Lois Snyder

American College of Physicians Ethics Manual: Sixth Edition

Medicine, law, and social values are not static. Reexamining the ethical tenets of medicine and their application in new circumstances is a necessary exercise. The sixth edition of the American College of Physicians (ACP) Ethics Manual covers emerging issues in medical ethics and revisits older ones that are still very pertinent. It reflects on many of the ethical tensions in medicine and attempts to shed light on how existing principles extend to emerging concerns. In addition, by reiterating ethical principles that have provided guidance in resolving past ethical problems, the Manual may help physicians avert future problems. The Manual is not a substitute for the experience and integrity of individual physicians, but it may serve as a reminder of the shared duties of the medical profession.

Ethics Manual: Fifth Edition

The secret of the care of the patient is in caring for the patient. Francis Weld Peabody (1) Some aspects of medicine are fundamental and timeless. Medical practice, however, does not stand still. Clinicians must be prepared to deal with changes and reaffirm what is fundamental. This fifth edition of the Ethics Manual examines emerging issues in medical ethics and revisits older issues that are still very pertinent. Changes to the Manual since the 1998 edition include new or expanded sections on professionalism, the physician and patient, third-party evaluations, confidentiality, complementary and alternative care, boundaries and privacy, gifts from patients, care of patients at the end of life, solid organ transplantation, physician-assisted suicide, the changing practice environment and managed care ethics, physician-industry issues, selling products out of the office, health and human rights, patient safety, prisoners as patients, strikes and joint actions, consultation and shared care, and research ethics. A case method for ethics decision making is included (Appendix). The Manual is intended to facilitate the process of making ethical decisions in clinical practice and medical research and to describe and explain underlying principles of decision making. Because ethics must be understood within a historical and cultural context, the second edition of the Manual included a brief overview of the cultural, philosophical, and religious underpinnings of medical ethics. In this edition, we refer the reader to that overview (2, 3) and to other sources (4-9) that more fully explore the rich heritage of medical ethics. The Manual raises ethical issues and presents general guidelines. In applying these guidelines, physicians should consider the circumstances of the individual patient at issue and use their best judgment. Physicians have moral and legal obligations, and the two may not be concordant. Physician participation in torture is legal in some countries but is never morally defensible. Physicians must keep in mind the distinctions and potential conflicts between legal and ethical obligations when making clinical decisions and should seek counsel when they are concerned about the potential legal consequences of decisions. We refer to the law in this Manual for illustrative purposes only; these references should not be taken as a statement of the law or of the legal consequences of a physicians actions, which can vary from state to state. Physicians must develop and maintain an adequate knowledge of key components of the laws and regulations that affect their patients and practices. Medical and professional ethics often establish positive duties (that is, what one should do) to a greater extent than the law. Current understanding of medical ethics is based on the principles from which positive duties emerge. These principles include beneficence (a duty to promote good and act in the best interest of the patient and the health of society) and nonmaleficence (the duty to do no harm to patients). Also included is respect for patient autonomythe duty to protect and foster a patients free, uncoerced choices (10). From the principle of respect for autonomy are derived the rules for truth-telling. The relative weight granted to these principles and the conflicts among them often account for the ethical dilemmas physicians face. Physicians who will be challenged to resolve those dilemmas must have such virtues as compassion, courage, and patience in all aspects of their practice. In addition, considerations of justice must inform the physicians role as citizen and clinical decisions about resource allocation. The principle of distributive justice requires that we seek to equitably distribute the life-enhancing opportunities afforded by health care. How to accomplish this distribution is the focus of intense debate. More than ever, concerns about justice challenge the traditional role of physician as patient advocate. The environment for the delivery of health care continues to change. Sites of care are shifting, with progressively more care being provided in ambulatory settings while the intensity of inpatient care continues to increase. Yet the U.S. health care system does not serve all of its citizens well, and major reform is needed. Health care financing is a serious concern, and societys values will be tested in decisions about resource allocation. Ethical issues attract widespread public attention, and debate about them is covered regularly in the press. Through legislation, administrative action, or judicial decision, government is increasingly involved in medical ethics. Today, the convergence of various forcesscientific advances, patient and public education, the Internet, the civil rights and consumer movements, the effects of law and economics on medicine, and the heterogeneity of our societydemands that physicians clearly articulate the ethical principles that guide their behavior, whether in clinical care, research, and teaching or as citizens. It is crucial that a responsible physician perspective be heard as societal decisions are made. From genetic testing before conception to dilemmas at the end of life, physicians, patients, and their families are called upon to make difficult ethical decisions. The 1970s saw the development of bioethics as a field, followed by a series of reports from the U.S. Presidents Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. Important issues then (and now) include informed consent (11, 12), access to health care (13), genetic screening and engineering (14, 15), and forgoing life-sustaining treatment (16, 17). These and other issuesAIDS, physician-assisted suicide, technological changes including increasing computerization of medical records, and the physician as entrepreneurchallenge us to periodically reconsider such topics as the patientphysician relationship, decisions to limit treatment, and confidentiality. This Manual was written for our colleagues in medicine. The College believes that the Manual provides the best approach to the challenges addressed in it. We hope that it will stimulate reasoned debate and serve as a reference for persons who seek the Colleges position on ethical issues. Debates about medical ethics may also stimulate critical evaluation and discussion of law and public policy on the difficult ethical issues facing patients, physicians, and society. Professionalism Medicine is not a trade to be learned, but a profession to be entered (1). A profession is characterized by a specialized body of knowledge that its members must teach and expand, by a code of ethics and a duty of service that put patient care above self-interest, and by the privilege of self-regulation granted by society (18). Physicians must individually and collectively fulfill the duties of the profession. While outside influences on medicine and the patientphysician relationship are many, the ethical foundations of the profession must remain in sharp focus (19). The Physician and the Patient The patientphysician relationship entails special obligations for the physician to serve the patients interest because of the specialized knowledge that physicians possess and the imbalance of power caused by the medical relationship. The physicians primary commitment must always be to the patients welfare and best interests, whether the physician is preventing or treating illness or helping patients to cope with illness, disability, and death. The physician must respect the dignity of all persons and respect their uniqueness. The interests of the patient should always be promoted regardless of financial arrangements; the health care setting; or patient characteristics such as decision-making capacity or social status. At the beginning of and throughout the patientphysician relationship, the physician must work toward an understanding of the patients health problems, concerns, goals, and expectations. After patient and physician agree on the problem and the goal of therapy, the physician presents one or more courses of action. If both parties agree, the patient may authorize the physician to initiate a course of action; the physician can then accept that responsibility. The relationship has mutual obligations. The physician must be professionally competent, act responsibly, seek consultation when necessary, and treat the patient with compassion and respect, and the patient should participate responsibly in the care, including giving informed consent or refusal to care as the case might be. Effective communication is critical to a strong patientphysician relationship. Communication through means such as e-mail can supplement face-to-face encounters; however, it must be done under appropriate guidelines (20), and it may not be effective for some patients. Care and respect should guide the performance of the physical examination. The location and degree of privacy should be appropriate for the examination being performed. A chaperone should be offered to the patient or requested by the physician for physical examinations as needed. An appropriate setting and sufficient time should be allocated to encourage exploration of aspects of the patients life pertinent to health, including habits, relationships, sexuality, vocation, religion, and spirituality. Although the physician should be fairly compensated for services rendered, a sense of duty to the patient should take precedence over concern about compensation. Initiating and Discontinuing the PatientPhysician Relationship By history, tradition, and professional oath, physicians have a moral obligation to provide care for ill persons. Although this obligation is collective, each individual physician is obliged to do his or her fair share to ensure that all ill persons receive appropriate treatment (21). A physician may not discriminate against a class or category of patients. An individual

Physician-Assisted Suicide

Is physician-assisted suicide the answer? This may depend on the question. Is it an issue of patient rights? Of medicines limitations? Of trust? Of fear and control for patients? Is it a legal issue? An ethical or moral issue? An individual issue? A societal issue? It is all of these. Many have theorized about the merits or dangers of physician-assisted suicide. But whether it should be legally sanctioned is a question with no easy answers. Physician-assisted suicide is only one of many clinically and ethically distinguishable practices in end-of-life care. Most commonly, life-sustaining treatments are withheld or withdrawn when patients refuse such treatment. The ethical and legal consensus about such practices is well established. Physician-assisted suicide, however, is a different type of act, and is far more controversial. In physician-assisted suicide, medical help is provided to enable a patient to perform an act that is specifically intended to take his or her own life, for example, overdosing on pills as prescribed by the physician for that purpose. Physician-assisted suicide should be distinguished from euthanasia, in which the physician performs an act that is specifically intended to take the patients life, through, for example, lethal injection (1). Our use of these terms throughout this paper is based on these definitions. Terms such as aid-in-dying or physician-assisted death, which lump together categories, can obscure the ethics of what is at stake. Recent voter initiatives and court decisions have reflected public interest in physician-assisted suicide. Many people fear a painful and protracted death or desire more control over the dying process. Some fears have been justified. Our societal emphasis on cure and the medical emphasis on intervention have sometimes been at the expense of good end-of-life care. We have been slow to embrace the practice and principles of hospice, and dissemination of state-of-the-art palliative care, especially pain control techniques, has been incomplete. Reimbursement disincentives for comfort care have exacerbated the problem, and cost-control pressures that discourage expensive long-term care loom large over care at the end of life. Most individuals who contemplate or succeed at suicide are depressed or have other psychiatric comorbid conditions (2-6). Among terminally ill patients who desire death, the wish fluctuates significantly over time (7, 8). Others are not receiving effective pain and symptom control, are not experiencing caring and compassion from their health care providers (or family or friends), or live in fear that they will not receive these when needed (9, 10). Some are concerned about finances or being a burden on their family. Some fear loss of control and self-image or the prospect of being in a long-term care or other facility. Some are alone, or are vulnerable in other ways. The Institute of Medicines report, Approaching Death: Improving Care at the End of Life, found end-of-life care in the United States to be lacking in many ways (11), as did the

Substituted Interests and Best Judgments: An Integrated Model of Surrogate Decision Making

28 million Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment (12, 13). The cultural norm of medicine and of hospital life is to fight hard to preserve life, and in most cases this is the right thing to do. However, inappropriate aggressive care at the end of life can be emotionally, physically, and financially detrimental to patients, their families, and health care providers. Clinical Duties: Reaching Consensus on Palliative Care Traditionally, the decision to forgo life-sustaining treatment has been ethically, legally, and clinically distinguished from a request for physician assistance with suicide or euthanasia (14-16). Although the Hippocratic Oath proscribes euthanasia and assisted suicide (17), abating treatment has been considered appropriate when patients are overmastered by disease (18). Some lower-court decisions have questioned the importance of this distinction (19), but the U.S. Supreme Court has consistently distinguished the refusal of treatment from suicide (20, 21). The withdrawal of treatment based on patient wishes respects a patients right to be free of unwanted medical treatment, while physician-assisted suicide and euthanasia invoke a right to have the physician provide a new intervention for the patient (22). The American College of PhysiciansAmerican Society of Internal Medicine (ACPASIM) continues to believe that this distinction is important (23). Patients have a firmly established legal right to refuse unwanted medical treatment. Physicians should not refrain from withholding or withdrawing medical interventions according to now well-established ethical and clinical standards. Patients might otherwise feel pressured to refuse a trial of life-sustaining treatment, or even to request assisted suicide or active euthanasia, in order to avoid what they fear might become prolonged use of life support. Patients often fear the prospect of unrelieved pain. Many patients with terminal illness are, in fact, undermedicated (24-27). Some physicians withhold pain medication because of largely ungrounded fears that terminally ill patients will become tolerant of or addicted to the medication or will abuse medications (24). When patients select palliation as their highest goal, physicians should make relief of suffering the highest priority (23). Some physicians withhold palliative doses of opioids because they fear that the required higher doses may hasten death through respiratory suppression. Usually, adequate pain relief does not hasten death (28). Even if life may be shortened, there is strong support for increasing medications for terminally ill patients to levels that relieve pain (23, 29, 30). The Question of Physician-Assisted Suicide For years, the consensus has been that, after a careful weighing of patient autonomy, medical beneficence, and societal interests, a patient may forgo life-sustaining treatment. Some now argue that physician-assisted suicide is the logical next step. Suicide and attempted suicide have been decriminalized in the United States. They are now subjects of mental health law, not criminal law. Society does, however, seek to prevent suicide by allowing others to intervene to prevent acts of self-destruction and involuntary hospitalization and by criminalizing the aiding of a suicide. Our society and the medical profession are divided on the issue of legalizing physician-assisted suicide and euthanasia for patients at the end of life. In the past, the ACPASIM and others have questioned whether a blanket condemnation of physician-assisted suicide, with no other comment, misses an opportunity to improve the care of dying patients (23, 31-34). Polls show significant public support (35, 36), and many physicians, while reluctant to perform assisted suicide or euthanasia themselves, support the legalization of assisted suicide (37-42). Nonetheless, assisting a suicide remains a specific statutory offense in most states (2). Euthanasia is illegal everywhere in the United States. One stateOregonhas legalized physician-assisted suicide (43-45). In other states, recent referenda and bills to legalize assisted suicide have been defeated (46-49), and 15 states newly criminalized it between 1986 and 1999 (50, 51). Other countries have experimented with physician-assisted suicide and euthanasia. In the Netherlands, both practices had been illegal but tolerated under detailed guidelines. Recently, these practices were legalized (52). Euthanasia was briefly legalized, from July 1996 to March 1997, in the Northern Territory of Australia (53). The U.S. Supreme Court Decisions on Assisted Suicide In landmark decisions in July 1997, the U.S. Supreme Court ruled that there is no constitutional right to assisted suicide (21, 54). Given the lack of consensus in this country on legalization, the uncertainties about whether regulation could confine the practice to competent terminally or irreversibly ill persons, the current inadequate provision of palliative care, and the collective failure of our society to assure universal access to health care, the finding of a new constitutional right to physician-assisted suicide would have foreclosed debate. A ruling by one of the lower courtsthe Ninth U.S. Circuit Court of Appealsin Compassion in Dying v. Washington (55), was the first federal appellate court decision on physician-assisted suicide. In this case, it was held that individuals have a right to choose how and when they die. As applied to the limited circumstance of the competent, terminally ill adult who wants a physicians prescription for a lethal dose of medication, the Washington State criminal statute banning physician-assisted suicide was found unconstitutional as a violation of the Due Process Clause of the 14th Amendment. That clause says a state may not deprive any person of life, liberty, or property without due process of law. By contrast, in recognition of previous decisions by the Supreme Court, the Second Circuit had said it specifically declined to identify a new fundamental right in the absence of a clear direction from the Court whose precedents we are bound to follow. Instead, in Quill v. Vacco (19), the Second Circuit found a New York law to be unconstitutional on much narrower grounds. The Equal Protection Clause of the 14th Amendment says that no state shall deny to any person within its jurisdiction the equal protection of the laws. The law was found to violate that clause because competent patients at the end of life were being treated differently: Some patients could refuse life-sustaining treatment and thereby hasten death, but others were prohibited from seeking prescriptions from physicians to hasten death. The U.S. Supreme Court did not find either of the lower-court decisions persuasive. Instead, the Supreme Court specifically distinguished refusal of treatment from physician-assisted suicide. Refusal of treat

The Doctor Will See You Shortly: The Ethical Significance of Time for the Patient-Physician Relationship

AKING DECISIONS ON BEHALF OF PATIENTS WITHoutdecision-makingcapacityremainschallenging, especially at the end of life. Under the currentUSmodel,formalwrittenororaldirectives expressing patient wishes for future care are preferred. Lackingthat,surrogatesareinstructedtoprovidesubstitutedjudgments, choosing what the patient would have chosen. If the patientneverhadcapacityorthepatient’spreferencesareunknown, a decision should be made in the patient’s best interests. This hierarchical model of separate standards, however, does not always reflect clinical reality or the interests of patients and families. In this commentary, we propose an alternative approach: the substituted interests model. Decision making under the substituted interests model would be individualized and patient-centered and combineuniversalprincipleswithempiricalevidenceaboutwhat individualsvalueandhowtheymakedecisions.Thismodel emphasizes authenticity (ie, a decision true to who the person really is) rather than the autonomy the patient cannot exercise, 1 asking surrogates to provide knowledge of patients’ authentic values and interests (“substituted interests”) rather than guessing what the patient would have decided. A “best judgment” about what decision advances the good of each patient as a unique individual follows. Substituted Interests Model Thesubstitutedinterestsmodelintegratesthecurrentlyseparate standards into a contextualized process, unique to each patient, yet universal in its ethic. Rather than interpreting a text or making a substituted judgment about what the patient might have wanted in imperfectly foreseen circumstances, the surrogate is asked to apply the patient’s authentic values and real interests, including the patient’s known preferences. The key question under best interests is, “What

Physician–Industry Relations

Many physicians and health care leaders express concern about the amount of time available for clinical practice. While debates rage on about how much time is truly available, the perception that time is inadequate is now pervasive. This perception has ethical significance, because it may cause clinicians to forego activities and behaviors that promote important aspects of the patient-physician relationship, to shortcut shared decision making, and to fall short of obligations to act as patient advocates. Furthermore, perceived time constraints can hinder the just distribution of physician time. Although creating more time in the clinical encounter would certainly address these ethical concerns, specific strategies—many of which do not take significantly more time—can effectively change the perception that time is inadequate. These approaches are critical for clinicians and health systems to maintain their ethical commitments and simultaneously deal with the realities of time.

The Role of Guidelines in the Practice of Physician-Assisted Suicide

TO THE EDITOR: The American College of Physicians (ACP) continues to evaluate issues related to relationships between physicians and industry and between physician organizations and industry and to work to emphasize relationships that maximize the interests of the patient. Recently, the College approved a revision to position 1 (Industry Gifts, Hospitality, Services, and Subsidies) of our position paper (part 1 of 2) on physicianindustry relations (1). The revision was developed by the ACP Ethics and Human Rights Committee to help clarify the statement, including moving some language from the rationale directly into the position. The revised position is as follows: The acceptance by a physician of gifts, hospitality, trips, and subsidies of all types from the health care industry that might diminish, or appear to others to diminish, the objectivity of professional judgment is strongly discouraged. As documented by some studies, the acceptance of even small gifts can affect clinical judgment and heighten the perception and/or reality of a conflict of interest. Accordingly, physicians need to gauge regularly whether any gift relationship is ethically appropriate and evaluate any potential for influence on clinical judgment. In making such evaluations, it is recommended that physicians consider such questions as 1) What would the public or my patients think of this arrangement? 2) What is the purpose of the industry offer? 3) What would my colleagues think about this arrangement? 4) What would I think if my own physician accepted this offer? In all instances, it is the individual responsibility of each physician to assess any potential relationship with industry to assure that it enhances patient care and medical knowledge and does not compromise clinical judgment. We hope that physicians will find this revision and the rest of the content of the 2002 position paper helpful and will continually evaluate their relationships with industry as well.

The Patient-Centered Medical Home: An Ethical Analysis of Principles and Practice

Proponents and opponents of physician-assisted suicide can agree on at least one thing: the importance of regulatory guidelines if the practice is to be legal. However, there is much disagreement about the moral import of even trying to formulate guidelines; about how guidelines can affect physician practice, health care providers, patients, or families; and about whether guidelines can really protect against harm or abuse. Questions once only of theoretical interest have taken on new urgency since Oregon legalized physician-assisted suicide. The debate about guidelines swirls around several interrelated questions. What has been the experience of efforts to implement physician-assisted suicide using consensus guidelines? What goals are guidelines intended to serve? Who should formulate them? Can guidelines be practical? Are there obstacles to creating or implementing guidelines? Is dying a process amenable to direction under guidelines by physicians, departments of health, blue ribbon panels, or other regulatory bodies? What Is Known about the Value of Guidelines for Physician-Assisted Suicide? The Netherlands, where euthanasia and physician-assisted suicide are decriminalized, is the only place where guidelines have existed for any significant period. These guidelines were created by the national medical association, along with groups such as pharmacologist organizations (1-4). Americans often invoke data from the Netherlands to support their positions on guidelines for physician-assisted suicide (5-7), but there are limits to what can be learned from the Dutch experience. Although the Dutch people value guidelines for a practice that is still technically illegal there, the force and precision of guidelines are not what would be expected were the practice legal. Dutch physicians note that many physicians do not follow guidelines (8), and formal studies have reported high rates of noncompliance (9). How well Dutch guidelines regulate the practice of physician-assisted suicide is a matter of dispute (1, 5, 6-8, 10). Reports of euthanasia without an unambiguous request to die prompted a re-examination of prevailing guidelines. The Netherlands has adopted more restrictive rules, with tougher reporting and witness requirements (8, 9). Studies comparing practices in 1995 with those in 1990 have found that involuntary euthanasia continues to occur at a minimally lower rate. However, many deaths with assistance are not reported to the authorities (11). Differences in the health systems and social structure between the Netherlands and the United States further complicate comparisons. What Is the Purpose of Guidelines for Physician-Assisted Suicide? The first published proposals for U.S. guidelines to govern the implementation of legal physician-assisted suicide appeared in the early 1990s. The movement to create guidelines has been a key component in efforts toward legalization and has focused on how to implement a decision to proceed with physician-assisted suicide (rather than on how to decide that physician-assisted suicide is the right course for an individual patient). Some of the efforts have created model statutes or legislation, but most talk has focused on providing practical guidance about implementing physician-assisted suicide in an authoritative document. Legalization is not a prerequisite for the creation of guidelines. Many who initially called for guidelines noted that physician-assisted suicide was already occurring in the United States. They argued that it would be better to have some sort of guidance for physicians rather then leaving physicians and patients to their own devices. Those favoring legalization thought that the cause of legalization would be advanced by promoting practical guidelines. This created a situation in which guidelines were often viewed as nothing more then a stalking horse for efforts to legalize physician-assisted suicide. Jack Kevorkians actions and advocacy brought new urgency to guideline writing efforts. Lonnie Shavelson (12) documented several cases in which he felt that persons had assisted others to die for morally dubious reasons. The popularity of books such as Final Exit (13) and Last Wish (14) made it clear that the public was interested in assisted suicide. Sherwin Nulands book How We Die (15) reinforced the view that the prevailing standard of clinical care for the dying was often not what patients and their families wanted. The inadequate state of end-of-life care became further evident in the findings of the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment (SUPPORT) (16, 17). It was obvious that something had to be done to standardize and improve the overall care of dying patients. If such improvements did not take place, assisted suicide might become commonplace, without input from those most experienced in caring for the terminally ill. Those calling for regulation of physician-assisted suicide often made analogies to the effect that law and regulation had had on the practice of forgoing, withdrawing, and withholding life support. The willingness of society to accept the cessation of ventilator use, renal dialysis, antibiotic therapy, and other life-sustaining interventions on the basis of policies, guidelines, and review by ethics committees made many believe that what had worked effectively for forgoing life-sustaining treatment could work for physician-assisted suicide (5, 18). Finally, in several opinion surveys of the early 1990s, it became clear that many patients and physicians would consider undertaking physician-assisted suicide for reasons that experts in end-of-life care found troubling or simply erroneous (19). Those polled said that they would consider physician-assisted suicide if they were in terrible pain or had to depend on machines. This made some proponents think that regulation was essential to ensure that persons who were disabled or in pain would not prematurely seize upon physician-assisted suicide. Who Should Write Guidelines? Despite all the efforts directed toward guideline development, there has been relatively little discussion of who should create them. In Oregon, responsibility for guideline development fell to the Department of Health, although a medical society (20) and a blue ribbon panel also offered guidance (21). Other organized groups that have issued guidelines have tended to consist of professors and academics, with or without clinicians. Political necessity, more than expertise or clinical involvement with terminally ill patients, may have motivated these groups to formulate guidelines (22, 23). One notable exception was the Bay Area Network of Ethics Committee, which in 1997 issued guidelines to help clinicians respond to requests for assisted suicide (24). In part, these guidelines were created in response to numerous requests for physician-assisted suicide from San Francisco residents dying of AIDS. Obviously, persons favoring legalization are most likely to write guidelines. In the few instances in which medical groups (Michigan Medical Society and New York Academy of Medicine) tried to write guidelines without previous agreement about the desirability of physician-assisted suicide, the efforts collapsed (25). Critics sometimes address the specifics of proposed guidelines but more often reject guidelines on general grounds (for example, no guidelines could ever be sufficient to prevent the inclusion of inappropriate cases [7, 25]) or as an opportunity to engage in further debate about the general moral merits of legalization (25-27). Of interest, when proponents write guidelines, the intended audience is clinicians or public policymakers rather than the general public. Although religious groups have spoken about the morality of physician-assisted suicide, none has issued specific guidelines on its implementation or monitoring (28). The Task Force to Improve the Care of Terminally-Ill Oregonians, formed to provide guidance in implementing the Oregon law, was composed mostly of physicians, nurses, and attorneys (21). No patient or consumer groups have issued specific guidelines. This is especially noteworthy given the growing interest in the spiritual and psychological dimensions of dying, as reflected in the enormous popularity of books focusing on these aspects of dying (29-35). Guidelines have mostly been seen as norms or rules for physicians, not as general principles about how Americans ought to think about, control, or implement physician-assisted suicide. In fact, the U.S. debate about assisted suicide seems to focus on the presumption that the persons who should be most concerned about implementing assisted suicide are physicians (36). Perhaps this stance is partly fueled by the vociferous opposition to assisted suicide by organized medicine and nursing throughout the 1990s on the grounds that such behavior violates norms of professional ethics. But the centrality of clinicians as the audience for guidelines may also reflect a deeply held U.S. view that dying is a matter with which health care professionals and biomedical science must contend (15, 35). Content of Guidelines for Physician-Assisted Suicide A sample of the guidelines reveals consistent core content (Table). In examining the first set of guidelines published in a major medical journal (37), other guidelines reported in prominent publications (22-24), and state requirements (Oregon), many common themes emerge. All require the individuals informed consent for participation, and most recommend a waiting period to ensure the authenticity of a request. Most guidelines call for consent to be written and witnessed. Table. Guidelines for Implementing Physician-Assisted Suicide Guidelines that involve more physician input include references to conscientious objection. These guidelines also try to capture the importance of good physicianpatient relationships with discussions of meaningful or established relationships. T

Complementary and Alternative Medicine

ABSTRACTThe patient-centered medical home (PCMH), with its focus on patient-centered care, holds promise as a way to reinvigorate the primary care of patients and as a necessary component of health care reform. While its tenets have been the subject of review, the ethical dimensions of the PCMH have not been fully explored. Consideration of the ethical foundations for the core principles of the PCMH can and should be part of the debate concerning its merits. The PCMH can align with the principles of medical ethics and potentially strengthen the patient–physician relationship and aspects of health care that patients value. Patient choice and these ethical considerations are central and at least as important as the economic and practical arguments in support of the PCMH, if not more so. Further, the ethical principles that support key concepts of the PCMH have implications for the design and implementation of the PCMH. This paper explores the PCMH in light of core principles of ethics and professionalism, with an emphasis both on how the concept of the PCMH may reinforce core ethical principles of medical practice and on further implications of these principles.

LESSONS IN LAW AND AGING: A TOOL FOR EDUCATORS AND STUDENTS

Many Americans use complementary and alternative medicine (CAM) in pursuit of health and well-being. The 2007 National Health Interview Survey (NHIS), which included a comprehensive survey of CAM use by Americans, showed that approximately 38 percent of adults use CAM. This fact sheet presents an overview of CAM, types of CAM, summary information on safety and regulation, the mission of the National Center for Complementary and Alternative Medicine (NCCAM), and additional resources.