Language and reality at the end of life

Journal of Law, Medicine and Ethics

Volumn 28, Issue 3, 2000, Pages 267-278

  Cohen Almagor, Raphael ^a  

^a NONE

Author keywords

[No Author keywords available]

Indexed keywords

BRAIN DEATH; COMMUNICATION DISORDER; DEATH AND EUTHANASIA; DEHUMANIZATION; HUMAN; HUMAN RELATION; MEDICAL ETHICS; PERSISTENT VEGETATIVE STATE; PROFESSIONAL PATIENT RELATIONSHIP; PSYCHOLOGICAL ASPECT; PUBLIC RELATIONS; REVIEW; RIGHT TO DIE; SEMANTICS; TERMINAL CARE; TREATMENT OUTCOME;

DEATH AND EUTHANASIA; PROFESSIONAL PATIENT RELATIONSHIP;

BRAIN DEATH; COMMUNICATION BARRIERS; DEHUMANIZATION; DOUBLE EFFECT; ETHICS, MEDICAL; HUMANS; INTERPROFESSIONAL RELATIONS; MEDICAL FUTILITY; PERSISTENT VEGETATIVE STATE; PROFESSIONAL-PATIENT RELATIONS; RIGHT TO DIE; SEMANTICS; TERMINAL CARE;

EID: 0034278484     PISSN: 10731105     EISSN: None     Source Type: Journal    
DOI: None     Document Type: Article

References (132)

1. H. Kuhse, The Sanctity of Life Doctrine in Medicine: A Critique (Oxford: Clarendon Press, 1987); H. Kuhse, "Quality of Life and the Death of 'Baby M,'" Bioethics, 6, no. 3 (1992): 233-250; H. Kuhse and P. Singer, Should the Baby Live? The Problem of Handicapped Infants (Oxford: Oxford University Press, 1985); P. Singer, Practical Ethics, 2nd ed. (Cambridge: Cambridge University Press, 1993); L. Chelluri, A. Grenvik, and M. Silverman, "Intensive Care For Critically Ill Elderly: Mortality, Costs, and Quality of Life," Archives of Internal Medicine, 155 (1995): 1013-1022. See also J.C. Joerden, "Peter Singer's Theories and Their Reception in Germany," in R. Cohen-Almagor, ed., Medical Ethics at the Dawn of the 21st Century (New York: New York Academy of Sciences, 2000): 150-156.
2. H. Kuhse, The Sanctity of Life Doctrine in Medicine: A Critique (Oxford: Clarendon Press, 1987); H. Kuhse, "Quality of Life and the Death of 'Baby M,'" Bioethics, 6, no. 3 (1992): 233-250; H. Kuhse and P. Singer, Should the Baby Live? The Problem of Handicapped Infants (Oxford: Oxford University Press, 1985); P. Singer, Practical Ethics, 2nd ed. (Cambridge: Cambridge University Press, 1993); L. Chelluri, A. Grenvik, and M. Silverman, "Intensive Care For Critically Ill Elderly: Mortality, Costs, and Quality of Life," Archives of Internal Medicine, 155 (1995): 1013-1022. See also J.C. Joerden, "Peter Singer's Theories and Their Reception in Germany," in R. Cohen-Almagor, ed., Medical Ethics at the Dawn of the 21st Century (New York: New York Academy of Sciences, 2000): 150-156.
3. H. Kuhse, The Sanctity of Life Doctrine in Medicine: A Critique (Oxford: Clarendon Press, 1987); H. Kuhse, "Quality of Life and the Death of 'Baby M,'" Bioethics, 6, no. 3 (1992): 233-250; H. Kuhse and P. Singer, Should the Baby Live? The Problem of Handicapped Infants (Oxford: Oxford University Press, 1985); P. Singer, Practical Ethics, 2nd ed. (Cambridge: Cambridge University Press, 1993); L. Chelluri, A. Grenvik, and M. Silverman, "Intensive Care For Critically Ill Elderly: Mortality, Costs, and Quality of Life," Archives of Internal Medicine, 155 (1995): 1013-1022. See also J.C. Joerden, "Peter Singer's Theories and Their Reception in Germany," in R. Cohen-Almagor, ed., Medical Ethics at the Dawn of the 21st Century (New York: New York Academy of Sciences, 2000): 150-156.
4. H. Kuhse, The Sanctity of Life Doctrine in Medicine: A Critique (Oxford: Clarendon Press, 1987); H. Kuhse, "Quality of Life and the Death of 'Baby M,'" Bioethics, 6, no. 3 (1992): 233-250; H. Kuhse and P. Singer, Should the Baby Live? The Problem of Handicapped Infants (Oxford: Oxford University Press, 1985); P. Singer, Practical Ethics, 2nd ed. (Cambridge: Cambridge University Press, 1993); L. Chelluri, A. Grenvik, and M. Silverman, "Intensive Care For Critically Ill Elderly: Mortality, Costs, and Quality of Life," Archives of Internal Medicine, 155 (1995): 1013-1022. See also J.C. Joerden, "Peter Singer's Theories and Their Reception in Germany," in R. Cohen-Almagor, ed., Medical Ethics at the Dawn of the 21st Century (New York: New York Academy of Sciences, 2000): 150-156.
5. H. Kuhse, The Sanctity of Life Doctrine in Medicine: A Critique (Oxford: Clarendon Press, 1987); H. Kuhse, "Quality of Life and the Death of 'Baby M,'" Bioethics, 6, no. 3 (1992): 233-250; H. Kuhse and P. Singer, Should the Baby Live? The Problem of Handicapped Infants (Oxford: Oxford University Press, 1985); P. Singer, Practical Ethics, 2nd ed. (Cambridge: Cambridge University Press, 1993); L. Chelluri, A. Grenvik, and M. Silverman, "Intensive Care For Critically Ill Elderly: Mortality, Costs, and Quality of Life," Archives of Internal Medicine, 155 (1995): 1013-1022. See also J.C. Joerden, "Peter Singer's Theories and Their Reception in Germany," in R. Cohen-Almagor, ed., Medical Ethics at the Dawn of the 21st Century (New York: New York Academy of Sciences, 2000): 150-156.
6. H. Kuhse, The Sanctity of Life Doctrine in Medicine: A Critique (Oxford: Clarendon Press, 1987); H. Kuhse, "Quality of Life and the Death of 'Baby M,'" Bioethics, 6, no. 3 (1992): 233-250; H. Kuhse and P. Singer, Should the Baby Live? The Problem of Handicapped Infants (Oxford: Oxford University Press, 1985); P. Singer, Practical Ethics, 2nd ed. (Cambridge: Cambridge University Press, 1993); L. Chelluri, A. Grenvik, and M. Silverman, "Intensive Care For Critically Ill Elderly: Mortality, Costs, and Quality of Life," Archives of Internal Medicine, 155 (1995): 1013-1022. See also J.C. Joerden, "Peter Singer's Theories and Their Reception in Germany," in R. Cohen-Almagor, ed., Medical Ethics at the Dawn of the 21st Century (New York: New York Academy of Sciences, 2000): 150-156.
7. Compare E.W. Keyserlingk, Sanctity of Life or Quality of Life (Ottawa: Law Reform Commission in Canada, 1980): at 18; J.F. Keenan, "The Concept of Sanctity of Life and Its Use in Contemporary Bioethical Discussion," in Kurt Bayertz, ed., Sanctity of Life and Human Dignity (Dordrecht: Kluwer, 1996): 1-18; M.P. Previn, "Assisted Suicide and Religion: Conflicting Conceptions of the Sanctity of Human Life," Georgetown Law Journal, 84 (February 1996): 589-616; D.J. Bleich, "Life as an Intrinsic Rather Than Instrumental Good: The 'Spiritual' Case Against Euthanasia," Issues in Law & Medicine, 9, no. 2 (Fall 1993): 139-149; N. Rotenstreich, "On the Sanctity of Life," in Yeshayahu Gafni and Aviezer Ravitzki, eds., The Sanctity of Life and the Defying of the Spirit (in Hebrew) (Jerusalem: The Zalman Shazar Center for the Study of Jewish History, 1993): 27-34.
8. Compare E.W. Keyserlingk, Sanctity of Life or Quality of Life (Ottawa: Law Reform Commission in Canada, 1980): at 18; J.F. Keenan, "The Concept of Sanctity of Life and Its Use in Contemporary Bioethical Discussion," in Kurt Bayertz, ed., Sanctity of Life and Human Dignity (Dordrecht: Kluwer, 1996): 1-18; M.P. Previn, "Assisted Suicide and Religion: Conflicting Conceptions of the Sanctity of Human Life," Georgetown Law Journal, 84 (February 1996): 589-616; D.J. Bleich, "Life as an Intrinsic Rather Than Instrumental Good: The 'Spiritual' Case Against Euthanasia," Issues in Law & Medicine, 9, no. 2 (Fall 1993): 139-149; N. Rotenstreich, "On the Sanctity of Life," in Yeshayahu Gafni and Aviezer Ravitzki, eds., The Sanctity of Life and the Defying of the Spirit (in Hebrew) (Jerusalem: The Zalman Shazar Center for the Study of Jewish History, 1993): 27-34.
9. Compare E.W. Keyserlingk, Sanctity of Life or Quality of Life (Ottawa: Law Reform Commission in Canada, 1980): at 18; J.F. Keenan, "The Concept of Sanctity of Life and Its Use in Contemporary Bioethical Discussion," in Kurt Bayertz, ed., Sanctity of Life and Human Dignity (Dordrecht: Kluwer, 1996): 1-18; M.P. Previn, "Assisted Suicide and Religion: Conflicting Conceptions of the Sanctity of Human Life," Georgetown Law Journal, 84 (February 1996): 589-616; D.J. Bleich, "Life as an Intrinsic Rather Than Instrumental Good: The 'Spiritual' Case Against Euthanasia," Issues in Law & Medicine, 9, no. 2 (Fall 1993): 139-149; N. Rotenstreich, "On the Sanctity of Life," in Yeshayahu Gafni and Aviezer Ravitzki, eds., The Sanctity of Life and the Defying of the Spirit (in Hebrew) (Jerusalem: The Zalman Shazar Center for the Study of Jewish History, 1993): 27-34.
10. Compare E.W. Keyserlingk, Sanctity of Life or Quality of Life (Ottawa: Law Reform Commission in Canada, 1980): at 18; J.F. Keenan, "The Concept of Sanctity of Life and Its Use in Contemporary Bioethical Discussion," in Kurt Bayertz, ed., Sanctity of Life and Human Dignity (Dordrecht: Kluwer, 1996): 1-18; M.P. Previn, "Assisted Suicide and Religion: Conflicting Conceptions of the Sanctity of Human Life," Georgetown Law Journal, 84 (February 1996): 589-616; D.J. Bleich, "Life as an Intrinsic Rather Than Instrumental Good: The 'Spiritual' Case Against Euthanasia," Issues in Law & Medicine, 9, no. 2 (Fall 1993): 139-149; N. Rotenstreich, "On the Sanctity of Life," in Yeshayahu Gafni and Aviezer Ravitzki, eds., The Sanctity of Life and the Defying of the Spirit (in Hebrew) (Jerusalem: The Zalman Shazar Center for the Study of Jewish History, 1993): 27-34.
11. Compare E.W. Keyserlingk, Sanctity of Life or Quality of Life (Ottawa: Law Reform Commission in Canada, 1980): at 18; J.F. Keenan, "The Concept of Sanctity of Life and Its Use in Contemporary Bioethical Discussion," in Kurt Bayertz, ed., Sanctity of Life and Human Dignity (Dordrecht: Kluwer, 1996): 1-18; M.P. Previn, "Assisted Suicide and Religion: Conflicting Conceptions of the Sanctity of Human Life," Georgetown Law Journal, 84 (February 1996): 589-616; D.J. Bleich, "Life as an Intrinsic Rather Than Instrumental Good: The 'Spiritual' Case Against Euthanasia," Issues in Law & Medicine, 9, no. 2 (Fall 1993): 139-149; N. Rotenstreich, "On the Sanctity of Life," in Yeshayahu Gafni and Aviezer Ravitzki, eds., The Sanctity of Life and the Defying of the Spirit (in Hebrew) (Jerusalem: The Zalman Shazar Center for the Study of Jewish History, 1993): 27-34.
12. Compare U. Lowental, "Euthanasia: A Serene Voyage to Death," in Amnon Carmi, ed., Euthanasia (Berlin: Springer-Verlag, 1984): 180-184. For discussion on the origin and rationale of the concept of dignity, see K. Bayertz, "Human Dignity: Philosophical Origin and Scientific Erosion of an Idea," in K. Bayertz, ed., Sanctity of Life and Hitman Dignity (Dordrecht: Kluwer, 1996):73-90; D.J. Velleman, "A Right of Self-Termination," Ethics, 109, no. 3 (April 1999): 611-617.
13. Compare U. Lowental, "Euthanasia: A Serene Voyage to Death," in Amnon Carmi, ed., Euthanasia (Berlin: Springer-Verlag, 1984): 180-184. For discussion on the origin and rationale of the concept of dignity, see K. Bayertz, "Human Dignity: Philosophical Origin and Scientific Erosion of an Idea," in K. Bayertz, ed., Sanctity of Life and Hitman Dignity (Dordrecht: Kluwer, 1996):73-90; D.J. Velleman, "A Right of Self-Termination," Ethics, 109, no. 3 (April 1999): 611-617.
14. Compare U. Lowental, "Euthanasia: A Serene Voyage to Death," in Amnon Carmi, ed., Euthanasia (Berlin: Springer-Verlag, 1984): 180-184. For discussion on the origin and rationale of the concept of dignity, see K. Bayertz, "Human Dignity: Philosophical Origin and Scientific Erosion of an Idea," in K. Bayertz, ed., Sanctity of Life and Hitman Dignity (Dordrecht: Kluwer, 1996):73-90; D.J. Velleman, "A Right of Self-Termination," Ethics, 109, no. 3 (April 1999): 611-617.
15. L.P. Ulrich, The Patient Self-Determination Act (Washington D.C.: Georgetown University Press, 1999): at 88.
16. L.R. Kass, "Death with Dignity and the Sanctity of Life," in B.S. Kogan, ed., A Time to Be Born and a Time to Die (New York: Aldine DeGruyter, 1991): at 133. Kass argues that one has no more right to dignity than to beauty, courage, or wisdom. While it is puzzling to speak of a right to beauty, courage, or wisdom, I think all people have a right to dignity. It is part of a fundamental principle of respect for others that underlies liberal democracies.
17. Haim Cohn holds that human dignity is the source from which human rights are derived, and along with human rights, it is the foundation of freedom, justice, and peace. Cf. H.H. Cohn, "On the Meaning of Human Dignity," Israel Yearbook of Human Rights, 13 (1983): 226-251, at 226.
18. R. Cohen-Almagor, "Reflections on the Intriguing Issue of the Right to Die in Dignity," Israel Law Review, 29, no. 4 (1995): 677-701; R. Cohen-Almagor and M. Shmueli, "Can Life Be Evaluated? The Jewish Halachic Approach vs. the Quality of Life Approach in Medical Ethics: A Critical View," Theoretical Medicine and Bioethics, 21, no. 2 (2000): 117-137.
19. R. Cohen-Almagor, "Reflections on the Intriguing Issue of the Right to Die in Dignity," Israel Law Review, 29, no. 4 (1995): 677-701; R. Cohen-Almagor and M. Shmueli, "Can Life Be Evaluated? The Jewish Halachic Approach vs. the Quality of Life Approach in Medical Ethics: A Critical View," Theoretical Medicine and Bioethics, 21, no. 2 (2000): 117-137.
20. An eloquent characterization of this transformation is presented in Margaret Edson's 1999 Pulitzer-winning play, Wit.
21. Compare Z. Groswasser and L. Sazbon, "Outcome in 134 Patients with Prolonged Posttraumatic Unawareness," Journal of Neurosurgery, 72 (1990): at 81; C. Tommasino, "Coma and Vegetative State Are Not Interchangeable Terms," Anesthesiology, 83, no. 4 (October 1995): at 888.
22. Compare Z. Groswasser and L. Sazbon, "Outcome in 134 Patients with Prolonged Posttraumatic Unawareness," Journal of Neurosurgery, 72 (1990): at 81; C. Tommasino, "Coma and Vegetative State Are Not Interchangeable Terms," Anesthesiology, 83, no. 4 (October 1995): at 888.
23. B. Jennet and F. Plum, "Persistent Vegetative State after Brain Damage: A Syndrome in Search of a Name," The Lancet, 1 (1972): 734-737.
24. Id., at 735.
25. B. Jennett, "Clinical and Pathological Features of Vegetative Survival," in H.S. Levin and A.L. Benton, eds., Catastrophic Brain Injury (New York: Oxford University Press, 1996): at 5.
26. Ronald Dworkin has no qualms referring to some patients as vegetables. See, for instance, Life's Dominion (New York: Knopf, 1993): at 180, 230-232. See also C. Borthwick, "The Proof of the Vegetable: A Commentary on Medical Futility," Journal of Medical Ethics, 21 (1995): 206-208.
27. Ronald Dworkin has no qualms referring to some patients as vegetables. See, for instance, Life's Dominion (New York: Knopf, 1993): at 180, 230-232. See also C. Borthwick, "The Proof of the Vegetable: A Commentary on Medical Futility," Journal of Medical Ethics, 21 (1995): 206-208.
28. S.A.M. McLean, "Legal and Ethical Aspects of the Vegetative State "Journal of Clinical Pathology, 52 (1999): 490-493. Sandra Horton writes that "The difference between coma and vegetative state is that coma appears to have gradations, whereas PVS is a 'permanent' state of unawareness." See Horton, "Persistent Vegetative State: What Decides the Cut-off Point?" Intensive and Critical Care Nursing, 12 (February 1996): at 41.
29. S.A.M. McLean, "Legal and Ethical Aspects of the Vegetative State "Journal of Clinical Pathology, 52 (1999): 490-493. Sandra Horton writes that "The difference between coma and vegetative state is that coma appears to have gradations, whereas PVS is a 'permanent' state of unawareness." See Horton, "Persistent Vegetative State: What Decides the Cut-off Point?" Intensive and Critical Care Nursing, 12 (February 1996): at 41.
30. Compare statements of Safar and Meisel in "Philosophical, Ethical and Legal Aspects of Resuscitation Medicine. III. Discussion," Critical Care Medicine, 16, no. 10 (1988): 1069-1076, at 1069, 1074.
31. Compare The Hastings Center, Guidelines on the Termination of Life-Sustaining Treatment and the Care of the Dying (Bloomington, Indiana: Indiana University Press, 1987): at 112; Task Force on Ethics of the Society of Critical Care Medicine, "Consensus Report on the Ethics of Foregoing Life-Sustaining Treatments in the Critically Ill," Critical Care Medicine, 18 (1990): 1435-1439; R.D. Truog, A.S. Brett, and J. Frader, "The Problem with Futility," N. Engl. J. of Med., 326, no. 23 (1992): 1560-1564, at 1563. For a critical review of this approach, see S.J. Youngner, "Futility in Context," JAMA, 264, no. 10 (1990): 1295-1296.
32. Compare The Hastings Center, Guidelines on the Termination of Life-Sustaining Treatment and the Care of the Dying (Bloomington, Indiana: Indiana University Press, 1987): at 112; Task Force on Ethics of the Society of Critical Care Medicine, "Consensus Report on the Ethics of Foregoing Life-Sustaining Treatments in the Critically Ill," Critical Care Medicine, 18 (1990): 1435-1439; R.D. Truog, A.S. Brett, and J. Frader, "The Problem with Futility," N. Engl. J. of Med., 326, no. 23 (1992): 1560-1564, at 1563. For a critical review of this approach, see S.J. Youngner, "Futility in Context," JAMA, 264, no. 10 (1990): 1295-1296.
33. Compare The Hastings Center, Guidelines on the Termination of Life-Sustaining Treatment and the Care of the Dying (Bloomington, Indiana: Indiana University Press, 1987): at 112; Task Force on Ethics of the Society of Critical Care Medicine, "Consensus Report on the Ethics of Foregoing Life-Sustaining Treatments in the Critically Ill," Critical Care Medicine, 18 (1990): 1435-1439; R.D. Truog, A.S. Brett, and J. Frader, "The Problem with Futility," N. Engl. J. of Med., 326, no. 23 (1992): 1560-1564, at 1563. For a critical review of this approach, see S.J. Youngner, "Futility in Context," JAMA, 264, no. 10 (1990): 1295-1296.
34. Compare The Hastings Center, Guidelines on the Termination of Life-Sustaining Treatment and the Care of the Dying (Bloomington, Indiana: Indiana University Press, 1987): at 112; Task Force on Ethics of the Society of Critical Care Medicine, "Consensus Report on the Ethics of Foregoing Life-Sustaining Treatments in the Critically Ill," Critical Care Medicine, 18 (1990): 1435-1439; R.D. Truog, A.S. Brett, and J. Frader, "The Problem with Futility," N. Engl. J. of Med., 326, no. 23 (1992): 1560-1564, at 1563. For a critical review of this approach, see S.J. Youngner, "Futility in Context," JAMA, 264, no. 10 (1990): 1295-1296.
35. See, especially, J.C. Hackler and F.C. Hiller, "Family Consent to Orders Not to Resuscitate, Reconsidering Hospital Policy," JAMA, 264 (1990): 1281-1283; G.F. Molinari, "Persistent Vegetative State, Do Not Resuscitate . . . and Still More Words Doctors Use," Journal of the Neurological Sciences, 102 (1991): 125-127; T. Tomlinson and H. Brody, "Futility and the Ethics of Resuscitation," JAMA, 261 (1990): 1276-1280.
36. See, especially, J.C. Hackler and F.C. Hiller, "Family Consent to Orders Not to Resuscitate, Reconsidering Hospital Policy," JAMA, 264 (1990): 1281-1283; G.F. Molinari, "Persistent Vegetative State, Do Not Resuscitate . . . and Still More Words Doctors Use," Journal of the Neurological Sciences, 102 (1991): 125-127; T. Tomlinson and H. Brody, "Futility and the Ethics of Resuscitation," JAMA, 261 (1990): 1276-1280.
37. See, especially, J.C. Hackler and F.C. Hiller, "Family Consent to Orders Not to Resuscitate, Reconsidering Hospital Policy," JAMA, 264 (1990): 1281-1283; G.F. Molinari, "Persistent Vegetative State, Do Not Resuscitate . . . and Still More Words Doctors Use," Journal of the Neurological Sciences, 102 (1991): 125-127; T. Tomlinson and H. Brody, "Futility and the Ethics of Resuscitation," JAMA, 261 (1990): 1276-1280.
38. G.G. Celesia, "Persistent Vegetative State: Clinical and Ethical Issues," Theoretical Medicine, 18 (1997): 222-233.
39. M. Keatings, "The Biology of the Persistent Vegetative State, Legal and Ethical Implications for Transplantation: Viewpoints from Nursing," Transplantation Proceedings, 2, no. 3 (1990): 997-999, at 998.
40. C. Borthwick, "The Permanent Vegetative State: Ethical Crux, Medical Fiction?" Issues in Law & Medicine, 12, no. 2 (1996): 167-185, at 178.
41. R. Cohen-Almagor, "Some Observations on Post-Coma Unawareness Patients and on Other Forms of Unconscious Patients: Policy Proposals," Medicine and Law, 16, no. 3 (1997): 451-471. Consider, for instance, the following documented case: a 43-year-old man who was in prolonged unawareness for 17 months following anoxic brain damage before showing the first signs of awareness. He progressed to being able to tell stories and jokes, though was unable to recognize complex collections of objects in pictures and was unable to read. See G.A. Rosenberg, S.F. Johnson, and R.P. Brenner, "Recovery of Cognition after Prolonged Vegetative State," Annals of Neurology, 2 (1977): 167-168. In another case, a 44-year-old man who was in prolonged unawareness showed signs of recovery one year following a subarachnoid hemorrhage and eventually regained nearly normal physical and mental capabilities. See P.G. May and R. Kaelbling, "Coma of a Year's Duration with Favourable Outcome," Diseases of the Nervous System (December 1968): 837-840. Childs and Mercer reported the case of an 18-year-old woman who suffered a traumatic brain injury in a motor vehicle accident. After 15 months, the medical staff reported some responses on her part. Seventeen months after the injury, she became able to follow simple commands and could complete simple arithmetic problems and multiple-choice questions using eye blinks. She wrote: "Mom, I love you." N.L. Childs and WN. Mercer, "Brief Report: Late Improvement in Consciousness after Post-Traumatic Vegetative State," N. Engl. J. Med., 334 (1996): 24-25. See also the correspondence on "Late Improvement After Post-Traumatic Vegetative State," N. Engl. J. Med., 334 (1996): 1201-1202.
42. R. Cohen-Almagor, "Some Observations on Post-Coma Unawareness Patients and on Other Forms of Unconscious Patients: Policy Proposals," Medicine and Law, 16, no. 3 (1997): 451-471. Consider, for instance, the following documented case: a 43-year-old man who was in prolonged unawareness for 17 months following anoxic brain damage before showing the first signs of awareness. He progressed to being able to tell stories and jokes, though was unable to recognize complex collections of objects in pictures and was unable to read. See G.A. Rosenberg, S.F. Johnson, and R.P. Brenner, "Recovery of Cognition after Prolonged Vegetative State," Annals of Neurology, 2 (1977): 167-168. In another case, a 44-year-old man who was in prolonged unawareness showed signs of recovery one year following a subarachnoid hemorrhage and eventually regained nearly normal physical and mental capabilities. See P.G. May and R. Kaelbling, "Coma of a Year's Duration with Favourable Outcome," Diseases of the Nervous System (December 1968): 837-840. Childs and Mercer reported the case of an 18-year-old woman who suffered a traumatic brain injury in a motor vehicle accident. After 15 months, the medical staff reported some responses on her part. Seventeen months after the injury, she became able to follow simple commands and could complete simple arithmetic problems and multiple-choice questions using eye blinks. She wrote: "Mom, I love you." N.L. Childs and WN. Mercer, "Brief Report: Late Improvement in Consciousness after Post-Traumatic Vegetative State," N. Engl. J. Med., 334 (1996): 24-25. See also the correspondence on "Late Improvement After Post-Traumatic Vegetative State," N. Engl. J. Med., 334 (1996): 1201-1202.
43. R. Cohen-Almagor, "Some Observations on Post-Coma Unawareness Patients and on Other Forms of Unconscious Patients: Policy Proposals," Medicine and Law, 16, no. 3 (1997): 451-471. Consider, for instance, the following documented case: a 43-year-old man who was in prolonged unawareness for 17 months following anoxic brain damage before showing the first signs of awareness. He progressed to being able to tell stories and jokes, though was unable to recognize complex collections of objects in pictures and was unable to read. See G.A. Rosenberg, S.F. Johnson, and R.P. Brenner, "Recovery of Cognition after Prolonged Vegetative State," Annals of Neurology, 2 (1977): 167-168. In another case, a 44-year-old man who was in prolonged unawareness showed signs of recovery one year following a subarachnoid hemorrhage and eventually regained nearly normal physical and mental capabilities. See P.G. May and R. Kaelbling, "Coma of a Year's Duration with Favourable Outcome," Diseases of the Nervous System (December 1968): 837-840. Childs and Mercer reported the case of an 18-year-old woman who suffered a traumatic brain injury in a motor vehicle accident. After 15 months, the medical staff reported some responses on her part. Seventeen months after the injury, she became able to follow simple commands and could complete simple arithmetic problems and multiple-choice questions using eye blinks. She wrote: "Mom, I love you." N.L. Childs and WN. Mercer, "Brief Report: Late Improvement in Consciousness after Post-Traumatic Vegetative State," N. Engl. J. Med., 334 (1996): 24-25. See also the correspondence on "Late Improvement After Post-Traumatic Vegetative State," N. Engl. J. Med., 334 (1996): 1201-1202.
44. R. Cohen-Almagor, "Some Observations on Post-Coma Unawareness Patients and on Other Forms of Unconscious Patients: Policy Proposals," Medicine and Law, 16, no. 3 (1997): 451-471. Consider, for instance, the following documented case: a 43-year-old man who was in prolonged unawareness for 17 months following anoxic brain damage before showing the first signs of awareness. He progressed to being able to tell stories and jokes, though was unable to recognize complex collections of objects in pictures and was unable to read. See G.A. Rosenberg, S.F. Johnson, and R.P. Brenner, "Recovery of Cognition after Prolonged Vegetative State," Annals of Neurology, 2 (1977): 167-168. In another case, a 44-year-old man who was in prolonged unawareness showed signs of recovery one year following a subarachnoid hemorrhage and eventually regained nearly normal physical and mental capabilities. See P.G. May and R. Kaelbling, "Coma of a Year's Duration with Favourable Outcome," Diseases of the Nervous System (December 1968): 837-840. Childs and Mercer reported the case of an 18-year-old woman who suffered a traumatic brain injury in a motor vehicle accident. After 15 months, the medical staff reported some responses on her part. Seventeen months after the injury, she became able to follow simple commands and could complete simple arithmetic problems and multiple-choice questions using eye blinks. She wrote: "Mom, I love you." N.L. Childs and WN. Mercer, "Brief Report: Late Improvement in Consciousness after Post-Traumatic Vegetative State," N. Engl. J. Med., 334 (1996): 24-25. See also the correspondence on "Late Improvement After Post-Traumatic Vegetative State," N. Engl. J. Med., 334 (1996): 1201-1202.
45. R. Cohen-Almagor, "Some Observations on Post-Coma Unawareness Patients and on Other Forms of Unconscious Patients: Policy Proposals," Medicine and Law, 16, no. 3 (1997): 451-471. Consider, for instance, the following documented case: a 43-year-old man who was in prolonged unawareness for 17 months following anoxic brain damage before showing the first signs of awareness. He progressed to being able to tell stories and jokes, though was unable to recognize complex collections of objects in pictures and was unable to read. See G.A. Rosenberg, S.F. Johnson, and R.P. Brenner, "Recovery of Cognition after Prolonged Vegetative State," Annals of Neurology, 2 (1977): 167-168. In another case, a 44-year-old man who was in prolonged unawareness showed signs of recovery one year following a subarachnoid hemorrhage and eventually regained nearly normal physical and mental capabilities. See P.G. May and R. Kaelbling, "Coma of a Year's Duration with Favourable Outcome," Diseases of the Nervous System (December 1968): 837-840. Childs and Mercer reported the case of an 18-year-old woman who suffered a traumatic brain injury in a motor vehicle accident. After 15 months, the medical staff reported some responses on her part. Seventeen months after the injury, she became able to follow simple commands and could complete simple arithmetic problems and multiple-choice questions using eye blinks. She wrote: "Mom, I love you." N.L. Childs and WN. Mercer, "Brief Report: Late Improvement in Consciousness after Post-Traumatic Vegetative State," N. Engl. J. Med., 334 (1996): 24-25. See also the correspondence on "Late Improvement After Post-Traumatic Vegetative State," N. Engl. J. Med., 334 (1996): 1201-1202.
46. It is beyond the scope of this essay to provide a comprehensive account on the rehabilitation of post-coma unawareness patients. However, let me provide some some data. The Multi-Society Task Force, comprised of representatives of the American Academy of Neurology, the Child Neurology Society, the American Neurological Association, the American Association of Neurological Surgeons, and the American Academy of Pediatrics, considered data on 434 head injury patients. The task force noted that of those patients who had not died or recovered by the end of the first year 52 percent of the patients had recovered consciousness, 33 percent had died, 15 percent were still in post-coma unawareness, and 10.6 percent (7 out of 65) recovered after 12 months. See The Multi-Society Task Force on PVS, "Medical Aspects of the Persistent Vegetative State," N. Eng. J. Med. (1994): at 1572; C. Borthwick, "The Permanent Vegetative State: Ethical Crux, Medical Fiction?" Issues in Law & Medicine, 12, no. 2 (1996): at 179. Heindl and Laub studied two groups of children: 82 patients with traumatic brain injury (TBI), and 45 patients with hypoxic brain injury (HBI). They found significant differences between the two groups. The TBI patients progressed better than the HBI patients. Of the patients in the TBI group, 34 percent (compared with 13 percent of the HBI group) regained consciousness after three months. One year after the trauma, 80 percent of the patients in this group had left post-coma unawareness. See U.T. Heindl and M.C. Laub, "Outcome of Persistent Vegetative State Following Hypoxic or Traumatic Brain Injury in Children and Adolescents," Neuropediatrics, 27 (1996): 94-100. Information from the Traumatic Data Bank Study of 84 post-coma unawareness patients who were followed up long term found that 41 percent became conscious by six months, a further 11 percent between six months and a year, and an additional 6 percent between one and two-and-half years. See H.S. Levin et al., "Vegetative State after Closed Head Injury: A Traumatic Data Zank," Archives of Neurology, 48 (1991): 580-585.
47. It is beyond the scope of this essay to provide a comprehensive account on the rehabilitation of post-coma unawareness patients. However, let me provide some some data. The Multi-Society Task Force, comprised of representatives of the American Academy of Neurology, the Child Neurology Society, the American Neurological Association, the American Association of Neurological Surgeons, and the American Academy of Pediatrics, considered data on 434 head injury patients. The task force noted that of those patients who had not died or recovered by the end of the first year 52 percent of the patients had recovered consciousness, 33 percent had died, 15 percent were still in post-coma unawareness, and 10.6 percent (7 out of 65) recovered after 12 months. See The Multi-Society Task Force on PVS, "Medical Aspects of the Persistent Vegetative State," N. Eng. J. Med. (1994): at 1572; C. Borthwick, "The Permanent Vegetative State: Ethical Crux, Medical Fiction?" Issues in Law & Medicine, 12, no. 2 (1996): at 179. Heindl and Laub studied two groups of children: 82 patients with traumatic brain injury (TBI), and 45 patients with hypoxic brain injury (HBI). They found significant differences between the two groups. The TBI patients progressed better than the HBI patients. Of the patients in the TBI group, 34 percent (compared with 13 percent of the HBI group) regained consciousness after three months. One year after the trauma, 80 percent of the patients in this group had left post-coma unawareness. See U.T. Heindl and M.C. Laub, "Outcome of Persistent Vegetative State Following Hypoxic or Traumatic Brain Injury in Children and Adolescents," Neuropediatrics, 27 (1996): 94-100. Information from the Traumatic Data Bank Study of 84 post-coma unawareness patients who were followed up long term found that 41 percent became conscious by six months, a further 11 percent between six months and a year, and an additional 6 percent between one and two-and-half years. See H.S. Levin et al., "Vegetative State after Closed Head Injury: A Traumatic Data Zank," Archives of Neurology, 48 (1991): 580-585.
48. It is beyond the scope of this essay to provide a comprehensive account on the rehabilitation of post-coma unawareness patients. However, let me provide some some data. The Multi-Society Task Force, comprised of representatives of the American Academy of Neurology, the Child Neurology Society, the American Neurological Association, the American Association of Neurological Surgeons, and the American Academy of Pediatrics, considered data on 434 head injury patients. The task force noted that of those patients who had not died or recovered by the end of the first year 52 percent of the patients had recovered consciousness, 33 percent had died, 15 percent were still in post-coma unawareness, and 10.6 percent (7 out of 65) recovered after 12 months. See The Multi-Society Task Force on PVS, "Medical Aspects of the Persistent Vegetative State," N. Eng. J. Med. (1994): at 1572; C. Borthwick, "The Permanent Vegetative State: Ethical Crux, Medical Fiction?" Issues in Law & Medicine, 12, no. 2 (1996): at 179. Heindl and Laub studied two groups of children: 82 patients with traumatic brain injury (TBI), and 45 patients with hypoxic brain injury (HBI). They found significant differences between the two groups. The TBI patients progressed better than the HBI patients. Of the patients in the TBI group, 34 percent (compared with 13 percent of the HBI group) regained consciousness after three months. One year after the trauma, 80 percent of the patients in this group had left post-coma unawareness. See U.T. Heindl and M.C. Laub, "Outcome of Persistent Vegetative State Following Hypoxic or Traumatic Brain Injury in Children and Adolescents," Neuropediatrics, 27 (1996): 94-100. Information from the Traumatic Data Bank Study of 84 post-coma unawareness patients who were followed up long term found that 41 percent became conscious by six months, a further 11 percent between six months and a year, and an additional 6 percent between one and two-and-half years. See H.S. Levin et al., "Vegetative State after Closed Head Injury: A Traumatic Data Zank," Archives of Neurology, 48 (1991): 580-585.
49. It is beyond the scope of this essay to provide a comprehensive account on the rehabilitation of post-coma unawareness patients. However, let me provide some some data. The Multi-Society Task Force, comprised of representatives of the American Academy of Neurology, the Child Neurology Society, the American Neurological Association, the American Association of Neurological Surgeons, and the American Academy of Pediatrics, considered data on 434 head injury patients. The task force noted that of those patients who had not died or recovered by the end of the first year 52 percent of the patients had recovered consciousness, 33 percent had died, 15 percent were still in post-coma unawareness, and 10.6 percent (7 out of 65) recovered after 12 months. See The Multi-Society Task Force on PVS, "Medical Aspects of the Persistent Vegetative State," N. Eng. J. Med. (1994): at 1572; C. Borthwick, "The Permanent Vegetative State: Ethical Crux, Medical Fiction?" Issues in Law & Medicine, 12, no. 2 (1996): at 179. Heindl and Laub studied two groups of children: 82 patients with traumatic brain injury (TBI), and 45 patients with hypoxic brain injury (HBI). They found significant differences between the two groups. The TBI patients progressed better than the HBI patients. Of the patients in the TBI group, 34 percent (compared with 13 percent of the HBI group) regained consciousness after three months. One year after the trauma, 80 percent of the patients in this group had left post-coma unawareness. See U.T. Heindl and M.C. Laub, "Outcome of Persistent Vegetative State Following Hypoxic or Traumatic Brain Injury in Children and Adolescents," Neuropediatrics, 27 (1996): 94-100. Information from the Traumatic Data Bank Study of 84 post-coma unawareness patients who were followed up long term found that 41 percent became conscious by six months, a further 11 percent between six months and a year, and an additional 6 percent between one and two-and-half years. See H.S. Levin et al., "Vegetative State after Closed Head Injury: A Traumatic Data Zank," Archives of Neurology, 48 (1991): 580-585.
50. S.B. Rubin, When Doctors Say No: The Battleground of Medical Futility (Bloomington, Indiana: Indiana University Press, 1998): 42; L.K. Stell, "Real Futility: Historical Beginnings and Continuing Debate About Futile Treatment," North Carolina Medical Journal, 56, no. 9 (1995): at 434.
51. S.B. Rubin, When Doctors Say No: The Battleground of Medical Futility (Bloomington, Indiana: Indiana University Press, 1998): 42; L.K. Stell, "Real Futility: Historical Beginnings and Continuing Debate About Futile Treatment," North Carolina Medical Journal, 56, no. 9 (1995): at 434.
52. L.J. Schneiderman and N.S. Jecker, Wrong Medicine (Baltimore: Johns Hopkins University Press, 1995): at 11; L.J. Schneiderman and N.S. Jecker, "Is the Treatment Beneficial, Experimental, or Futile?" Cambridge Quarterly of Healthcare Ethics, 5, no. 2 (Spring 1996): at 249.
53. L.J. Schneiderman and N.S. Jecker, Wrong Medicine (Baltimore: Johns Hopkins University Press, 1995): at 11; L.J. Schneiderman and N.S. Jecker, "Is the Treatment Beneficial, Experimental, or Futile?" Cambridge Quarterly of Healthcare Ethics, 5, no. 2 (Spring 1996): at 249.
54. See J. Lynn and J.F. Childress, "Must Patients Always be Given Food and Water?" in J. Lynn, ed., By No Extraordinary Means (Bloomington, Indiana: Indiana University Press, 1986): at 51.
55. J.D. Lantos, "Futility Assessments and the Doctor-Patient Relationship," Journal of the American Geriatrics Society, 42 (August 1994): at 869.
56. M. Sonnenblick, Y. Friedlander, and A. Steinberg, "Dissociation Between the Wishes of Terminally Ill Parents and Decisions by Their Offspring," Journal of the American Geriatric Society, 41, no. 6 (1993): 599-604.
57. See Memorandum by Dr. David Lamb, House of Lords, Select Committee on Medical Ethics, 1993-94 Session, Vol. III, Minutes of Oral Evidence (London: HMSO, 1994): at 133; Ulrich, supra note 4, at 190.
58. Schneiderman and Jecker, Wrong Medicine, supra note 24, at 97; L.J. Schneiderman, N.S. Jecker, and A.R. Jonsen, "Medical Futility: Its Meaning and Ethical Implications," Annual International Medicine, 112 (1990): 949-954; L.J. Schneiderman, K. Faber-Langendoen, and N.S. Jecker, "Beyond Futility to an Ethic of Care "American Journal of Medicine, 86 (1994): 110-114.
59. Schneiderman and Jecker, Wrong Medicine, supra note 24, at 97; L.J. Schneiderman, N.S. Jecker, and A.R. Jonsen, "Medical Futility: Its Meaning and Ethical Implications," Annual International Medicine, 112 (1990): 949-954; L.J. Schneiderman, K. Faber-Langendoen, and N.S. Jecker, "Beyond Futility to an Ethic of Care "American Journal of Medicine, 86 (1994): 110-114.
60. Schneiderman and Jecker, Wrong Medicine, supra note 24, at 97; L.J. Schneiderman, N.S. Jecker, and A.R. Jonsen, "Medical Futility: Its Meaning and Ethical Implications," Annual International Medicine, 112 (1990): 949-954; L.J. Schneiderman, K. Faber-Langendoen, and N.S. Jecker, "Beyond Futility to an Ethic of Care "American Journal of Medicine, 86 (1994): 110-114.
61. R.D. Truog, A.S. Brett, and J. Frader, "The Problem with Futility," N. Engl. J. Med., 326, no. 23 (1992): at 1561. For further criticism of Schneiderman et al.; see G.G. Griener, "The Physician's Authority to Withhold Futile Treatment," Journal of Medicine and Philosophy, 20 (1995): 216-218.
62. R.D. Truog, A.S. Brett, and J. Frader, "The Problem with Futility," N. Engl. J. Med., 326, no. 23 (1992): at 1561. For further criticism of Schneiderman et al.; see G.G. Griener, "The Physician's Authority to Withhold Futile Treatment," Journal of Medicine and Philosophy, 20 (1995): 216-218.
63. J.D. Lantos, P.A. Singer, R.M. Walker et al., "The Illusion of Futility in Clinical Practice," American Journal of Medicine, 87 (July 1989): 81-83.
64. Council on Ethical and Judicial Affairs, American Medical Association, "Medical Futility in End-of-Life Care," JAMA, 281, no. 10 (1999): 938-940.
65. Rubin, supra note 23, at 115-117.
66. J.F. Childress, Practical Reasoning in Bioethics (Bloomington, Indiana: Indiana University Press, 1997): at 163. For a contrasting view, see N.S. Jecker, "Is Refusal of Futile Treatment Unjustified Paternalism?," Journal of Clinical Ethics, 6, no. 2 (1995): 133-137.
67. J.F. Childress, Practical Reasoning in Bioethics (Bloomington, Indiana: Indiana University Press, 1997): at 163. For a contrasting view, see N.S. Jecker, "Is Refusal of Futile Treatment Unjustified Paternalism?," Journal of Clinical Ethics, 6, no. 2 (1995): 133-137.
68. Rubin, supra note 23, at 20. For further analysis, see In re Conservatorship of Wanglie, No. PX-91-283 (Minn. Dist. Ct., June 28, 1991, reviewed in 16 [1] MPDLR 46).
69. S. Ashwal et al., "The Persistent Vegetative State in Children: Report of the Child Neurology Society Ethics Committee," Annals of Neurology, 32 (1992): 570-576; H.S. Levin et al., "Vegetative State after Closed Head Injury: A Traumatic Data Bank," Archives of Neurology, 48 (1991): 580-585; W.F.M. Arts et al., "Unexpected Improvement after Prolonged Post-traumatic Vegetative State," Journal of Neurology, Neurosurgery, and Psychiatry, 48 (1985): 1300-1303; L. Sazbon et al., "Course and Outcome of Patients in Vegetative State of Nontraumatic Aetiology," Journal of Neurology, Neurosurgery, and Psychiatry, 56 (1993): 407-409; K. Andrews, "Vegetative State - Background and Ethics," Journal of the Royal Society of Medicine, 90 (November 1997): at 594.
70. S. Ashwal et al., "The Persistent Vegetative State in Children: Report of the Child Neurology Society Ethics Committee," Annals of Neurology, 32 (1992): 570-576; H.S. Levin et al., "Vegetative State after Closed Head Injury: A Traumatic Data Bank," Archives of Neurology, 48 (1991): 580-585; W.F.M. Arts et al., "Unexpected Improvement after Prolonged Post-traumatic Vegetative State," Journal of Neurology, Neurosurgery, and Psychiatry, 48 (1985): 1300-1303; L. Sazbon et al., "Course and Outcome of Patients in Vegetative State of Nontraumatic Aetiology," Journal of Neurology, Neurosurgery, and Psychiatry, 56 (1993): 407-409; K. Andrews, "Vegetative State - Background and Ethics," Journal of the Royal Society of Medicine, 90 (November 1997): at 594.
71. S. Ashwal et al., "The Persistent Vegetative State in Children: Report of the Child Neurology Society Ethics Committee," Annals of Neurology, 32 (1992): 570-576; H.S. Levin et al., "Vegetative State after Closed Head Injury: A Traumatic Data Bank," Archives of Neurology, 48 (1991): 580-585; W.F.M. Arts et al., "Unexpected Improvement after Prolonged Post-traumatic Vegetative State," Journal of Neurology, Neurosurgery, and Psychiatry, 48 (1985): 1300-1303; L. Sazbon et al., "Course and Outcome of Patients in Vegetative State of Nontraumatic Aetiology," Journal of Neurology, Neurosurgery, and Psychiatry, 56 (1993): 407-409; K. Andrews, "Vegetative State - Background and Ethics," Journal of the Royal Society of Medicine, 90 (November 1997): at 594.
72. S. Ashwal et al., "The Persistent Vegetative State in Children: Report of the Child Neurology Society Ethics Committee," Annals of Neurology, 32 (1992): 570-576; H.S. Levin et al., "Vegetative State after Closed Head Injury: A Traumatic Data Bank," Archives of Neurology, 48 (1991): 580-585; W.F.M. Arts et al., "Unexpected Improvement after Prolonged Post-traumatic Vegetative State," Journal of Neurology, Neurosurgery, and Psychiatry, 48 (1985): 1300-1303; L. Sazbon et al., "Course and Outcome of Patients in Vegetative State of Nontraumatic Aetiology," Journal of Neurology, Neurosurgery, and Psychiatry, 56 (1993): 407-409; K. Andrews, "Vegetative State - Background and Ethics," Journal of the Royal Society of Medicine, 90 (November 1997): at 594.
73. S. Ashwal et al., "The Persistent Vegetative State in Children: Report of the Child Neurology Society Ethics Committee," Annals of Neurology, 32 (1992): 570-576; H.S. Levin et al., "Vegetative State after Closed Head Injury: A Traumatic Data Bank," Archives of Neurology, 48 (1991): 580-585; W.F.M. Arts et al., "Unexpected Improvement after Prolonged Post-traumatic Vegetative State," Journal of Neurology, Neurosurgery, and Psychiatry, 48 (1985): 1300-1303; L. Sazbon et al., "Course and Outcome of Patients in Vegetative State of Nontraumatic Aetiology," Journal of Neurology, Neurosurgery, and Psychiatry, 56 (1993): 407-409; K. Andrews, "Vegetative State - Background and Ethics," Journal of the Royal Society of Medicine, 90 (November 1997): at 594.
74. Airedale NHS v. Bland, 1 All ER 821, 826 (1993).
75. South Australian Voluntary Euthanasia Society, DID YOU KNOW? The Principle of Double Effect SAVES, Fact Sheet No. 23 (October 1997), E-mail: metty@ozemail.com.au.
76. Joseph Boyle wrote extensively on this topic. See, e.g., J.M. Boyle Jr., "Toward Understanding the Principle of Double Effect," Ethics, 90 (July 1980): 527-538, and "Who Is Entitled to Double Effect?" The Journal of Medicine and Philosophy, 16 (1991): 475-494. See also the testimony of Dr. Walter R. Hunter before the Committee on the Judiciary (June 24, 1999) 〈http:// www.house.gov/judiciary/hunt0624.htm〉 ; EM. Kamm, "Physician-Assisted Suicide, the Doctrine of Double Effect, and the Ground of Value," Ethics, 109, 3 (1999): 586-591; C.F. McKhann, A Time to Die: The Place for Physician Assistance (New Haven, Connecticut: Yale University Press, 1999): 102-106.
77. Joseph Boyle wrote extensively on this topic. See, e.g., J.M. Boyle Jr., "Toward Understanding the Principle of Double Effect," Ethics, 90 (July 1980): 527-538, and "Who Is Entitled to Double Effect?" The Journal of Medicine and Philosophy, 16 (1991): 475-494. See also the testimony of Dr. Walter R. Hunter before the Committee on the Judiciary (June 24, 1999) 〈http:// www.house.gov/judiciary/hunt0624.htm〉 ; EM. Kamm, "Physician-Assisted Suicide, the Doctrine of Double Effect, and the Ground of Value," Ethics, 109, 3 (1999): 586-591; C.F. McKhann, A Time to Die: The Place for Physician Assistance (New Haven, Connecticut: Yale University Press, 1999): 102-106.
78. Joseph Boyle wrote extensively on this topic. See, e.g., J.M. Boyle Jr., "Toward Understanding the Principle of Double Effect," Ethics, 90 (July 1980): 527-538, and "Who Is Entitled to Double Effect?" The Journal of Medicine and Philosophy, 16 (1991): 475-494. See also the testimony of Dr. Walter R. Hunter before the Committee on the Judiciary (June 24, 1999) 〈http:// www.house.gov/judiciary/hunt0624.htm〉 ; EM. Kamm, "Physician-Assisted Suicide, the Doctrine of Double Effect, and the Ground of Value," Ethics, 109, 3 (1999): 586-591; C.F. McKhann, A Time to Die: The Place for Physician Assistance (New Haven, Connecticut: Yale University Press, 1999): 102-106.
79. Joseph Boyle wrote extensively on this topic. See, e.g., J.M. Boyle Jr., "Toward Understanding the Principle of Double Effect," Ethics, 90 (July 1980): 527-538, and "Who Is Entitled to Double Effect?" The Journal of Medicine and Philosophy, 16 (1991): 475-494. See also the testimony of Dr. Walter R. Hunter before the Committee on the Judiciary (June 24, 1999) 〈http:// www.house.gov/judiciary/hunt0624.htm〉 ; EM. Kamm, "Physician-Assisted Suicide, the Doctrine of Double Effect, and the Ground of Value," Ethics, 109, 3 (1999): 586-591; C.F. McKhann, A Time to Die: The Place for Physician Assistance (New Haven, Connecticut: Yale University Press, 1999): 102-106.
80. Joseph Boyle wrote extensively on this topic. See, e.g., J.M. Boyle Jr., "Toward Understanding the Principle of Double Effect," Ethics, 90 (July 1980): 527-538, and "Who Is Entitled to Double Effect?" The Journal of Medicine and Philosophy, 16 (1991): 475-494. See also the testimony of Dr. Walter R. Hunter before the Committee on the Judiciary (June 24, 1999) 〈http:// www.house.gov/judiciary/hunt0624.htm〉 ; EM. Kamm, "Physician-Assisted Suicide, the Doctrine of Double Effect, and the Ground of Value," Ethics, 109, 3 (1999): 586-591; C.F. McKhann, A Time to Die: The Place for Physician Assistance (New Haven, Connecticut: Yale University Press, 1999): 102-106.
81. Compare "When Doctors Might Kill Their Patients," British Medical Journal, 318 (1999): 1431-1432. Further information on this and related issues is available from Hon. Secretary, SAVES, P.O. Box 2151, Kent Town, SA 5071, Australia.
82. For general discussions concerning the progressive neuromuscular disease, Amyotrophic Lateral Sclerosis (ALS) and assisted suicide, see N. Engl. J. Med. (October 1998).
83. (T.A.) 1141/90 Benjamin Eyal v. Dr. Nachman Willensky and Others, 51(3) P.M. 187, 192.
84. Opening Motion (T.A.) 1141/1990 Benjamin Eyal v. Lichtenstaedter Hospital 1991(3) P.M. at 194.
85. Opening Motion (T.A.) 1141/1990 Benjamin Eyal v. Lichtenstaedter Hospital 1991(3) P.M. at 87. For other similar cases, see (B.S.) 1030/95 Israel Gilad v. Soroka Medical Center and Others (October 23, 1995); Opening Motion (T.A.) 2339 and 2242/95 A.A. and Y. S. v. Kupat Holim and State of Israel (January 11, 1996); Opening Motion (T.A.) 2242/95 Eitay Arad v. Kupat Holim and State of Israel (October 1, 1998). In the Arad case, Judge Talgam emphasized that the starting point must be the dignity of the patient, not the hesitancy of the doctor.
86. Sue Rodriguez also suffered from amyotrophic lateral sclerosis. She publicly expressed a desire to have a physician assist her in ending her life at a time of her choosing when she herself would be unable to do so, rather than wait helplessly to die by suffocation or choking. Ms. Rodriguez sought to challenge the Criminal Code of Canada's prohibition on assisted suicide on the grounds that it violated the country's Charter of Rights and Freedoms. Her appeal was rejected by the Supreme Court of Canada in a 5 (Sopinka, La Forest, Gonthier, Iacobucci, and Major) to 4 (McLachlin, L'Heureaux-Dube, Lamer, and Cory) landmark decision. The court said that it did not want to intervene in this delicate public matter; it deferred to the legislature to change the law if such a change was deemed needed. See Sue Rodriguez v. The Attorney General of Canada, File No. 23476 (September 1993). I benefited from a discussion with the Honorable Justice Ian Binnie, the Honorable Justice Peter de C. Cory, and the Honorable Justice Frank Iacobucci of the Supreme Court of Canada (September 28, 1998). See also E. Kluge, "Doctors, Death and Sue Rodriguez," Canadian Medical Association Journal, 148, no. 6 (1993): 1015-1017.
87. T. Quill, R. Dresser, and D. Brock, "The Rule of Double Effect - A Critique of Its Role in End-of-Live Decision Making," N. Engl. J. Med., 337 (1997): 1768-1771. See also the correspondence on the rule of double effect in N. Engl. J. Med., 338, no. 19 (1998): 1389-1390.
88. T. Quill, R. Dresser, and D. Brock, "The Rule of Double Effect - A Critique of Its Role in End-of-Live Decision Making," N. Engl. J. Med., 337 (1997): 1768-1771. See also the correspondence on the rule of double effect in N. Engl. J. Med., 338, no. 19 (1998): 1389-1390.
89. Report of the Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death, "A Definition of Irreversible Coma," JAMA (August 1968): 337-340.
90. S.J. Youngner et al., "'Brain Death' and Organ Retrieval. A Cross-sectional Survey of Knowledge and Concepts among Health Professionals," JAMA, 261, no.15 (April 1989): 2205-2210.
91. D. Wikler and A.J. Weisbard, "Appropriate Confusion over 'Brain Death,'" JAMA, 261, no. 15 (1989): at 2246.
92. One anonymous peer reviewer at the Journal of Law, Medicine & Ethics noted that brain death is not only used for purposes of transplantation. There are cases in which the family's wish for continued treatment or the patient's advance directive depends upon whether brain death has been determined. Many patients in this category, due to age, infectious disease (e.g., HIV), or other criteria, are not suitable organ donors.
93. R.D. Truog, "Organ Transplantation without Brain Death," in R. Cohen-Almagor, ed., Medical Ethics at the Dawn of the 21st Century (New York: New York Academy of Sciences, 2000): 229-239.
94. R.D. Truog, "Is It Time to Abandon Brain Death?" Hastings Center Report, 27, no. 1 (1997): at 30.
95. D.J. Self and E. Davenport, "Measurement of Moral Development in Medicine," Cambridge Quarterly of Healthcare Ethics, 5, no. 2 (Spring
96. D.J. Self and E. Davenport, "Measurement of Moral Development in Medicine," Cambridge Quarterly of Healthcare Ethics, 5, no. 2 (Spring 1996): 269-277; D.J. Self, D.C. Baldwin Jr., and ED. Wolinsky, "Evaluation of Teaching Medical Ethics by an Assessment of Moral Reasoning," Medical Education, 26 (1992): 178-184; S. Holm et al., "Changes in Moral Reasoning and the Teaching of Medical Ethics," Medical Education, 29 (1995): 420-423; T.J. Sheehan et al., "Moral Judgment as a Predictor of Clinical Performance," Evaluation & The Health Professions, 3 (1980): 394-404.
97. D.J. Self and E. Davenport, "Measurement of Moral Development in Medicine," Cambridge Quarterly of Healthcare Ethics, 5, no. 2 (Spring 1996): 269-277; D.J. Self, D.C. Baldwin Jr., and ED. Wolinsky, "Evaluation of Teaching Medical Ethics by an Assessment of Moral Reasoning," Medical Education, 26 (1992): 178-184; S. Holm et al., "Changes in Moral Reasoning and the Teaching of Medical Ethics," Medical Education, 29 (1995): 420-423; T.J. Sheehan et al., "Moral Judgment as a Predictor of Clinical Performance," Evaluation & The Health Professions, 3 (1980): 394-404.
98. D.J. Self and E. Davenport, "Measurement of Moral Development in Medicine," Cambridge Quarterly of Healthcare Ethics, 5, no. 2 (Spring 1996): 269-277; D.J. Self, D.C. Baldwin Jr., and ED. Wolinsky, "Evaluation of Teaching Medical Ethics by an Assessment of Moral Reasoning," Medical Education, 26 (1992): 178-184; S. Holm et al., "Changes in Moral Reasoning and the Teaching of Medical Ethics," Medical Education, 29 (1995): 420-423; T.J. Sheehan et al., "Moral Judgment as a Predictor of Clinical Performance," Evaluation & The Health Professions, 3 (1980): 394-404.
99. H.S. Perkins, C.M.A. Geppert, and H.P. Hazuda, "Challenges in Teaching Ethics in Medical Schools," American Journal of the Medical Sciences, 319, no. 5 (2000).
100. D.J. Self, D.C. Baldwin Jr., and M. Olivarez, "Teaching Medical Ethics to First-Year Students by Using Film Discussion to Develop Moral Reasoning," Academic Medicine, 68 (1993): 383-385.
101. Lantos argues that in the literature genre, the open-endedness of the format and the relative intellectual marginality of the discipline allow questions to be raised about doctors and medicine, healing and illness, suffering and dying, that cannot be raised in any other discourse. Literature is thus avant garde in raising these issues and beginning to question the patently messianic vision of medicine as a sort of secular salvation. See J. Lantos, "Open Heart" (Shiva M'Hodu), in R. Cohen-Almagor, ed., Medical Ethics at the Dawn of the 21st Century (New York: New York Academy of Sciences, 2000): 41-51.
102. In the Yale curriculum for Ethical and Humanistic Medicine, students and residents watch each other role play clinical tasks such as obtaining informed consent, delivering bad news, and discussing "do not resuscitate" orders. Students compare the techniques that they observe and perform, then discuss practical suggestions specific to each interactional skill. E. Fox, R.M. Arnold, and B. Brody, "Medical Ethics Education: Past, Present, and Future," Academic Medicine, 70, no. 9 (1995): 761-769, at 763. See also J.W Tysinger et al., "Teaching Ethics Using Small-group, Problem-based Learning," Journal of Medical Ethics, 23, no. 5 (1997): 315-318; E.D. Pellegrino, M. Siegler, and P.A. Singer, "Teaching Clinical Ethics," Journal of Clinical Ethics, 1, no. 3 (Fall 1990): 175-180; P. Hebert et al., "Evaluating Ethical Sensitivity in Medical Students: Using Vignettes as an Instrument," Journal of Medical Ethics, 16, no. 3 (1990): 141-145.
103. In the Yale curriculum for Ethical and Humanistic Medicine, students and residents watch each other role play clinical tasks such as obtaining informed consent, delivering bad news, and discussing "do not resuscitate" orders. Students compare the techniques that they observe and perform, then discuss practical suggestions specific to each interactional skill. E. Fox, R.M. Arnold, and B. Brody, "Medical Ethics Education: Past, Present, and Future," Academic Medicine, 70, no. 9 (1995): 761-769, at 763. See also J.W Tysinger et al., "Teaching Ethics Using Small-group, Problem-based Learning," Journal of Medical Ethics, 23, no. 5 (1997): 315-318; E.D. Pellegrino, M. Siegler, and P.A. Singer, "Teaching Clinical Ethics," Journal of Clinical Ethics, 1, no. 3 (Fall 1990): 175-180; P. Hebert et al., "Evaluating Ethical Sensitivity in Medical Students: Using Vignettes as an Instrument," Journal of Medical Ethics, 16, no. 3 (1990): 141-145.
104. In the Yale curriculum for Ethical and Humanistic Medicine, students and residents watch each other role play clinical tasks such as obtaining informed consent, delivering bad news, and discussing "do not resuscitate" orders. Students compare the techniques that they observe and perform, then discuss practical suggestions specific to each interactional skill. E. Fox, R.M. Arnold, and B. Brody, "Medical Ethics Education: Past, Present, and Future," Academic Medicine, 70, no. 9 (1995): 761-769, at 763. See also J.W Tysinger et al., "Teaching Ethics Using Small-group, Problem-based Learning," Journal of Medical Ethics, 23, no. 5 (1997): 315-318; E.D. Pellegrino, M. Siegler, and P.A. Singer, "Teaching Clinical Ethics," Journal of Clinical Ethics, 1, no. 3 (Fall 1990): 175-180; P. Hebert et al., "Evaluating Ethical Sensitivity in Medical Students: Using Vignettes as an Instrument," Journal of Medical Ethics, 16, no. 3 (1990): 141-145.
105. In the Yale curriculum for Ethical and Humanistic Medicine, students and residents watch each other role play clinical tasks such as obtaining informed consent, delivering bad news, and discussing "do not resuscitate" orders. Students compare the techniques that they observe and perform, then discuss practical suggestions specific to each interactional skill. E. Fox, R.M. Arnold, and B. Brody, "Medical Ethics Education: Past, Present, and Future," Academic Medicine, 70, no. 9 (1995): 761-769, at 763. See also J.W Tysinger et al., "Teaching Ethics Using Small-group, Problem-based Learning," Journal of Medical Ethics, 23, no. 5 (1997): 315-318; E.D. Pellegrino, M. Siegler, and P.A. Singer, "Teaching Clinical Ethics," Journal of Clinical Ethics, 1, no. 3 (Fall 1990): 175-180; P. Hebert et al., "Evaluating Ethical Sensitivity in Medical Students: Using Vignettes as an Instrument," Journal of Medical Ethics, 16, no. 3 (1990): 141-145.
106. T. Hope and K.W.M. Fulford, "The Oxford Practice Skills Project: Teaching Ethics, Law and Communication Skills to Clinical Medical Students," Journal of Medical Ethics, 20 (1994): 229-234; R.A. Hope, K.W.M. Fulford, and A. Yates, The Oxford Practice Skills Course (Oxford: Oxford University Press, 1996); F. Baylis and J. Downie, "Ethics Education for Canadian Medical Students," Academic Medicine, 66, no. 7 (1991): 413-414; A. Browne, M. Broudo, and V Sweeney, "Results of a Survey on Undergraduate Ethics Education in Canadian Medical Schools," Division of Bio-Medical Ethics, University of British Columbia (working paper).
107. T. Hope and K.W.M. Fulford, "The Oxford Practice Skills Project: Teaching Ethics, Law and Communication Skills to Clinical Medical Students," Journal of Medical Ethics, 20 (1994): 229-234; R.A. Hope, K.W.M. Fulford, and A. Yates, The Oxford Practice Skills Course (Oxford: Oxford University Press, 1996); F. Baylis and J. Downie, "Ethics Education for Canadian Medical Students," Academic Medicine, 66, no. 7 (1991): 413-414; A. Browne, M. Broudo, and V Sweeney, "Results of a Survey on Undergraduate Ethics Education in Canadian Medical Schools," Division of Bio-Medical Ethics, University of British Columbia (working paper).
108. T. Hope and K.W.M. Fulford, "The Oxford Practice Skills Project: Teaching Ethics, Law and Communication Skills to Clinical Medical Students," Journal of Medical Ethics, 20 (1994): 229-234; R.A. Hope, K.W.M. Fulford, and A. Yates, The Oxford Practice Skills Course (Oxford: Oxford University Press, 1996); F. Baylis and J. Downie, "Ethics Education for Canadian Medical Students," Academic Medicine, 66, no. 7 (1991): 413-414; A. Browne, M. Broudo, and V Sweeney, "Results of a Survey on Undergraduate Ethics Education in Canadian Medical Schools," Division of Bio-Medical Ethics, University of British Columbia (working paper).
109. T. Hope and K.W.M. Fulford, "The Oxford Practice Skills Project: Teaching Ethics, Law and Communication Skills to Clinical Medical Students," Journal of Medical Ethics, 20 (1994): 229-234; R.A. Hope, K.W.M. Fulford, and A. Yates, The Oxford Practice Skills Course (Oxford: Oxford University Press, 1996); F. Baylis and J. Downie, "Ethics Education for Canadian Medical Students," Academic Medicine, 66, no. 7 (1991): 413-414; A. Browne, M. Broudo, and V Sweeney, "Results of a Survey on Undergraduate Ethics Education in Canadian Medical Schools," Division of Bio-Medical Ethics, University of British Columbia (working paper).
110. M. Parle, P. Maguire, and C. Heaven, "The Development of a Training Model to Improve Health Professionals' Skills, Self-Efficacy and Outcome Expectancies When Communicating With Cancer Patients," Social Science & Medicine, 44, no. 2 (1997): 231-240; K. Szauter, E. Boisaubin, and M. Levetown, "Teaching Professionalism in Medical Grand Rounds," Academic Medicine, 74, no. 5 (1999): 581-582; K.M. Markakis et al., "The Path to Professionalism: Cultivating Humanistic Values and Attitudes in Residency Training," Academic Medicine, 75, no. 2 (2000): 141-149.
111. M. Parle, P. Maguire, and C. Heaven, "The Development of a Training Model to Improve Health Professionals' Skills, Self-Efficacy and Outcome Expectancies When Communicating With Cancer Patients," Social Science & Medicine, 44, no. 2 (1997): 231-240; K. Szauter, E. Boisaubin, and M. Levetown, "Teaching Professionalism in Medical Grand Rounds," Academic Medicine, 74, no. 5 (1999): 581-582; K.M. Markakis et al., "The Path to Professionalism: Cultivating Humanistic Values and Attitudes in Residency Training," Academic Medicine, 75, no. 2 (2000): 141-149.
112. M. Parle, P. Maguire, and C. Heaven, "The Development of a Training Model to Improve Health Professionals' Skills, Self-Efficacy and Outcome Expectancies When Communicating With Cancer Patients," Social Science & Medicine, 44, no. 2 (1997): 231-240; K. Szauter, E. Boisaubin, and M. Levetown, "Teaching Professionalism in Medical Grand Rounds," Academic Medicine, 74, no. 5 (1999): 581-582; K.M. Markakis et al., "The Path to Professionalism: Cultivating Humanistic Values and Attitudes in Residency Training," Academic Medicine, 75, no. 2 (2000): 141-149.
113. See, for example, D.J. Self, F.D. Wolinsky, and D.C. Baldwin Jr., "The Effect of Teaching Medical Ethics on Medical Students' Moral Reasoning," Academic Medicine, 64 (1989): 755-759.
114. D.P. Sulmasy et al., "Medical House Officers' Knowledge, Attitudes and Confidence Regarding Medical Ethics," Archives of Internal Medicine, 150 (1990): 2509-2513; D.P. Sulmasy et al., "A Randomized Trial of Ethics Education for Medical House Officers," Journal of Mediail Ethics, 19, no. 3 (1993): 157-163; D.P. Sulmasy and E.S. Marx, "Ethics Education for Medical House Officers: Long-Term Improvements in Knowledge and Confidence," Journal of Medical Ethics, 23 (1997): 88-92.
115. D.P. Sulmasy et al., "Medical House Officers' Knowledge, Attitudes and Confidence Regarding Medical Ethics," Archives of Internal Medicine, 150 (1990): 2509-2513; D.P. Sulmasy et al., "A Randomized Trial of Ethics Education for Medical House Officers," Journal of Mediail Ethics, 19, no. 3 (1993): 157-163; D.P. Sulmasy and E.S. Marx, "Ethics Education for Medical House Officers: Long-Term Improvements in Knowledge and Confidence," Journal of Medical Ethics, 23 (1997): 88-92.
116. D.P. Sulmasy et al., "Medical House Officers' Knowledge, Attitudes and Confidence Regarding Medical Ethics," Archives of Internal Medicine, 150 (1990): 2509-2513; D.P. Sulmasy et al., "A Randomized Trial of Ethics Education for Medical House Officers," Journal of Mediail Ethics, 19, no. 3 (1993): 157-163; D.P. Sulmasy and E.S. Marx, "Ethics Education for Medical House Officers: Long-Term Improvements in Knowledge and Confidence," Journal of Medical Ethics, 23 (1997): 88-92.
117. N.S. Wenger, L. Honghu, and J.R. Lieberman, "Teaching Medical Ethics to Orthopaedic Surgery Residents," Journal of Bone and Joint Surgery, 80A, no. 8 (1998): 1125-1131.
118. S. Wear, Informed Consent, Patient Autonomy and Clinician Beneficence within Health Care (Washington, D.C.: Georgetown University Press, 1998): at 61.
119. WB. Carter et al., "Outcome-Based Doctor-Patient Interaction Analysis," Medical Care, 20 (1982): 550-566; J.A. Hall, D.L. Roter, and N.R. Katz, "Meta-Analysis of Correlates of Provider Behavior in Medical Encounters,"Medical Care, 26 (1988): 657-675; P.D. Cleary and B.J. McNeil, "Patient Satisfaction as an Indicator of Quality of Care," Inquiry, 25 (1988): 25-36; L.G. Frederickson, "Exploring Information-Exchange in Consultation: The Patients' View of Performance and Outcomes," Patient Education and Counseling, 25 (1995): 237-246; D.L. Roter et al., "Communication Patterns of Primary Care Physicians," JAMA, 277 (1997): 350-356.
120. WB. Carter et al., "Outcome-Based Doctor-Patient Interaction Analysis," Medical Care, 20 (1982): 550-566; J.A. Hall, D.L. Roter, and N.R. Katz, "Meta-Analysis of Correlates of Provider Behavior in Medical Encounters,"Medical Care, 26 (1988): 657-675; P.D. Cleary and B.J. McNeil, "Patient Satisfaction as an Indicator of Quality of Care," Inquiry, 25 (1988): 25-36; L.G. Frederickson, "Exploring Information-Exchange in Consultation: The Patients' View of Performance and Outcomes," Patient Education and Counseling, 25 (1995): 237-246; D.L. Roter et al., "Communication Patterns of Primary Care Physicians," JAMA, 277 (1997): 350-356.
121. WB. Carter et al., "Outcome-Based Doctor-Patient Interaction Analysis," Medical Care, 20 (1982): 550-566; J.A. Hall, D.L. Roter, and N.R. Katz, "Meta-Analysis of Correlates of Provider Behavior in Medical Encounters,"Medical Care, 26 (1988): 657-675; P.D. Cleary and B.J. McNeil, "Patient Satisfaction as an Indicator of Quality of Care," Inquiry, 25 (1988): 25-36; L.G. Frederickson, "Exploring Information-Exchange in Consultation: The Patients' View of Performance and Outcomes," Patient Education and Counseling, 25 (1995): 237-246; D.L. Roter et al., "Communication Patterns of Primary Care Physicians," JAMA, 277 (1997): 350-356.
122. WB. Carter et al., "Outcome-Based Doctor-Patient Interaction Analysis," Medical Care, 20 (1982): 550-566; J.A. Hall, D.L. Roter, and N.R. Katz, "Meta-Analysis of Correlates of Provider Behavior in Medical Encounters,"Medical Care, 26 (1988): 657-675; P.D. Cleary and B.J. McNeil, "Patient Satisfaction as an Indicator of Quality of Care," Inquiry, 25 (1988): 25-36; L.G. Frederickson, "Exploring Information-Exchange in Consultation: The Patients' View of Performance and Outcomes," Patient Education and Counseling, 25 (1995): 237-246; D.L. Roter et al., "Communication Patterns of Primary Care Physicians," JAMA, 277 (1997): 350-356.
123. WB. Carter et al., "Outcome-Based Doctor-Patient Interaction Analysis," Medical Care, 20 (1982): 550-566; J.A. Hall, D.L. Roter, and N.R. Katz, "Meta-Analysis of Correlates of Provider Behavior in Medical Encounters,"Medical Care, 26 (1988): 657-675; P.D. Cleary and B.J. McNeil, "Patient Satisfaction as an Indicator of Quality of Care," Inquiry, 25 (1988): 25-36; L.G. Frederickson, "Exploring Information-Exchange in Consultation: The Patients' View of Performance and Outcomes," Patient Education and Counseling, 25 (1995): 237-246; D.L. Roter et al., "Communication Patterns of Primary Care Physicians," JAMA, 277 (1997): 350-356.
124. See J. Garcia, L.D. Gruppen, and C.M. Grum, "A Program to Elucidate Differences in Medical Students' Communication Skills," Academic Medicine, 72, no. 5 (1997): 427-428; J.B. Brown et al., "Effect of Clinician Communication Skills Training on Patient Satisfaction," Annals of Internal Medicine, 131 (1999): 822-829, at 826.
125. See J. Garcia, L.D. Gruppen, and C.M. Grum, "A Program to Elucidate Differences in Medical Students' Communication Skills," Academic Medicine, 72, no. 5 (1997): 427-428; J.B. Brown et al., "Effect of Clinician Communication Skills Training on Patient Satisfaction," Annals of Internal Medicine, 131 (1999): 822-829, at 826.
126. Brown et al., supra note 65, at 828-829.
127. I.S. Switankowsky, A New Paradigm for Informed Consent (Lanham, Maryland: University Press of America, 1998): at 105. See also E.J. Cassell, Talking with Patients, vol. I, II (Cambridge, Massachusetts: MIT Press, 1985).
128. I.S. Switankowsky, A New Paradigm for Informed Consent (Lanham, Maryland: University Press of America, 1998): at 105. See also E.J. Cassell, Talking with Patients, vol. I, II (Cambridge, Massachusetts: MIT Press, 1985).
129. J. Katz, The Silent World of Doctor and Patient (New York: The Free Press, 1984): 4-5, 207-229.
130. Ulrich, supra note 4, at 9.
131. W. Levinson, "In Context: Physician-Patient Communication and Managed Care," Journal of Medical Practice Management, 14, no. 5 (1999): 226-30.
132. Wear, supra note 63, at 179.