Withholding and withdrawing of life support: a medicolegal dilemma

The developments in medicine in general and the technology of life support in particular have provided the means of maintaining organ function for prolonged periods of time. However, there are many situations where life-sustaining treatment in an intensive care unit (ICU) may lead to a death with lingering and suffering of the patient, as well as burdening their family. Although often equated, withholding and/or withdrawing life-prolonging treatments that allow the patient to die needs to be differentiated from the physician-assisted suicides and euthanasia that involve the active ending of life. There is a difference between an unintended but accepted consequence of forgoing therapy and an intended result of death from suicide or euthanasia. The present-day physicians view most patient deaths as an inevitable process secondary to disorders unresponsive to treatment and/or multiple organ dysfunction syndromes. The large majority of patients dying in ICUs today succumb not after cardiopulmonary resuscitation, but rather, after the forgoing of life-sustaining treatment. Such approach has frequently caused families, institutions, and conservators of patients to resort to judicial fiat for resolution.     

The legal basis for ethical withholding and withdrawing of life-sustaining medical treatment in children

Withholding and withdrawing life-sustaining medical treatment are common in paediatric practice, especially in intensive care units. However, not all clinicians apparently adhere to principles in ethical guidelines or to the principles which are to be found in judgments from common law cases arising when doctors and parents dispute treatment. This article examines selected ethical guidelines and compares them to judgments in leading cases. The rationale to forgo treatment is usually the child's "best interests" in both clinical practice guidelines and legal cases but in the former "best interests" may remain ill defined. Although "best interests" must essentially pertain to the individual child, the interests of others are not irrelevant. In legal cases "best interests" of the child are defined in terms such as "burden versus benefit", "futility", "indignity", "intolerability", "prolonging death rather than saving life" and "quality of life". These or like terms should form the basis of ethical decisions in discussions with parents when contemplating withholding or withdrawing life-sustaining treatment.     

Legislative and educational alternatives to a judicial remedy for the transfer trauma dilemma

Transfer trauma is alleged to be an increase in morbidity and mortality in institutionally relocated chronically ill elderly. Efforts by the legal profession to persuade courts that transfer trauma should be a legally recognized phenomenon invoking judicial protections against transfer (the "transfer trauma argument") have been unproductive. In O'Bannon v. Town Court Nursing Center, Inc., the United States Supreme Court denied standing to elderly persons claiming a property interest in remaining in alleged substandard facilities. The Court rejected the argument that the possibility of transfer trauma constituted a deprivation of life or liberty that would have required due process protections of notice and hearing. Despite the Court's preclusion of transfer trauma litigation in a constitutional context and the general unwillingness of lower courts to recognize the phenomenon, attorneys continue to burden the judicial system with frivolous transfer trauma arguments. The unfruitful pursuit of a judicial remedy for the ethical and social problems that arise with relocation of the elderly continues, in part, because of a misguided belief that this distressing social phenomenon is best remedied by the courts. Judicial unwillingness to recognize the transfer trauma argument, however, does not preclude legislative consideration of the humanitarian issues concerning the institutional relocation of elderly persons. This Article examines gerontological research in order to understand the judicial rejection of the transfer trauma argument and argues in support of legislative and educational solutions for the ethical and social problems attending transfer.     

Dangerous children: Juvenile delinquency and judicial intervention in the Netherlands, 1960–1995

In the continuing controversy in academic circles over the rise in reportedjuvenile violent delinquency, some scholars attribute it largely to theincrease in the actual number of offences while others emphasize changesin registration and intervention practices. This article reviews changes in theway justice workers try to control the behaviour of delinquent juveniles inthe Netherlands in the period 1960–1995. The study is based on ananalysis of files on adolescents and children placed in the Dutch juvenilejustice system by judges during the 1960s, 1970s, 1980s and 1990s.Comparing the older and recent files reveals that the interventions ofjuvenile justice workers became less harshly. This process has coincided witha rise in the severity of violence and crimes committed by the youngsters.As a result juvenile justice workers intervene indeed more frequently fromthe beginning of the 1980s, but still in a less punitive way. The externalconstraints in the Dutch judicial system are rather gentle and prudent, whilethe youngsters exercise more severe violence and crimes, suggesting furtherinquiry to the degree of autonomy of, and interaction between, adultsocialization among professionals and youth socialization.     

A line already drawn: the case for voluntary euthanasia after the withdrawal of life-sustaining hydration and nutrition

When life-sustaining hydration and nutrition is withheld from an incompetent and immobile patient like Terri Schiavo, death comes to the patient by dehydration within about two weeks. Americans should be permitted to arrange for euthanasia at that point, as opposed to merely dehydrating to death, and should be able to incorporate their desire for euthanasia into an advance directive. A state constitutional right of privacy could provide the legal avenue permitting effectuation of such a choice.     

The appointments clause: Judge Bork and the role of ideology in judicial confirmations

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Toxic or tolerant: chloral and the drug dilemma.

The role that a drug or combination of drugs plays in the causation of death cannot always be stated with certainty. Drugs associated with the development of tolerance create a particular problem, and there is need for additional data concerning tolerable concentrations achieved by drug abusers. The common drug chloral hydrate falls into this category, and a case of possible chloral hydrate intoxication has been presented.