The President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research undertook a study of “Deciding to Forego Life-Sustaining Treatment” because this issue seemed to the commissioners “to involve some of the most important and troubling ethical and legal questions in modern medicine,” even though it was not part of the commission's original legislative mandate. In submitting the report to the President, Morris Abrams, the chairman of the commission, noted: “Although our study has done nothing to decrease our estimation of the importance of this subject to physicians, patients, and their families, we have concluded that the cases that involve true ethical difficulties are many fewer than commonly believed and that the perception of difficulties occurs primarily because of misunderstandings of the dictates of law and ethics.”

High U.S. health costs have been one of the main barriers to enacting universal access to care in recent decades. It is therefore surprising that Massachusetts, with the nation's highest per capita health spending, last year promised health insurance to all citizens. Declaring that “the access of residents of the Commonwealth to basic health care services is a natural, essential, and unalienable right” protected by the Massachusetts Constitution, the new health law, Chapter 23 of the Acts of 1988, legislates a promise that insurance be offered to all by 1 April 1992.

The law was the product of almost three years of bargaining. One closely involved person said this was “the most controversial and heavily fought battle in the past 25 years in the Massachusetts State House.” Deals had to be struck. Perhaps the most important of the law's compromises is embodied in its title: “An Act to Make Health Security Available to All Citizens of the Commonwealth and to Improve Hospital Financing.” Obtaining the votes for the law's universal access provisions required promising Massachusetts hospitals substantially higher revenues.

The issuance of do-not-resuscitate orders was one of the first dilemmas scrutinized by lawyers, health care professionals and philosophers in the field of bioethics. In 1983, the President's Commission articulated the basic principles that should guide decisions about CPR: respect for the choices of patients capable of deciding for themselves, recognition of family members as appropriate surrogates for decisionally incapable patients and the importance of an open dialogue with the physician as a predicate to informed consent.

Six years have passed since the President's Commission issued its landmark report. More than a decade of discussion and written commentary has clarified the ethical and social questions presented by resuscitation decisions. In many states, judicial decisions and legislation have addressed some of the legal uncertainties associated with do-not-resuscitate (DNR) orders. Nonetheless, the gulf between recognized ethical principles and clinical practice remains broad and resistant to change. Nowhere is this gap more evident than in decisions about cardiopulmonary resuscitation (CPR) for competent patients.

What medical care will I receive if I am too sick to make decisions about my care? Many people worry about this question, particularly about how they can retain control over such decisions. The portrayal in this case of physicians who fail to prescribe adequate pain relief and who feel threatened by active family participation in decision-making only reinforces such concerns. It seems that the hospice movement has had no effect on these physicians. Traditional advice, from wise grandmothers, might be to have a child who is a doctor or who marries a doctor. A more modern suggestion might be to give advance directives about future care. At first reading, this case illustrates the usefulness of both suggestions. But on closer reading the case reveals serious problems with both approaches.

The issuance of do-not-resuscitate orders was one of the first dilemmas scrutinized by lawyers, health care professionals and philosophers in the field of bioethics. In 1983, the President's Commission articulated the basic principles that should guide decisions about CPR: respect for the choices of patients capable of deciding for themselves, recognition of family members as appropriate surrogates for decisionally incapable patients and the importance of an open dialogue with the physician as a predicate to informed consent.

Six years have passed since the President's Commission issued its landmark report. More than a decade of discussion and written commentary has clarified the ethical and social questions presented by resuscitation decisions. In many states, judicial decisions and legislation have addressed some of the legal uncertainties associated with do-not-resuscitate (DNR) orders. Nonetheless, the gulf between recognized ethical principles and clinical practice remains broad and resistant to change. Nowhere is this gap more evident than in decisions about cardiopulmonary resuscitation (CPR) for competent patients.

On August 22, 1986, as part of its response to the AIDS epidemic, the Public Health Service (PHS) invited U.S. industrial firms to collaborate with the government in the development of an AIDS vaccine. The framework for the collaboration was outlined in a PHS document entitled, “AIDS Vaccine Development: Private Sector/Government Collaborative Efforts.” This document identified the resources the government is prepared to make available to industry, including patents, facilities, data, and assistance with clinical trials. The overall aim of the PHS proposal was to establish a formal framework for coordinating existing government and private efforts and to foster industry participation in the search for an AIDS vaccine.

An example of private sector/government collaboration is provided in the human trial of an AIDS vaccine approved by the FDA in August 1987. The vaccine, named “VaxSyn HIV-1,“ is the product of a joint effort between a company called MicroGeneSys and investigators at the National Institute of Allergy and Infectious Disease (NIAID).

Although in its 1986 Report on medical malpractice, the General Accounting Office found “No Agreement on the Problem or Solution,” it is readily apparent to any participant in or informed observer of health care delivery in the United States today that problems do exist regarding both the occurrence of medically-induced patient injuries and the management and resolution of medical liability claims. Public policymakers, on both the federal and state levels, have devoted a great amount of attention and energy in the past several years to attempts to devise solutions to these troubling patient injury and provider liability difficulties, difficulties that arguably impact negatively on the quality of medical care, its accessibility, its costs, the physician/patient relationship, and the progress of medical innovation. Private organizations have also undertaken initiatives in this area.

Ever since I learned a year ago about the honor you intended to bestow upon me, I have asked myself: What is it in my life's work that led you to confer upon me your Second Presidents' Award? You could have chosen many other, perhaps more deserving, recipients. But tonight I do not wish to compare myself to others. It would be most ungracious to charge you with being mistaken, or too self-effacing to charge myself with being unworthy of your Award.

Ultimately, I concluded that you honor me less for the work I have published and more for the impact I have had on so many of you as your teacher and colleague during the last thirty years. I have lived my life with people—family, friends, students. I have cherished, and still cherish, the contacts with my students, a remarkable number of whom soon became collaborators, colleagues, friends or took off on their own, enriching in significant ways what we had first learned together.

This well known position of the AMA Judicial Council implies that the distinction between intentionally causing death and letting a patient die is conceptually clear and ethically significant. Most opponents of active voluntary euthanasia accept the validity of this distinction; proponents inevitably do not. The President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research is a notable exception.