""9,ldL(NNYart:Slrwttn'1Pr111, 1980). 8lawll-,J.,C-et1110eet.,,nt3edmt,.,.,f1ngPattent? &:dt lnllm t1e4 143: 975-980,MIV, 1983. Ntllr, N., &dckllNlr Sig, ( Nlw Ycri: Sprfngr Publllhtng Cl., 1979). Nt1111r, J. D. and Brush, L R., i1II Qrrelattan fl Attttudll tuwa d 3utctdl with Dllth Anxiety, All1glallty, and PII I Clalln111 t.o Suictdl, L\111111 11 1980. Mflchell, P., Ao kl g( tm; Ibo KtJJtm a( Aeocgt MPm1ok ( New Vert: Alfred Knopf, 1978). Nlantn, H., ........ In flarbmUe g( Rgthtc,, w. T. Rek:11, ed. (New Ycrt: Free Press and Mlcmt11111, 1978). ~tanel cammtsstan fer the Protection fl Human Subjects In B tamedlcll and BehlYfcnl A1111 ch, Ibl e,Jamt Bmrt EJbJmJ euto,11,., rm: tbl Pnmcuoo a( Humeo Setusts It Rn m, DHEW Publlcltton te. 1( OS) 78-0012 ( 1978) ?Cf 1...). \ I PAGE 81 : -.. Lt,; \. -::, '-Plrllli, l, ,_lltrtat at 8larga Wahington UnlYlrsstty, WllhtnglCII, D.C., P11 I ....,.tclttan, Jin, I 98S. 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H., Adllstltn, S. J., Cranb 11, R. t, et IL, -r. P"'9tctln's RIIIIGHslbntty Taward ltlpele11ty Ill Patllntl, M E J tlll l 10: 955-989, 19&4 ... 0 t1., IM ID famnx a:,..,, M. Rllltllltltn Ill (Nllw Yart: SIMI 111d _. t 1967). '#lllllll'd, A. J., 9QI tbl llailllltm fl Jlwllll La: Thi CIII fl Karen Quinlan, JICld LM Brt1fl 11 ( 3): 337-361, 1979 .. Wml, D., -SUlcldl a lllllnlllnt 11111d ExPI lllill, In :Wtctdl Dw PbUrnmbi:al 1nm, M. P. llltlnandD.J. ,-,,.,ldl. (NaYcn:SI. t1rttnPr111, 1980). .\ I. PAGE 83 ii' .. ... Appendix I ., '' u.s. !OfAL 10tULAn01 smc1m BADS ,a 100.000 11 nw-DA& AG& GttOUPs. 1933-1961* All .... 10-14 15-11 20-14 U-H -.JS-SI 45-41 5o-S4 JS-JI 6CM4 aw, 70-75 >75 >65 .... -. 1133 O.J 4.2 10., 12.1 15.0 11.1 24.1 n.s 35.3 41.3 44.t 44.t 47.4 42.1 45.0 15.9 1934 0.4 .. 10., ll.J 15.S 17.t 22., 27.4 n.o 35.6 .. .. 42.0 Jl.4 40.0 14.t ltU 0.4 4.2 10.J u.1 15.S 1,., 21.1 27.1 30.J 34.2 :SS.7 .:ss. 7 JS.4 3'.S JS.I 14.S 193' o.s ,.s ,., u.o 16.0 11.1 21.1 U.7 29.1 33.1 ,._, u., 33.0 JS.I 34.1 14.J 1137 o., 4.0 10.2 u.o 15.1 11., 23.6 21.1 31.4 34.J .. JS.J 32.1 3'.4 34.1 u.o 1131 0.3 4.1 ,., u.o 16.0 11., 24.1 21.s 33.0 36.6 31.3 35.1 32.1 34.4 34.1 u.2 ltJt 0.5 3.7 1.J U..4 14.6 17.3 20., u., 31.l JJ.J JS.7 11.1 34.1 34.0 u., 14.2 -it.a 0.4 ,.s .. 12.2 15.0 11.1 .. 2,.1 ., 34.0 "' J:S.l JJ.4 JJ.3 33.2 14.4 1141 0.4 ,., 1.2 U..3 u., 11.2 11.2 21.s 25.2 2,.0 l0.7 n., u.o J2.t u., 12.1 1142 .. ., 3.1 7.1 ,.1 u.2 14.7 1,., 20.0 22.7 21.J 21., 2,.1 21.2 31.1 2t.2 10.0 U4J o.s ,.o .. ,., 10.1 12.2 u.a u.1 11.s 22.7 u.1 24.1 2,.1 2 2,.2 10.0 1144 .. 2.1 ,., 7.2 t.4 11., 14.J u.1 11., 21.J 22.0 22.0 24.J 21.1 u.o ,., 1145 0.4 2., ,., 7.J 11.1 u., u.1 17.7 u., 23.0 24.7 24.5 27.1 n.2 27.1 10.1 1146 o.s ., 7.J 1.1 u.1 14.0 16.6 11., 23.S 24.7 2,~, 24.l 21.1 21., 21.2 11.J 1141 o.s 2., ,., 1.1 10-.t 13.7 1,., a.o 22., U.2 27.t 21., 21.0 JJ.O n., 11.4 1941 o.4 2., ,., .. 10.J 12.1 11.4 11., 22.1 U.7 2,.2 25.3 29.S 30.0 21.2 11.2 1949 o., 2.s ,.s 7.1 .. u., .1 19.0 23.0 27.0 2t.4 21.t 21.1 30.4 21.0 .11.S ltSO o., 2.1 ,.2 1.1 10.2 u.1 15.t 11., u., 25.t 21.1 2'.0 2,., 30.1 21., 11.4 1951 0.4 2., ,.1 1.0 ,.1 11.5 u.2 17.1 l.ttl 21 .. 1 24.1 n.1 21.1 21., 21.a 10.4 1'52 8.J i., ., .. 1., ,.o 11.J u.s 16.7 20.0 20., 24.J 25.0 2,., 2t.1 2, 10.0 1153 o.s 2.1 ,.o .... .. 11.0 14.J 17.4 20.J 21.0 i.o 24.7 26.5 21.7 2,., 10.1 1154 O.J 2., ,.o 1.5 ,.o 10.1 14.4 1, .... 20.1 22.2 2s.1 24.J 26.0 26.J 2,., 10.1 1955 o., 2., ,., 1., .. 10.J 14.S 11., 21., Z4.4 25.2 zs.2 24.7 21., 21.1 10.2 195' .. 2.s ,., ,., ,., 10., u.1 17.2 20.1 i,.4 zs.1 ZS.4 2S.1 21.1 2,.2 10.0 1'51 0.5 2.s .. .. ,., 10., 14.6 U.4 20.J 22.2 22., 23.1 24$4 27 .S 25.0 .. 1151 o., J.O 7.0 ,.2 10.J 12.0 u., 11.; 22., 23.5 24.7 24.4 21.0 21.5 26.J 10.7 1,,,--,~, ., .. .. ,.1 10 .s U.J u.o 11.1 21.1 23.t 24.1 24.J u.a 21.1 21.1 10.6 ltM o.s ,., 7.1 ,.o 10., u.2 u.2 1,.1 22., ZJ.1 u.1 21.4 u.o 21., 2,.1 10., 1161 0.4 J.4 7.1 ,.a lJ,.J u.2 u., 11., '22.2 u.a 22.J 21.1 22.l 21.2 u.1 10., 1162 o.,. J.7 1.2 ,., 12.1 u.1 16.J lt.4 22.1 14.0 U.J 21., n., 21.4 24.J 10., 1HJ .. ,.o ., n.o u., 15..s 1, 11.1 23.3 a,., Z2.4 u.s 23.4 21.2 2J.7 u.o 1H4 o.s 4.0 .. ,. 10.1 u.1 14.6 11., 11.J u.1 a:s., 21.7 n.1 22.1 u.o 2J.O 10.1 1N5 o., 4.0 .. 11.J 13.J IS.I 11.s ll.7 12.1 14.7 22.1 12.J 11., u.o 22.t 11.1 lHt o., 4.J t.2 U.4 u.s 14.1 11., 1,.0 21.1 2,.0 22.1 11.1 21.s 21.1 22.1 10., 1H7 o., .. ,.1 11.1 U.f' u., 17.J 11.2 21.0 22., u.1 lt.4 20.J u., zo.J 10.1 IHI o., ,.1 .. 11.4 12.1 u.2 17.1 u., 20.7 12.1 21.4 u., 1, 21.4 20.2 10.7 -*Souner J .... C. DlllOIT, "Uaitecl Statu Suict lat 1933'8: An Analyaia of ... frcla," Sui:iflm= CoeSffllf'ff Dnelpnta, edited 1'J Edwin s. Schneidman (llev York, Gniie I accon, pp. 49). (a.,calluc .. & Kar Grow Sllenlaa, Sdcida !!!!!!!.J!drlt