In 1990, I voiced strong doubts about a bill entitled the Patient Self-Determination Act (PSDA), which had been introduced in the U.S. Senate by John Danforth (R-MO) and Daniel Patrick Moynihan (D-NY). I hoped to see it defeated. In 1991, after the bill had become a small part of a massive status (the Omnibys Budget Reconciliation Act of 1990) adopted in the waning hours of the 101st Congress, I devoted countless hours to its implementation. I wanted to see it succeed. Why the change?

As Part of the Omnibus Budget Reconciliation Act of 1990, the Patient Self Determination Act (PSDA) legislates new responsibilites for healthcare facilities. The authors served as members of the California Consortium on Patient Self-Determination, and the materials produced by this group offer healthcare facilities a valuable guide for implementing the PSDA. The ACt follows a historical trend led by doctrines of informed consent and increasing patient autonomy regarding rights to accept or refuse medical treatment and to execute advance directives. The requirements of the Act will influence healthcare facilities and how they communicate with patients about advance directives. Although the Act seeks to increase awareness of advance directices among all participants in healthcare interactions, it could pose major stumbling blocks to providing sensitive and humane care if certain concerns are nor addressed adequatley. The benefits of the Act could be far reaching and substantial for patients and healthcare facilities alike.

The Patient Self-Determination Act (PSDA) imposes new requirements on health care providers for informing patients of their rights to make decisions concerning their medical care. The Act is intended to, and is likely to, encourage patients and residents of certain healhtcare facilities to consider their treatment preferences in advance of incapacity and, in particular, to determine the circumstances in which life-sustaining treatment will be provided to them. However, many questions concerning how healthcare providers will implement the Act remain unanswered.

Several recent articles raise an issue long unaddressed in the medical literature: physician compliance with patient or family requests for futile or ineffectice therapy. Although they agree philosophically that such treatment ought not be given, most physicians have followed the course described by Stanley Fiel, in which a young patient dying of cystic fibrosis was accepted “for evaluation” by a transplant center even though he has already passed the threshold of viability as a candidate for a heart-lung transplant. Dr. Fiel reported this action was taken not in the hope of doing the transplant but so that the family could assure themselves they had done “everything possible.” The patient, after a long and stressful cross-country flight, arrived at the hospital in respiratory failure. He died soon thereafter far from home and familiar surroundings.

Erhics committees and ethics consultants are becoming more involved in helping individuals make decisions and in advising institutions and legislatures about drafting policy. The role of these committees and consultants has been acknowledged in law, and their function is generally considered salutory and helpful. Ethics consultants and committees, furthermore, play a critical role in educating students and members of the hospital community and the public at large. More over, many ethicists engage in scholarky activities to expand the boundaries of our understanding and, in turn, facilitate our capacity for helping. The role of the ethicist and of the ethics committee is thus manifold. Ethics committees and ethics consultants somehow “in competition” is a mistaken notion: when ethics committees, ethics consultants, and the community work smoothly together, much good can be accomplished.

I find myself in a strange position writing a commentary to an article on ethics committees because in Germany, ethics committees in the American sense do not exist. What we call Ethikkommission are present in every German faculty of medicine and would be called institutional review boards (IRB) in the United States; committees that review research projects of faculty members with respect to ethical standards. So i most consult my imagination rather than my experience about what really happens in Americal ethics committees. There are only two things. I perhaps can fall back on to simultaneously inspire and bridle my imagination. I have been sitting for 5 years on the IRB of our faculty and have been giving ethics seminars and case discussions to students for more than 10 years. Ethics is an optional subject in Germany and attracts the more sensitive and thoughtful students. Perhaps the intellectual process generating itself in those groups in some ways similar to that occurring in ethics committees. As for the rest, I hope to profit from the so-called unprejudiced perspective of the foreigner. I agree with a great deal of Loewy's descriptions and even with suffering as a principle, but I have some doubt whether that occurring in ethics committees. As for the rest, I hope with a reat deal of Loewy's descriptions and even with suffering as a principle, but I have some doubt whether that principle has the highest possible generality.

The patient was a woman in her 30s who, until the rapid progression of an ultimately fatal neurologic disease, had been a very successful professional, enjoying athletics and an active social life. In the 6 months of swift deterioration, she had gone from being extremely vibrant and energetic to being totally unable to care for her personal needs. There had been no loss of intellectual capacity. Her sister later recounted to Dr. J., the emergency department physician, that she had found the patient unconscious and unresponsive at home and had immediately called the patient's neurologist in a neighboring city. He directed her to call the paramedics.

Most of us find the surgeon's surprise at this patient' request understandable, and it is hard to imagine any surgeon acceding to this patient's demand. On the other hand (the one left), the patient is right—the surgeon is denying his technical skill because his values are different from those of the patient, whose values the surgeon does not respect. The autonomy of the patient is being limited by the values of the doctor whose own interests, other than his interest in practicing medicine according to his own ethical values, would remain unaffected by his decision to provide the service.

Since at least the Karen Ann Quinlan case, the idea of autonomy has always been central to the discussion about whether to given life-prolonging treatment. Those on different sides of the debate may disagree strongly about some of the issues, but the importance of the patient's autonomy has been accepted by people of widely different points of view.

The shape, function, and dynamic of the field of bioethics is in constant flux, and nowhere is this more apparent than at gatherings of those immersed in th discipline. This section presents coverage and commentary on conferences and settings where voices out-side the mainstream of biomedical ethics can be heard.