Following the first enactment of living will legislation in California in 1976 the majority of the states of the USA have now passed similar laws. However, flaws have been identified in the way they work in practice and many states are considering reviewing their legislation. In Britain there is no legislation but the subject is currently commanding considerable interest. This paper assesses the future prospects for living wills in both the USA and Britain, analysing the different options available and comparing (...) the two countries. If patients who become permanently incompetent are to have their previous autonomous decision-making respected, there is general agreement that advance directives for health care must be introduced. The difficulty is in deciding how to implement them, and especially whether this should be by statutory or non-statutory means, the traditions in the two countries being very different in this respect. It is concluded that whichever route is taken, promoting respect for patient autonomy is as much a matter for education and persuasion of doctors as of the adoption of particular instruments. Doctors should therefore be trained in what constitutes good medical practice in this area and, to ensure that it can be carried out properly, the general level of medical facilities for these patients must also be protected and promoted. (shrink)

In the context of 'Do-not-resuscitate' (DNR) decisions, there is a lack of information in the UK on the opinions of patients and prospective patients. Written anonymous responses to questionnaires issued to 322 out-patient subjects showed that 97 per cent would opt for cardiopulmonary resuscitation (CPR) in their current state of health. In the hypothetical circumstance of having advanced senile dementia only 10 per cent would definitely want CPR, with 75 per cent preferring not to have CPR. There were no significant (...) correlations between the responses and sex or age. Of 270 patients asked verbally if they found the questions disturbing, none said they did. These findings show that the great majority of patients would not wish CPR if severely senile, and that patients are not disturbed by questions relating to their choice for or against CPR. This should encourage further investigations of patients' opinions on CPR in a broader range of conditions, and greater use of DNR orders. (shrink)

Some form of utilitarian approach can be discerned as underlying much current medical ethical decision-making. Criticisms of the practical effects of such an approach are not parried by asserting the fundamental strengths of utilitarianism as theory.

ABSTRACT This paper explores one of the most politically sensitive and intellectually neglected issues in bioethics – the interface between the history of contemporary end‐of‐life ethics and the economics of life and death. It suggests that contrary to general belief, economic impulses have increasingly become part of the conditions in which contemporary end‐of‐life ethics continues to evolve. Although this conclusion does not refute the philosophical justifications provided by the ethics for itself, it may cast new light upon its social role.

This paper argues that two characteristics of social life impinge importantly upon medical attempts to maintain high ethical standards. The first is the tension between the role of ethics in protecting the patient and maintaining the solidarity of the profession. The second derives from the observation that the foundations of contemporary medical ethics were laid at a time of one-to-one doctor-patient relations while nowadays most doctors work in or are associated with large-scale organisations. Records cease to be the property of (...) individual doctors, become available not only to other doctors but also to educational and social work personnel. Making records openly available to patients is suggested as the only antidote to this irreversible loss of individual practitioner control. The importance for doctors of understanding the nature of professional and bureaucratic organisations in order to deal with the hazards involved is stressed as is the responsibility of the General Medical Council to regulate medical competence as well as personal behaviour. (shrink)