Of assisted suicide and "the philosophers' brief"

Ethics

Volumn 109, Issue 3, 1999, Pages 548-578

  Weithman, Paul J ^a  

^a NONE

Author keywords

[No Author keywords available]

Indexed keywords

ANALYTICAL APPROACH; ARTICLE; ASSISTED SUICIDE; BEHAVIOR; CIVIL RIGHTS; DEATH AND EUTHANASIA; DOCTOR PATIENT RELATION; ETHICS; EUTHANASIA; FEMALE; GOVERNMENT; GOVERNMENT REGULATION; HUMAN; INFORMED CONSENT; JURISPRUDENCE; MALE; MEDICAL ETHICS; MISCELLANEOUS NAMED GROUPS; MORALITY; MOTIVATION; PALLIATIVE THERAPY; PASSIVE EUTHANASIA; PHYSICIAN; PROFESSIONAL PATIENT RELATIONSHIP; RIGHT TO DIE; SEXUAL CRIME; SEXUALITY; SOCIAL CHANGE; SOCIAL CONTROL; SOCIAL DOMINANCE; SOCIAL PSYCHOLOGY; TRUST; UNITED STATES; VACCO V. QUILL; VOLUNTARY EUTHANASIA; VULNERABLE POPULATION; WASHINGTON V. GLUCKSBERG;

ANALYTICAL APPROACH; DEATH AND EUTHANASIA; PROFESSIONAL PATIENT RELATIONSHIP; VACCO V. QUILL; WASHINGTON V. GLUCKSBERG;

CIVIL RIGHTS; CODES OF ETHICS; ETHICS; ETHICS, MEDICAL; ETHICS, PROFESSIONAL; EUTHANASIA; EUTHANASIA, ACTIVE, VOLUNTARY; EUTHANASIA, PASSIVE; FEMALE; GOVERNMENT REGULATION; HIPPOCRATIC OATH; HUMANS; INFORMED CONSENT; INTENTION; JURISPRUDENCE; MEN; MOTIVATION; PALLIATIVE CARE; PERSONS; PHYSICIAN-PATIENT RELATIONS; PHYSICIANS; RIGHT TO DIE; SEX OFFENSES; SEXUALITY; SOCIAL CHANGE; SOCIAL CONTROL, FORMAL; SOCIAL CONTROL, INFORMAL; SOCIAL DOMINANCE; SOCIAL VALUES; STATE GOVERNMENT; SUICIDE, ASSISTED; TRUST; UNITED STATES; VIRTUES; VULNERABLE POPULATIONS; WOMEN;

EID: 0033106468     PISSN: 00141704     EISSN: None     Source Type: Journal    
DOI: 10.1086/233921     Document Type: Article

References (84)

1. Scientific Papers: Physiology, Medicine, Surgery, Geology, vol. 38 of Harvard Classics, ed. Charles W. Eliot (Cambridge, Mass.: P. F. Collier & Sons, 1910), p. 3.
2. R. D. Orr, N. Pang, E. D. Pellegrino, and M. Seigier, "Use of the Hippocratic Oath: A Review of Twentieth Century Practice and a Content Analysis of Oaths Administered in Medical Schools in the U.S. and Canada in 1993 "Journal of Clinical Ethics 8 (1997): 377-88.
3. Ronald Dworkin et al., "Assisted Suicide: The Philosophers' Brief," New York Review of Books 44 (March 27, 1997): 41-47; pp. 41-42 are an introduction authored solely by Dworkin.
4. For an argument that the right to assisted suicide does not merit constitutional protection by an author who believes the practice should be legalized by democratic processes, see Cass Sunstein, "The Right to Die," Yale Law Journal 106 (1997): 1123-63.
5. Dworkin et al., p. 41.
6. Ibid., p. 44.
7. Ibid., p. 43, emphasis added.
8. John Rawls, Political Liberalism (New York: Columbia University Press, 1996), p. 243; cf. pp. 1-li, as well as "The Idea of Public Reason Revisited," University of Chicago Law Review 64 (1997): 765-807.
9. John Rawls, Political Liberalism (New York: Columbia University Press, 1996), p. 243; cf. pp. 1-li, as well as "The Idea of Public Reason Revisited," University of Chicago Law Review 64 (1997): 765-807.
10. Ibid., p. 42.
11. Ibid.
12. Ibid., p. 45, emphasis added.
13. R. W. Carlson, M. L. Campbell, and R. R. Frank, "Life Support: The Debate Continues," Chest 109 (1996): 852-53; a patient is "terminally weaned" when the support provided by the mechanical ventilator is gradually decreased but the endotracheal tube is left in place.
14. William C. Wilson, Nicholas G. Smedira, Carol Fink, James A. McDowell, and John M. Luce, "Ordering and Administration of Sedatives and Analgesics during the Withholding and Withdrawal of Life Support from Critically Ill Patients," Journal of the American Medical Association 267 (1992): 949-53, esp. p. 949.
15. Ibid., p. 953.
16. M. Andrews, T. R. Bell, S. A. Smith, J. F. Tischler, and J. M. Veglia, "Dehydration in Terminally Ill Patients: Is It Appropriate Palliative Care?" Postgraduate Medicine 93 (1993): 201-3, 206-8, cited at Howard Brody, Margaret L. Campbell, Kathy Faber-Langendoen, and Karen S. Ogle, "Withdrawing Intensive Lite-Sustaining Treatment - Recommendations for Compassionate Clinical Management," New England Journal of Medicine 336 (1997): 652-57, n. 50.
17. M. Andrews, T. R. Bell, S. A. Smith, J. F. Tischler, and J. M. Veglia, "Dehydration in Terminally Ill Patients: Is It Appropriate Palliative Care?" Postgraduate Medicine 93 (1993): 201-3, 206-8, cited at Howard Brody, Margaret L. Campbell, Kathy Faber-Langendoen, and Karen S. Ogle, "Withdrawing Intensive Lite-Sustaining Treatment - Recommendations for Compassionate Clinical Management," New England Journal of Medicine 336 (1997): 652-57, n. 50.
18. See Judith Jarvis Thomson, "Rights and Deaths," Philosophy and Public Affairs 2 (1973): 146-59, sec. II; also Thomas Nagel, "War and Massacre," Philosophy and Public Affairs 1 (1972): 123-44, pp. 130-31.
19. See Judith Jarvis Thomson, "Rights and Deaths," Philosophy and Public Affairs 2 (1973): 146-59, sec. II; also Thomas Nagel, "War and Massacre," Philosophy and Public Affairs 1 (1972): 123-44, pp. 130-31.
20. Dworkin et al., p. 42; see also F. M. Kamm, "A Right to Choose Death?" Boston Review 22 (1997): 20-23, esp. n. 1 and accompanying text.
21. Dworkin et al., p. 42; see also F. M. Kamm, "A Right to Choose Death?" Boston Review 22 (1997): 20-23, esp. n. 1 and accompanying text.
22. See Robert P. George, Making Men Moral (New York: Oxford University Press, 1993), p. 190.
23. See the brief but very illuminating remarks of Thomas Scanlon, "Promises and Practices," Philosophy and Public Affairs 19 (1990): 199-226, pp. 223 ff.
24. Whether the reasons provided by an oath substitute for other of the agent's reasons or supplement other reasons which remain in force is an interesting question but one I cannot pursue here. On substitutional and supplementary reasons generally, see Joseph Raz, "Authority and Justification," Philosophy and Public Affairs 14 (1985): 3-29.
25. For the thought that the prohibitions of the Hippocratic Oath respond to what I have called the "role-specific temptations" of phydcians, I am indebted to Leon Kass, "Why Doctors Must Not Kill," Commonweal 118 (1991): 472-76, particularly p. 474.
26. I say "typically" because X might have reasons to seduce Y with the intention of breaking off at the last moment; cf. Albert Camus, The Stranger (New York: Vintage, 1954), p. 40.
27. See American Medical Association (AMA), Council on Ethical and Judicial Affairs, "Sexual Misconduct in the Practice of Medicine," Journal of the American Medical Association 266 (1991): 2741-45, nn. 2-4 and accompanying text.
28. Kass, pp. 473 and 476; see also Richard A. McCormick, S.J., "Euthanasia or Allowing to Die: Ethical Distinctions" (unpublished manuscript, University of Notre Dame), p. 19.
29. Kass, pp. 473 and 476; see also Richard A. McCormick, S.J., "Euthanasia or Allowing to Die: Ethical Distinctions" (unpublished manuscript, University of Notre Dame), p. 19.
30. See generally Mary Vachon, Occupational Stress in the Care of the Critically Ill, the Dying and the Bereaved (New York: Hemisphere Publishing, 1987).
31. Kass, p. 474.
32. John McDowell, "Are Moral Requirements Hypothetical Imperatives?" Proceedings of the Aristotelian Society (1978), pp. 13-29, p. 27. There may seem to be something paradoxical about the suggestion that a virtue should be centered on or associated with an absolute prohibition. Virtue theories typically accord a preeminent role to the cultivation of practical wisdom. They do so, it might be thought, because good actions proceed from properly conducted practical deliberation about the circumstances of an action and its probable consequences. Good action, on this view, requires just the sort of reasoned flexibility that is precluded by adherence to absolute prohibitions. This is why many contemporary defenses of virtue theory oppose it to the rigidity of rule-based theories of morality. There is, however, no paradox in asserting that a person's virtuous character depends in part upon her honoring absolute prohibitions. The thought that there is depends upon an unduly restricted conception of virtue theory. Thus as one would expect, absolute prohibitions occupy a central place in the powerful and richly detailed virtue theory of Thomas Aquinas. It is important that Aquinas's arguments for the claim that it is always wrong to perform an act of a given sort typically turn on the claim that acts of that kind are contrary to one or another of the virtues. Furthermore, in Aquinas's view, the virtuous agent does not exercise practical reason to determine whether she may act against a putatively absolute prohibition in the case at hand. Rather she exerc ses it to determine whether the action she is considering is, under the circumstances, of a type governed by the absolute prohibition in question. Aquinas's famous discussion of whether an agent who takes another's property in desperation violates the absolute prohibition of theft is exemplary in this regard; see Summa theologiae II-IiI66,7 ad 2. Finally, though I cannot argue the point here, I would conjecture that the emergence of casuistry as a theory of moral reasoning in the early modern period is best explained by the fact that thinkers like Aquinas had assigned practical reason precisely the task I have just described. For the compatibility of virtue theory with absolute prohibitions, see generally Joseph Boyle, "Natural Law and the Ethics of Traditions," in Natural Law Theory: Contemporary Essays ed. Robert P. George (New York: Oxford University Press, 1992), pp. 3-30, For an attempt to accommodate an absolute prohibition on lying within a Thomistic theory of the virtues but without Aquinas's theological presuppositions, see Alasdair MacIntyre, "Truthfulness, Lies and Moral Philosophers: What Can We Learn from Mill and Kant?" in Tanner Lectures on Human Values, vol. 16 (Salt Lake City: University of Utah Press, 1995), pp. 307-62. On the emergence of casuistry with explicit reference to Aquinas's discussion of theft, see Edmund Leites, ed., Conscience and Casuistry in Early Modern Europe (New York: Cambridge University Press, 1988), p. 7.
33. John McDowell, "Are Moral Requirements Hypothetical Imperatives?" Proceedings of the Aristotelian Society (1978), pp. 13-29, p. 27. There may seem to be something paradoxical about the suggestion that a virtue should be centered on or associated with an absolute prohibition. Virtue theories typically accord a preeminent role to the cultivation of practical wisdom. They do so, it might be thought, because good actions proceed from properly conducted practical deliberation about the circumstances of an action and its probable consequences. Good action, on this view, requires just the sort of reasoned flexibility that is precluded by adherence to absolute prohibitions. This is why many contemporary defenses of virtue theory oppose it to the rigidity of rule-based theories of morality. There is, however, no paradox in asserting that a person's virtuous character depends in part upon her honoring absolute prohibitions. The thought that there is depends upon an unduly restricted conception of virtue theory. Thus as one would expect, absolute prohibitions occupy a central place in the powerful and richly detailed virtue theory of Thomas Aquinas. It is important that Aquinas's arguments for the claim that it is always wrong to perform an act of a given sort typically turn on the claim that acts of that kind are contrary to one or another of the virtues. Furthermore, in Aquinas's view, the virtuous agent does not exercise practical reason to determine whether she may act against a putatively absolute prohibition in the case at hand. Rather she exerc ses it to determine whether the action she is considering is, under the circumstances, of a type governed by the absolute prohibition in question. Aquinas's famous discussion of whether an agent who takes another's property in desperation violates the absolute prohibition of theft is exemplary in this regard; see Summa theologiae II-IiI66,7 ad 2. Finally, though I cannot argue the point here, I would conjecture that the emergence of casuistry as a theory of moral reasoning in the early modern period is best explained by the fact that thinkers like Aquinas had assigned practical reason precisely the task I have just described. For the compatibility of virtue theory with absolute prohibitions, see generally Joseph Boyle, "Natural Law and the Ethics of Traditions," in Natural Law Theory: Contemporary Essays ed. Robert P. George (New York: Oxford University Press, 1992), pp. 3-30, For an attempt to accommodate an absolute prohibition on lying within a Thomistic theory of the virtues but without Aquinas's theological presuppositions, see Alasdair MacIntyre, "Truthfulness, Lies and Moral Philosophers: What Can We Learn from Mill and Kant?" in Tanner Lectures on Human Values, vol. 16 (Salt Lake City: University of Utah Press, 1995), pp. 307-62. On the emergence of casuistry with explicit reference to Aquinas's discussion of theft, see Edmund Leites, ed., Conscience and Casuistry in Early Modern Europe (New York: Cambridge University Press, 1988), p. 7.
34. John McDowell, "Are Moral Requirements Hypothetical Imperatives?" Proceedings of the Aristotelian Society (1978), pp. 13-29, p. 27. There may seem to be something paradoxical about the suggestion that a virtue should be centered on or associated with an absolute prohibition. Virtue theories typically accord a preeminent role to the cultivation of practical wisdom. They do so, it might be thought, because good actions proceed from properly conducted practical deliberation about the circumstances of an action and its probable consequences. Good action, on this view, requires just the sort of reasoned flexibility that is precluded by adherence to absolute prohibitions. This is why many contemporary defenses of virtue theory oppose it to the rigidity of rule-based theories of morality. There is, however, no paradox in asserting that a person's virtuous character depends in part upon her honoring absolute prohibitions. The thought that there is depends upon an unduly restricted conception of virtue theory. Thus as one would expect, absolute prohibitions occupy a central place in the powerful and richly detailed virtue theory of Thomas Aquinas. It is important that Aquinas's arguments for the claim that it is always wrong to perform an act of a given sort typically turn on the claim that acts of that kind are contrary to one or another of the virtues. Furthermore, in Aquinas's view, the virtuous agent does not exercise practical reason to determine whether she may act against a putatively absolute prohibition in the case at hand. Rather she exerc ses it to determine whether the action she is considering is, under the circumstances, of a type governed by the absolute prohibition in question. Aquinas's famous discussion of whether an agent who takes another's property in desperation violates the absolute prohibition of theft is exemplary in this regard; see Summa theologiae II-IiI66,7 ad 2. Finally, though I cannot argue the point here, I would conjecture that the emergence of casuistry as a theory of moral reasoning in the early modern period is best explained by the fact that thinkers like Aquinas had assigned practical reason precisely the task I have just described. For the compatibility of virtue theory with absolute prohibitions, see generally Joseph Boyle, "Natural Law and the Ethics of Traditions," in Natural Law Theory: Contemporary Essays ed. Robert P. George (New York: Oxford University Press, 1992), pp. 3-30, For an attempt to accommodate an absolute prohibition on lying within a Thomistic theory of the virtues but without Aquinas's theological presuppositions, see Alasdair MacIntyre, "Truthfulness, Lies and Moral Philosophers: What Can We Learn from Mill and Kant?" in Tanner Lectures on Human Values, vol. 16 (Salt Lake City: University of Utah Press, 1995), pp. 307-62. On the emergence of casuistry with explicit reference to Aquinas's discussion of theft, see Edmund Leites, ed., Conscience and Casuistry in Early Modern Europe (New York: Cambridge University Press, 1988), p. 7.
35. As the American Medical Association's "Code of Medical Ethics" says: "The Oath of Hippocrates (Christianized in the tenth or eleventh century A.D. to eliminate reference to pagan gods) has remained in western civilization as an expression of ideal conduct for the physician" ; see Code of Medical Ethics: Current Opinions with Annotations (Chicago: American Medical Association, 1994). On conception-dependent desires, see Rawls, Political Liberalism, pp. 82 ff.
36. As the American Medical Association's "Code of Medical Ethics" says: "The Oath of Hippocrates (Christianized in the tenth or eleventh century A.D. to eliminate reference to pagan gods) has remained in western civilization as an expression of ideal conduct for the physician" ; see Code of Medical Ethics: Current Opinions with Annotations (Chicago: American Medical Association, 1994). On conception-dependent desires, see Rawls, Political Liberalism, pp. 82 ff.
37. See n. 2 above.
38. "The Oath of the Class of 1994," on file with the Office of Student Affairs, Harvard Medical School, Cambridge, Mass.
39. Rawls, Political Liberalism, p. lix.
40. According to a 1990 study, 50 percent of Dutch physicians "suggest" physician-assisted suicide to their patients. See Herbert Hendin, "Correspondence," New England Journal of Medicine 336 (1997): 1385,
41. citing Paul J. van der Maas, J. M. van Delden, and Loes Pijenborg, "Euthanasia and Other Medical Decisions Concerning the End of Life," Health Policy 22 (1992): 1-262. One reason for thinking the percentage would be higher in the United States than in the Netherlands is connected with the requirements of informed consent. Some hospital counsels warn that if physician-assisted suicide were legalized here, staff physicians at American hospitals would be required to present assisted suicide as an option to the terminally ill in order to obtain their informed consent to any treatment of their condition. Or at least, they warn that physicians would be required to do so in the absence of prohibition by a legislatively imposed "gag rule"; the model statute cited at n. 34 below does not contain any such rule. It may even be that worries about informed consent account for the high incidence of discussion of physician-assisted suicide between Dutch doctors and their patients. I am grateful to Maura Ryan for these points.
42. Derek Humphry, Letter to the Editor, New York Times, quoted in New York Times (October 26, 1997), sec. 1, p. 19.
43. For the latter, see Hanson, Tulsky, and Danis, "Can Clinical Interventions Change Care at the End of Life?" Annals of Internal Medicine 126 (1997): 381-88; also "Doctors Ignoring Last Wishes of the Dying, Study Finds," New York Times News Service (November 22, 1995).
44. For the latter, see Hanson, Tulsky, and Danis, "Can Clinical Interventions Change Care at the End of Life?" Annals of Internal Medicine 126 (1997): 381-88; also "Doctors Ignoring Last Wishes of the Dying, Study Finds," New York Times News Service (November 22, 1995).
45. Charles H. Baron et al., "A Model State Act to Authorize and Regulate Physician-Assisted Suicide," Harvard Journal of Legislation 33 (1996): 1-34, see pp. 27-28. As of this writing the model statute is also available through the Deathnet homepage at http:// www.rights.org/deathnet/MSA.html.
46. Baron et al., p. 17.
47. According to a Harris poll released April 28, 1997, more Americans regard medicine as a "very prestigious" profession than any other occupation. The poll also concludes that 87 percent of Americans regard medicine as "prestigious" - far more than any other occupation except scientist, which medicine edged out by a single percentage point. Results of the poll are on file with Louis Harris and Associates, Inc. I am grateful to the Information Services section of Harris and Associates for maki ng their data available to me.
48. See Baron et al., pp. 5-6.
49. As the American Medical Association acknowledges; see "Brief of the American Medical Association, the American Nurses Association and the American Psychiatric Association, et al.," pp. 7-8, filed in Vaccov. Quill, 117 S. Ct. 2232 (1997).
50. Ibid.
51. See van der Maas, van Delden, and Pijenborg, p. 50, cited at Susan M. Wolf, "Gender, Feminism and Death," in Feminism and Bioethics: Beyond Reproduction, ed. Susan M. Wolf (New York: Oxford University Press, 1996), pp. 282-317, p. 313, n. 62. Wolf's essay is an outstanding feminist analysis of euthanasia and physician-assisted suicide, with special attention to the way self-sacrificial images of women in literature and culture bear on the questions at issue.
52. See van der Maas, van Delden, and Pijenborg, p. 50, cited at Susan M. Wolf, "Gender, Feminism and Death," in Feminism and Bioethics: Beyond Reproduction, ed. Susan M. Wolf (New York: Oxford University Press, 1996), pp. 282-317, p. 313, n. 62. Wolf's essay is an outstanding feminist analysis of euthanasia and physician-assisted suicide, with special attention to the way self-sacrificial images of women in literature and culture bear on the questions at issue.
53. Seidlitz, Duberstein, Cox, and Conwell, "Attitudes of Older People toward Suicide and Assisted Suicide: An Analysis of Gallup Poll Findings," Journal of the American Geriatric Society 43 (1995): 993-98, p. 996.
54. The 'may' is important for two reasons. One is that there are a number of possible explanations for Gallup's polling data. The other is that a Harris poll conducted immediately after the U.S. Supreme Court decided Glucksberg and Quill showed that a majority of those polled disagreed with the Court's decision, regardless of race or annual income. Whether the results of the poll indicate an enduring trend or merely an episodic reaction to the Court's decision can only be shown by further polling. One reason for questioning the significance of its results is that it showed those polled were equally likely to disagree with the Court's decision whether or not they were familiar with the cases decided. Unlike the earlier Gallup poll, the Harris poll surveyed adults in all age groups. Results of this poll are on file with Louis Harris and Associates, Inc. I am grateful to the Information Services section of Harris and Associates for making their data available to me and to the editors of Ethics for stressing the need to clarify the first of I hese points.
55. Dworkin et al., p. 46.
56. Ibid.
57. Bowers v. Hardwick may indicate the Supreme Court's refusal to recognize this interest, but Dworkin's writing suggests that he thinks citizens have it. Indeed it is precisely because he thinks citizens have this interest and the Court refused to recognize it that he thinks Bowers mistaken. See Ronald Dworkin, A Matter of Principle (Cambridge, Mass.: Harvard University Press, 1985), p. 68.
58. Richard A. Posner and Katharine B. Silbaugh, A Guide to America's Sex Laws (Chicago: University of Chicago Press, 1996), pp. 111-28.
59. Ibid., p. 113, emphasis added.
60. Ibid.
61. The purposes are prosecution for an injury resulting from sexual conduct during treatment; see 750.520b. (1) (f) (iv) of the Michigan Criminal Code. 50. See "Public Vulnerable to Bad Doctors, Study Says," Los Angeles Times (April 16, 1989), sec. I, p. 3: "In a 100-page report, the University of San Diego's Center for Public Interest Law asserted that a massive restructuring of the California Board of Medical Quality Assurance and the procedures it uses for disciplining physicians will have to be undertaken by the Legislature before consumers can be assured that incompetent doctors are being weeded out of the medical system." That the story from the Times is included in the legislative history of the California statute suggests that the Legislature passed the bill at least in part in response to the study, which clearly evinced concern with public confidence in the medical profession. I am grateful to the staff of the Archives of the California State Assembly for making documents relevant to the bill's legislative history available to me.
62. It might be objected that there is a disanalogy between the cases because statutes prohibiting sexual relations between physicians and patients do not make it impossible for patients to act on their liberty interest in having nex with other competent and consenting adults. They simply forbid them to act on it with their doctors. But there is no disanalogy. Statutes prohibiting physician-assisted suicide do not make it impossible for patients to act on their alleged liberty interest in determining the time and manner of their deaths. They simply forbid one way of acting on that interest, actions which involve the help of their doctors.
63. I am grateful to Cass Sunstein for urging me to emphasize this important point.
64. Rawls, Political Liberalism, p. 248.
65. Ibid., p. 82.
66. Ibid., p. 77.
67. Ibid., p. lix.
68. See Michael Walzer,"Feed the Face," New Republic 84 (June 9, 1997): 29.
69. See n. 38.
70. I am grateful to Maura Ryan for invaluable discussion and bibliographic advice.
71. I am indebted to Steven H. Miles, "Physicians and Their Patients' Suicides," Journal of the American Medical Association 271 (1994): 1786-88.
72. Robert N. Butler, "Psychiatry and the Elderly: An Overview," American Journal of Psychiatry 132 (1975): 893-900; also Pirkko J. Clarke, "Exploration of Countertransference toward the Dying," American Journal of Orthopsychiatry 51 (1981): 71-77. The point is especially well put in Edmund D. Pellegrino, "Compassion Needs Reason Too," Journal of the American Medical Association 270 (1993): 874-75.
73. Robert N. Butler, "Psychiatry and the Elderly: An Overview," American Journal of Psychiatry 132 (1975): 893-900; also Pirkko J. Clarke, "Exploration of Countertransference toward the Dying," American Journal of Orthopsychiatry 51 (1981): 71-77. The point is especially well put in Edmund D. Pellegrino, "Compassion Needs Reason Too," Journal of the American Medical Association 270 (1993): 874-75.
74. Robert N. Butler, "Psychiatry and the Elderly: An Overview," American Journal of Psychiatry 132 (1975): 893-900; also Pirkko J. Clarke, "Exploration of Countertransference toward the Dying," American Journal of Orthopsychiatry 51 (1981): 71-77. The point is especially well put in Edmund D. Pellegrino, "Compassion Needs Reason Too," Journal of the American Medical Association 270 (1993): 874-75.
75. See n. 31.
76. See Richard Uhlmann and Robert Pearlman, "Perceived Quality of Life and Preferences for Life-Sustaining Treatment in Older Adults," Archives of Internal Medicine 151 (1991): 495-97. Another study found that physicians significantly underestimated their chronically ill patients' desire for resuscitation. See Richard Uhlmann, Robert Pearlman, and Kevin Cain, "Physicians' and Spouses' Predictions of Elderly Patients' Resuscitation Preferences," Journal of Gerontology 43 (1988): M115-M121.
77. See Richard Uhlmann and Robert Pearlman, "Perceived Quality of Life and Preferences for Life-Sustaining Treatment in Older Adults," Archives of Internal Medicine 151 (1991): 495-97. Another study found that physicians significantly underestimated their chronically ill patients' desire for resuscitation. See Richard Uhlmann, Robert Pearlman, and Kevin Cain, "Physicians' and Spouses' Predictions of Elderly Patients' Resuscitation Preferences," Journal of Gerontology 43 (1988): M115-M121.
78. "It's Over Debbie," Journal of the American Medical Association 259 (1988): 272.
79. See, e.g., Timothy Quill, Death and Dignity (New York: Norton, 1993), pp. 16, 38-39.
80. Council on Judicial and Ethical Affairs of the American Medical Association (AMA), "Black-White Disparities in Health Care," Journal of the American Medical Association 263 (1990): 2344-46.
81. Robert Blendon, Linda Aiken, Howard Freeman, and Christopher Corey, "Access to Medical Care for Black and White Americans," Journal of the American Medical Association 261 (1989): 278-81.
82. Cited at James H. Jones, "The Tuskegee Legacy: AIDS and the Black Community," Hastings Center Report 22 (1992): 38-40, n. 1 and accompanying text.
83. On the difficulty and the explanation, see National Institutes of Health (NIH), NIH Outreach Notebook on the Inclusion of Women and Minorities as Subjects in Clinical Studies, NIH Publ. no. 94-0324-P (Bethesda, Md.: NIH), p. 13, where the Tuskegee Syphilis Study is mentioned. I am grateful to Sue Ellen Levkoff for helpful discussion of this matter.
84. Jones, p. 39, which attributes resistance to clinical studies of AIDS to the legacy of Tuskegee.