Some weeks ago, we learned that the matriarch of a family, my good friend Anna, is dying. She is 75 and has inoperable esophageal cancer, and the doctors say it will only take a few more weeks or months. Anna is dying the way I want to die–at home, surrounded and lovingly tended by her family: her devoted husband of 54 years, her three daughters, her three worshipful sons-in-law, her adoring granddaughters. All of them see her every day. All of them are a part of a mutual struggle to give Anna a “good death” Anna, too, is a part of it. And, in a very small way, I am part of it, because I have been invited to be. Every few days, I walk next door and spend a few minutes talking to Anna.

Past ages of medical care are condemned in modern philosophical and medical literature as being too paternalistic. The normal account of good medicine in the past was, indeed, paternalistic in an offensive way to modern persons. Imagine a Jean Paul Sartre going to the doctor and being treated without his consent or even his knowledge of what will transpire during treatment! From Hippocratic times until shortly after World War II, medicine operated in a closed, clubby manner. The knowledge learned in medicine was not shared with the patients, who were in general poorly educated and for the most part completely ignorant of the craft of medicine and the physicians (but not, perhaps, of folk medicine). Physicians were cautioned against telling patients too much about their Illness and/or their recovery, perhaps because physicians themselves did not have an enormous armamentarium to confront disease.

Today's ever-widening expert/novice gap–in technology generally but in healthcare technology especially–has been implicated as both cause and consequence of a sharp rise in fundamental misunderstandings between medical professionals and lay populace. Recently created social roles (e.g., clinical medical ethicists) and institutions (e.g., hospital ethics committees) have further prompted critics to suggest that a multiplication of “disinterested” experts not only fails to resolve such misunderstandings, it compounds them. As a result, it should come as no surprise that the problem of paternalistic expertise has emerged as an ethical issue of immense interest from both a theoretical and practical standpoint. For this reason, a critical inquiry in healthcare today centers on finding a practical model that most adequately and accurately characterizes patient–physician relationships.

A central concept in Dutch health law is the care of a good caregiver (de zorg van een goed hulpverlener). We find this standard in various (proposed) statutes and in legal doctrine. This concept is, however, vague and open and must be made more concrete in professional practice, in moral theory, and in law. In this article, we explore the implications of this complex standard and analyze what moral philosophy and jurisprudence can contribute to its clarification and implementation in professional practice and law. We start with some reflections on how practitioners see this norm and try to live up to it.

I graduated from, medical school in 1972. According to orders signed at the Kremlin by the Chairman of the Supreme Soviet of the USSR, I was obliged, along with every graduating medical student, to swear to a new professional code, “The Oath of the Soviet Physicians.” This was the second year the oath was used. Incorporated in the oath were promises to “conduct all my actions according to the principles of the Communist morality, to always keep in mind … the high responsibility I have to my people and to the Soviet government” I felt no discomfort joining with my friends in repeating words about the communist morality which by that time had already become a ritualized and meaningless official decoration of our life. The text of this oath fit into the political and medical ideology of that time. Not surprisingly, “The Oath of the Soviet Physicians” died along with the Soviet Union.

It is often said that because physicians and other healthcare professionals frequently play a critical role in determining the fate of their patients, they ought if at all possible to be their patient's friend. The relationship of necessity is intimate: physicians have knowledge of their patients' histories and of their bodies which under other circumstances would be reserved to the most intimate of friends, and physicians and patients meet under more or less critical (or at least anxiety-producing) situations. In this paper, I briefly examine the role of the physician as “friend,” an Issue to be much more extensively explored In a book In preparation.

In April 1991, a general meeting of the Japanese Medical Conference (called ev 4 years) was held in Kyoto and attracted 32,500 participants, the largest number ever. The theme of the meeting was “Medicine and Health Care in Transition,” and the program Included panel discussions on “How to Promote the Quality of Health Care” and “How Terminal Care Should Be Provided” and symposia on “Diagnosis of Brain Death and Its Problems,” “The Propriety of Organ Transplantation,” and “Brain Death and Organ Transplantation.” These titles reveal not only how medical professionals in Japan perceive the present situatior healthcare but also the Issues that most concern them.

When patients join a Health Maintenance Organization (HMO), they choose a primary care physician from among a set whose members are approved by a board according to preestablished criteria. To assist patients in making their choice of physician, the HMO provides them an information packet about each physician.

Recently, a physician (let us call him Dr. Exchs) requested permission to include in the information packet about himself that he would not accept patients who smoke and would not continue the care of current patients who smoke. His poignant statement follows.

Among the important functions of the healthcare provider in providing quality care is the monitoring of the social environment of the patient. Although it is increasingly recognized that caring activity must include the whole patient and not merely the technical and pharmacological aspects of the patient's needs, the impact of the social environment upon the total health state (which includes physical, emotional, and social components) has not been explored and debated to the extent that It might be.

The single greatest challenge facing managers in the developed countries of the world is to raise the productivity of knowledge and service workers. This challenge, which will dominate the management agenda for the next several decades, will ultimately determine the competitive performance of companies. Even more important, it will determine the very fabric of society and the quality of life of every industrialized nation. … Unless this challenge is met, the developed world will face increasing social tensions, increasing polarization, increasing radicalization, possibly even class war.

Any humane society needs a just and compassionate way to care for those who are sick, and should be vigilant in identifying and eliminating barriers that frustrate efforts to adequately care for the sick. Some current insurance underwriting practices constitute effective barriers to access to healthcare and serve to diminish the place of freedom and justice in our healthcare system.

Across the world, healthcare providers must wrestle with the twin ogres of finite resources and infinite demand. Successful healthcare delivery creates its own legacy of need. For example, a renal failure patient may now be given a greatly extended life by means of dialysis or organ transplantation. In the process, the healthcare provider has created a permanent demand for services during that extended life. It has been estimated that the recurrent cost of maintaining a patient on hemodialysis for 1 year in the United Kingdom is in the region of £20,000.

Over a 20-year period, the United States has developed a consensus of legal opinion concerning living wills and other advance directives. At the heart of this consensus are two interconnected principles. First, the state should minimally interfere with the wishes of patients and surrogates and the decisions of physicians about foregoing life-sustaining treatments. Second, state interference is permissible for the sake of protecting a compelling state interest. The overwhelming majority of states with advance directive laws have attained this balance of minimal interference and compelling state interest in developing their laws.

Recent contributions to the literature on the topic of futility have focused primarily on two areas: 1) definitions of the term and 2) the suggestion that cardiopulmonary resuscitation (CPR) may be futile in certain patients. This suggestion is based on “scientific” measures and analyses of outcomes, describing the low probability of success of CPR in patients over age 70, those with cancer, those with multiorgan failure, etc. The research reported suggests that with such patients the physician need not get the patient's (or the surrogate's) consent to withhold resuscitation; the physician need only inform either the patient or the surrogate that CPR will not be Instituted in the event of an arrest.

Mrs. A. is a 50-year-old woman, originally from Greece, who came to the United States with her family in 1973. A widow, with three grown children, she has been living near two of her sons and their families. For many years, Mrs. A. has suffered from, non-insulin-dependent diabetes, emphysema, and hypertension. On the day of a family picnic, she developed a high fever and vomiting. She was taken by her oldest son, Thomas, to the emergency department, where evidence was discovered of a severe infection of her kidneys that had spread to her blood.