Alzheimer's Dilemma Case
Introduction and Background
The care of terminal patients is often difficult and ethically challenging. The standards of competent and compassionate care that characterized a previous generation seem to be wavering, replaced by a post-modern mélange of newer conflicting theories and ethical values.
A shift from deontological principles to utilitarianism has occurred in the past thirty years, corresponding with the rise of the modern bioethics movement (Rae & Cox, 1999). Many members of an increasingly aging population are denied their autonomy on the basis of mental incompetence. The most common cause of the loss of competence is Alzheimer’s disease, which may afflict up to 50% of individuals 85 years and older (Alzheimer’s Disease, 2003). …show more content…
Decisions to withdraw treatment are often based on a lack of higher mental functioning as evidenced by self-awareness and self-control. On such utilitarian ideas of bioethics, there are degrees of person-hood as though it were a quantity that one individual could have more of than another. To lose these physiologic parameters means to lose something vaguely called the “quality of life.” Such “physiologic person-hood” ignores a patient’s personal history, and the fact that she has existed for more than a moment of time. Dependency and irrationality, with decisions made by others, would often deny such an individual the right to live.
Utilitarian considerations have even led to a “duty to die” in public discourse, a general sentiment that the elderly should “get out of the way” of the young. A report from a recent medical journal is chilling in this regard: An 85 year-old minister with dementia was abusive and irrational, posing a problem for caregivers in a nursing home. The minister’s wife and children agreed that he was “without quality to his life.” Therefore, they and the physicians decided to simply turn off his pacemaker to cause his death. In favoring this practice, the authors of the report made a purely utilitarian argument. Their act was convenient for the family, rather than based on any intrinsic value or person-hood of the patient (Rymes, McCullough, Luchi, Teasdale, & Wilson, 2000).
The Christian thus faces a unique dilemma in today’s health-care environment: How should he commit to compassionate and competent medical care within the current establishment, yet take a stand for the sanctity of life and respect for human dignity? Where is the balance between a commitment to life and a common-sense willingness to “let go” when the time comes?
Case Study
Mr. M., a 72 year-old retired accountant, presented to the emergency room in severe respiratory distress. He had a history of heavy tobacco use, having smoked two packs per day for 50 years. Though he completely quit smoking two years before this admission, he remained chronically short of breath. Mr. M. had three hospital admissions for respiratory failure in the previous year, two of which required short periods of mechanical ventilation. During the four months prior to this admission he required supplemental home oxygen. Three days before admission, Mr. M. began to notice an increase in his usual shortness of breath, a dry cough, and fever. On the day of admission, these symptoms grew worse and Mr. M. was brought to a nearby emergency room by ambulance.
On physical exam, Mr. M. was a thin, anxious, chronically ill appearing man in respiratory distress. His blood pressure was 140/80, respiratory rate 36/minute, and his heart rate was 124/minute. His temperature was 101.4 degrees Fahrenheit.
Admission laboratory studies revealed normal serum electrolytes, except for a slightly elevated potassium level. His serum bicarbonate was elevated at 36 mEq/l. His blood hemoglobin was normal. The white blood count was elevated at 14, 500 per cu. mm. Arterial blood gases (on supplemental oxygen by nasal cannula) were as follows: pH 7.34, pO2 46 mm Hg, pCO2 66 mm Hg. A chest X-ray showed a flat diaphragm, with hyperinflation of both lung fields and an infiltrate in the right lower lobe.
In the emergency room, Mr. M was orally intubated, and he was placed on a ventilator. He was admitted to the medical intensive care unit with a diagnosis of chronic emphysema, with superimposed right lower lobe pneumonia and acute respiratory failure. Over the next several days, physicians treated Mr. M. with antibiotics for his pneumonia. The lung infiltrate improved, and the patient’s temperature and white blood cell count became normal. However, multiple attempts to wean him from the ventilator failed. Off the ventilator, he became restless and agitated, with severe shortness of breath.
The primary physician, a specialist in the intensive management of respiratory diseases, discussed the various options with Mr. M. and his family. All agreed that continued long-term reliance on the ventilator was burdensome, and that his condition was terminal. Mr. M. was fully alert and competent; he and his family understood fully the implications of his illness. A “do not resuscitate” (DNR) order was entered in the chart, with the agreement of Mr. M. and his wife. After a night of rest, the physician removed the endotracheal tube and had the ventilator taken from the room. A strict “do not intubate / do not resuscitate” order was given, and the patient was left on supplemental oxygen. Twelve hours after discontinuing ventilator support, and with his family present, the patient died.
Was Cessation of Therapy Justified?
Was the cessation of therapy for Mr. M. justified? Yes, in that this is the withdrawal of futile care. The patient’s condition was terminal, and his death was imminent. There is no reason to second-guess the physician’s judgment here. There is no doubt that he was in respiratory failure and ventilator-dependent from an irreversible disease process (emphysema). He had received the best of aggressive medical therapy. This assumes medical competence on the part of the physicians, and assumes that the patient was maximally cooperative with his treatment.
One reason that this case seems difficult is that the doctors withdrew an already utilized treatment (the ventilator) as opposed to withholding it. Some might argue that the doctors in the emergency room should never have intubated Mr. M. and placed him on a ventilator in the first place, yet this would have been a denial of any attempt to treat him, and clearly inappropriate. Having established that further ventilator support was futile, the decision to withdraw it seems justified.
It is worth noting that medical personnel may abuse the concept of medical futility, often on arbitrary or utilitarian grounds. For example, treatment may be withdrawn because of a vague perception that there has been a loss of person-hood (as in the case of the 85 year-old minister cited earlier). However the case of Mr. M is an example of the best kind of doctor-patient relationship. Out of respect for his person-hood and aware of his dire medical condition, the physician communicated openly with the patient and his family. Full and informed consent was sought and given by all parties. Ethicist Christopher Hook has expressed it well:
The real source of power in medicine… is in the relationship, the coming together of the afflicted and the healer, the blending of needs and goals with knowledge and skill, so that they may come to as good an outcome as possible. There can be no true healing without this relationship (Hook, 1996, p. 92)
Assisted Suicide or Euthanasia?
Could this be an example of assisted suicide or at least of “passive euthanasia?” The answer is no to both questions. First of all, this was not physician-assisted suicide because the agent was the physician, not the patient. Is this therefore “passive euthanasia?” Not at all, because the intent was to relieve suffering, not to cause death. An important guide in this instance is the principle of double effect. This is the concept that intentions have great weight in moral decision-making. For example, caregivers are obligated to preserve life and at the same time to relieve pain. If a physician were to inject a massive overdose of morphine into a terminally ill cancer patient, with the intent of active euthanasia, this would be morally wrong.
However, a physician should endeavor to treat the pain of a suffering patient with adequate doses of analgesics, even narcotics.
This assumes that other medications have failed, and that imminent death makes addiction irrelevant. If such treatment hastens the death of the patient, but this was an unintended consequence of the intent to relieve suffering, then the act may be morally permissible (Jochemsen, 1996).
This principle applies to the case of Mr. M. As stated earlier, neither the patient nor his physicians intended his death. They did, however, intend to relieve him from a burdensome and futile treatment; his death was an unintended consequence. According to the principle of double effect, the action was justified.
Robert Orr and colleagues would not even call this act euthanasia: “Withdrawing or withholding treatment or artificial means of life support in someone who is dying is not euthanasia at all – not even ‘passive’ euthanasia – but acceptable, humane, and an often necessary part of everyday medical practice” (Orr, Schiedermayer, & Biebel, 1990, p. 152). More succinctly, Jochemsen has said: “Stopping disproportional medical treatment has always been good medical practice” (Jochemsen, 1996, p.
166).
Ethical Principles
What ethical principles are involved here? The classical general principles of bioethics are autonomy, non-maleficence, beneficence, and justice. The actions in this case are certainly compatible with these principles.
The principle of autonomy can be stated as follows: Rational people should be allowed to be self -determining and to make their own decisions (Munson, 2000). Contrast this with paternalism, where health-care providers make decisions independent of the patient and his family. In the case of Mr. M., full consultation with him and his family respected his autonomy. Autonomy is not absolute, however. Patients must respect the integrity of the medical profession, and the ability of caregivers to say no to unreasonable requests for inappropriate or futile treatment (Hook, 1996). Patients who disagree with available treatment options are free to seek a second opinion.
Non-maleficence means that a physician should never “by carelessness, malice, inadvertence, or avoidable ignorance” do anything to cause harm to a patient (Munson, 2000, p. 32). This principle is one of the oldest in medicine, and relates to the covenant between physician and patient. It dates back to the time of Hippocrates: “As to diseases, make a habit of two things -- to help, or at least to do no harm” (Strauss, 1968, p. 625).
Certainly, assisted suicide and active euthanasia would violate this rule. The utilitarian case for physician-assisted death requires that “harm” be equated with the continuation of life. Such a claim seems difficult to justify, especially in view of new treatment modalities to cope with pain and suffering. According to Stoddard, it is a false assumption “that seriously ill people must expect agonies and humiliations from which death itself is the only merciful release” (Stoddard, 2000, p. 241). Death with dignity does not require that physicians overtly intervene in a natural disease process.
However, this principle does require that burdensome treatments not be imposed on the terminally ill in whom death is imminent. In the case of Mr. M., further treatment was futile. Keeping the patient on a ventilator against his will would have been maleficent and hurtful, thus violating the principle. The principle of beneficence is the moral obligation to act in the best interest of others (Munson, 2000). It is difficult to claim that euthanasia accords with this principle. So how does the cessation of ventilator support fulfill it? In the case of Mr. M., the physicians went beyond mere non-maleficence and were overtly concerned about his benefit. Their compassionate interaction with the family and patient was consistent with beneficent intent.
Admittedly, the idea of beneficence would be more difficult to prove if the patient or family had opposed the treatment plan suggested by the physicians. However, even that eventuality would not violate beneficence if the case for futility were strong enough. As Beauchamp and Childress point out, “A justified claim that a medical procedure is futile removes it from the range of otherwise beneficial acts among which patients or their surrogates may choose” (2001, p. 192). Beneficence would also be suspect if the care team had acted out of strictly utilitarian concerns, e.g., “We really need this ventilator for the guy in 2B, so we ought to let Mr. M. die.” Such a cold calculus would go against the Hippocratic tradition of medicine.
The principle of justice has at its heart the idea that, “similar cases ought to be treated in similar ways” (Munson, 2000, p. 38). While this is not quite as important for Mr. M in the immediate context, terminal illness should be handled equitably for all patients. This assumes, for example, that medical staff members have thought through the implications of terminal respiratory failure. This is just good medical practice, and ensures that an “ethical standard of care” is followed with all patients who enter the intensive care unit.
Conclusion
This paper has explored the issues of euthanasia, futile care, and letting patients die. The case of Mr. M., tragically afflicted with end-stage lung disease, provided the backdrop for a discussion of secular and Christian principles of compassionate care at the end of life.
References Cited
Beauchamp, T. L., & Childress, J. F. (2001). Principles of Biomedical Ethics (Fifth ed.). New York: Oxford University Press.
General Information on Alzheimer 's Disease. (2003). Alzheimer 's Disease Education & Referral Center. Retrieved October 10, 2003, from http://www.alzheimers.org/generalinfo.htm
Hook, C. C. (1996). Medical Futility. In J. F. Kilner, A. B. Miller & E. D. Pellegrino (Eds.), Dignity and Dying: A Christian Appraisal (pp. 84-95). Grand Rapids: William B. Eerdmans.
Jochemsen, H. (1996). The Netherlands Experiment. In J. F. Kilner, A. B. Miller & E. D.
Munson, R. (2000). Intervention and Reflection: Basic Issues in Medical Ethics (Sixth ed.). Belmont, CA: Wadsworth-Thompson Learning. NASB. All Scripture references are from the New American Standard Bible (1995, Lockman Foundation).
Orr, R. (2004). Competence, Capacity, and Surrogate Decision-Making. Center for Bioethics and Human Dignity. Retrieved July 7, 2004, from http://www.cbhd.org/resources/healthcare/orr_2004-03-10.htm
Orr, R. D., Schiedermayer, D. L., & Biebel, D. B. (1990). Life and Death Decisions. Colorado Springs: Navpress.
Rachels, J. (1978). Active and Passive Euthanasia. In T. Beauchamp & S. Perlin (Eds.), Ethical Issues in Death and Dying. Englewood Cliffs, NJ: Prentice-Hall.
Rae, S. B., & Cox, P. M. (1999). Bioethics: A Christian Approach in a Pluralistic Age. Grand Rapids: William B. Eerdmans.
Rymes, J. A., McCullough, L. B., Luchi, R. J., Teasdale, T. A., & Wilson, N. (2000). Withdrawing Very Low-Burden Interventions in Chronically Ill Patients. Journal of the American Medical Association, 283(8), 1061-1063.
Stoddard, S. (2000). Terminal, but Not Hopeless. In R. Munson (Ed.), Intervention and Reflection: Basic Issues in Medical Ethics (Sixth ed., pp. 241-242). Belmont, CA: Wadsworth-Thompson Learning.
Strauss, M. B. (1968). Familiar Medical Quotations. Boston: Little, Brown, and Company.
The care of terminal patients is often difficult and ethically challenging. The standards of competent and compassionate care that characterized a previous generation seem to be wavering, replaced by a post-modern mélange of newer conflicting theories and ethical values.
A shift from deontological principles to utilitarianism has occurred in the past thirty years, corresponding with the rise of the modern bioethics movement (Rae & Cox, 1999). Many members of an increasingly aging population are denied their autonomy on the basis of mental incompetence. The most common cause of the loss of competence is Alzheimer’s disease, which may afflict up to 50% of individuals 85 years and older (Alzheimer’s Disease, 2003). …show more content…
Decisions to withdraw treatment are often based on a lack of higher mental functioning as evidenced by self-awareness and self-control. On such utilitarian ideas of bioethics, there are degrees of person-hood as though it were a quantity that one individual could have more of than another. To lose these physiologic parameters means to lose something vaguely called the “quality of life.” Such “physiologic person-hood” ignores a patient’s personal history, and the fact that she has existed for more than a moment of time. Dependency and irrationality, with decisions made by others, would often deny such an individual the right to live.
Utilitarian considerations have even led to a “duty to die” in public discourse, a general sentiment that the elderly should “get out of the way” of the young. A report from a recent medical journal is chilling in this regard: An 85 year-old minister with dementia was abusive and irrational, posing a problem for caregivers in a nursing home. The minister’s wife and children agreed that he was “without quality to his life.” Therefore, they and the physicians decided to simply turn off his pacemaker to cause his death. In favoring this practice, the authors of the report made a purely utilitarian argument. Their act was convenient for the family, rather than based on any intrinsic value or person-hood of the patient (Rymes, McCullough, Luchi, Teasdale, & Wilson, 2000).
The Christian thus faces a unique dilemma in today’s health-care environment: How should he commit to compassionate and competent medical care within the current establishment, yet take a stand for the sanctity of life and respect for human dignity? Where is the balance between a commitment to life and a common-sense willingness to “let go” when the time comes?
Case Study
Mr. M., a 72 year-old retired accountant, presented to the emergency room in severe respiratory distress. He had a history of heavy tobacco use, having smoked two packs per day for 50 years. Though he completely quit smoking two years before this admission, he remained chronically short of breath. Mr. M. had three hospital admissions for respiratory failure in the previous year, two of which required short periods of mechanical ventilation. During the four months prior to this admission he required supplemental home oxygen. Three days before admission, Mr. M. began to notice an increase in his usual shortness of breath, a dry cough, and fever. On the day of admission, these symptoms grew worse and Mr. M. was brought to a nearby emergency room by ambulance.
On physical exam, Mr. M. was a thin, anxious, chronically ill appearing man in respiratory distress. His blood pressure was 140/80, respiratory rate 36/minute, and his heart rate was 124/minute. His temperature was 101.4 degrees Fahrenheit.
Admission laboratory studies revealed normal serum electrolytes, except for a slightly elevated potassium level. His serum bicarbonate was elevated at 36 mEq/l. His blood hemoglobin was normal. The white blood count was elevated at 14, 500 per cu. mm. Arterial blood gases (on supplemental oxygen by nasal cannula) were as follows: pH 7.34, pO2 46 mm Hg, pCO2 66 mm Hg. A chest X-ray showed a flat diaphragm, with hyperinflation of both lung fields and an infiltrate in the right lower lobe.
In the emergency room, Mr. M was orally intubated, and he was placed on a ventilator. He was admitted to the medical intensive care unit with a diagnosis of chronic emphysema, with superimposed right lower lobe pneumonia and acute respiratory failure. Over the next several days, physicians treated Mr. M. with antibiotics for his pneumonia. The lung infiltrate improved, and the patient’s temperature and white blood cell count became normal. However, multiple attempts to wean him from the ventilator failed. Off the ventilator, he became restless and agitated, with severe shortness of breath.
The primary physician, a specialist in the intensive management of respiratory diseases, discussed the various options with Mr. M. and his family. All agreed that continued long-term reliance on the ventilator was burdensome, and that his condition was terminal. Mr. M. was fully alert and competent; he and his family understood fully the implications of his illness. A “do not resuscitate” (DNR) order was entered in the chart, with the agreement of Mr. M. and his wife. After a night of rest, the physician removed the endotracheal tube and had the ventilator taken from the room. A strict “do not intubate / do not resuscitate” order was given, and the patient was left on supplemental oxygen. Twelve hours after discontinuing ventilator support, and with his family present, the patient died.
Was Cessation of Therapy Justified?
Was the cessation of therapy for Mr. M. justified? Yes, in that this is the withdrawal of futile care. The patient’s condition was terminal, and his death was imminent. There is no reason to second-guess the physician’s judgment here. There is no doubt that he was in respiratory failure and ventilator-dependent from an irreversible disease process (emphysema). He had received the best of aggressive medical therapy. This assumes medical competence on the part of the physicians, and assumes that the patient was maximally cooperative with his treatment.
One reason that this case seems difficult is that the doctors withdrew an already utilized treatment (the ventilator) as opposed to withholding it. Some might argue that the doctors in the emergency room should never have intubated Mr. M. and placed him on a ventilator in the first place, yet this would have been a denial of any attempt to treat him, and clearly inappropriate. Having established that further ventilator support was futile, the decision to withdraw it seems justified.
It is worth noting that medical personnel may abuse the concept of medical futility, often on arbitrary or utilitarian grounds. For example, treatment may be withdrawn because of a vague perception that there has been a loss of person-hood (as in the case of the 85 year-old minister cited earlier). However the case of Mr. M is an example of the best kind of doctor-patient relationship. Out of respect for his person-hood and aware of his dire medical condition, the physician communicated openly with the patient and his family. Full and informed consent was sought and given by all parties. Ethicist Christopher Hook has expressed it well:
The real source of power in medicine… is in the relationship, the coming together of the afflicted and the healer, the blending of needs and goals with knowledge and skill, so that they may come to as good an outcome as possible. There can be no true healing without this relationship (Hook, 1996, p. 92)
Assisted Suicide or Euthanasia?
Could this be an example of assisted suicide or at least of “passive euthanasia?” The answer is no to both questions. First of all, this was not physician-assisted suicide because the agent was the physician, not the patient. Is this therefore “passive euthanasia?” Not at all, because the intent was to relieve suffering, not to cause death. An important guide in this instance is the principle of double effect. This is the concept that intentions have great weight in moral decision-making. For example, caregivers are obligated to preserve life and at the same time to relieve pain. If a physician were to inject a massive overdose of morphine into a terminally ill cancer patient, with the intent of active euthanasia, this would be morally wrong.
However, a physician should endeavor to treat the pain of a suffering patient with adequate doses of analgesics, even narcotics.
This assumes that other medications have failed, and that imminent death makes addiction irrelevant. If such treatment hastens the death of the patient, but this was an unintended consequence of the intent to relieve suffering, then the act may be morally permissible (Jochemsen, 1996).
This principle applies to the case of Mr. M. As stated earlier, neither the patient nor his physicians intended his death. They did, however, intend to relieve him from a burdensome and futile treatment; his death was an unintended consequence. According to the principle of double effect, the action was justified.
Robert Orr and colleagues would not even call this act euthanasia: “Withdrawing or withholding treatment or artificial means of life support in someone who is dying is not euthanasia at all – not even ‘passive’ euthanasia – but acceptable, humane, and an often necessary part of everyday medical practice” (Orr, Schiedermayer, & Biebel, 1990, p. 152). More succinctly, Jochemsen has said: “Stopping disproportional medical treatment has always been good medical practice” (Jochemsen, 1996, p.
166).
Ethical Principles
What ethical principles are involved here? The classical general principles of bioethics are autonomy, non-maleficence, beneficence, and justice. The actions in this case are certainly compatible with these principles.
The principle of autonomy can be stated as follows: Rational people should be allowed to be self -determining and to make their own decisions (Munson, 2000). Contrast this with paternalism, where health-care providers make decisions independent of the patient and his family. In the case of Mr. M., full consultation with him and his family respected his autonomy. Autonomy is not absolute, however. Patients must respect the integrity of the medical profession, and the ability of caregivers to say no to unreasonable requests for inappropriate or futile treatment (Hook, 1996). Patients who disagree with available treatment options are free to seek a second opinion.
Non-maleficence means that a physician should never “by carelessness, malice, inadvertence, or avoidable ignorance” do anything to cause harm to a patient (Munson, 2000, p. 32). This principle is one of the oldest in medicine, and relates to the covenant between physician and patient. It dates back to the time of Hippocrates: “As to diseases, make a habit of two things -- to help, or at least to do no harm” (Strauss, 1968, p. 625).
Certainly, assisted suicide and active euthanasia would violate this rule. The utilitarian case for physician-assisted death requires that “harm” be equated with the continuation of life. Such a claim seems difficult to justify, especially in view of new treatment modalities to cope with pain and suffering. According to Stoddard, it is a false assumption “that seriously ill people must expect agonies and humiliations from which death itself is the only merciful release” (Stoddard, 2000, p. 241). Death with dignity does not require that physicians overtly intervene in a natural disease process.
However, this principle does require that burdensome treatments not be imposed on the terminally ill in whom death is imminent. In the case of Mr. M., further treatment was futile. Keeping the patient on a ventilator against his will would have been maleficent and hurtful, thus violating the principle. The principle of beneficence is the moral obligation to act in the best interest of others (Munson, 2000). It is difficult to claim that euthanasia accords with this principle. So how does the cessation of ventilator support fulfill it? In the case of Mr. M., the physicians went beyond mere non-maleficence and were overtly concerned about his benefit. Their compassionate interaction with the family and patient was consistent with beneficent intent.
Admittedly, the idea of beneficence would be more difficult to prove if the patient or family had opposed the treatment plan suggested by the physicians. However, even that eventuality would not violate beneficence if the case for futility were strong enough. As Beauchamp and Childress point out, “A justified claim that a medical procedure is futile removes it from the range of otherwise beneficial acts among which patients or their surrogates may choose” (2001, p. 192). Beneficence would also be suspect if the care team had acted out of strictly utilitarian concerns, e.g., “We really need this ventilator for the guy in 2B, so we ought to let Mr. M. die.” Such a cold calculus would go against the Hippocratic tradition of medicine.
The principle of justice has at its heart the idea that, “similar cases ought to be treated in similar ways” (Munson, 2000, p. 38). While this is not quite as important for Mr. M in the immediate context, terminal illness should be handled equitably for all patients. This assumes, for example, that medical staff members have thought through the implications of terminal respiratory failure. This is just good medical practice, and ensures that an “ethical standard of care” is followed with all patients who enter the intensive care unit.
Conclusion
This paper has explored the issues of euthanasia, futile care, and letting patients die. The case of Mr. M., tragically afflicted with end-stage lung disease, provided the backdrop for a discussion of secular and Christian principles of compassionate care at the end of life.
References Cited
Beauchamp, T. L., & Childress, J. F. (2001). Principles of Biomedical Ethics (Fifth ed.). New York: Oxford University Press.
General Information on Alzheimer 's Disease. (2003). Alzheimer 's Disease Education & Referral Center. Retrieved October 10, 2003, from http://www.alzheimers.org/generalinfo.htm
Hook, C. C. (1996). Medical Futility. In J. F. Kilner, A. B. Miller & E. D. Pellegrino (Eds.), Dignity and Dying: A Christian Appraisal (pp. 84-95). Grand Rapids: William B. Eerdmans.
Jochemsen, H. (1996). The Netherlands Experiment. In J. F. Kilner, A. B. Miller & E. D.
Munson, R. (2000). Intervention and Reflection: Basic Issues in Medical Ethics (Sixth ed.). Belmont, CA: Wadsworth-Thompson Learning. NASB. All Scripture references are from the New American Standard Bible (1995, Lockman Foundation).
Orr, R. (2004). Competence, Capacity, and Surrogate Decision-Making. Center for Bioethics and Human Dignity. Retrieved July 7, 2004, from http://www.cbhd.org/resources/healthcare/orr_2004-03-10.htm
Orr, R. D., Schiedermayer, D. L., & Biebel, D. B. (1990). Life and Death Decisions. Colorado Springs: Navpress.
Rachels, J. (1978). Active and Passive Euthanasia. In T. Beauchamp & S. Perlin (Eds.), Ethical Issues in Death and Dying. Englewood Cliffs, NJ: Prentice-Hall.
Rae, S. B., & Cox, P. M. (1999). Bioethics: A Christian Approach in a Pluralistic Age. Grand Rapids: William B. Eerdmans.
Rymes, J. A., McCullough, L. B., Luchi, R. J., Teasdale, T. A., & Wilson, N. (2000). Withdrawing Very Low-Burden Interventions in Chronically Ill Patients. Journal of the American Medical Association, 283(8), 1061-1063.
Stoddard, S. (2000). Terminal, but Not Hopeless. In R. Munson (Ed.), Intervention and Reflection: Basic Issues in Medical Ethics (Sixth ed., pp. 241-242). Belmont, CA: Wadsworth-Thompson Learning.
Strauss, M. B. (1968). Familiar Medical Quotations. Boston: Little, Brown, and Company.