The illusion of futility in clinical practice.

ON Feb 24, the son of Mr. and Mrs. Robert H. T. Houle died following court-ordered emergency surgery at Maine Medical Center. The child was born Feb 9, horribly deformed. His entire left side was malformed; he had no left eye, was practically without a left ear, had a deformed left hand; some of his vertebrae were not fused. Furthermore, he was afflicted with a tracheal esophageal fistula and could not be fed by mouth. Air leaked into his stomach instead of going to the lungs, and fluid from the stomach pushed up into the lungs. As Dr. Andre Hellegers recently noted, "It takes little imagination to think there were further internal deformities" ( Obstetrical and Gynecological News , April 1974). As the days passed, the condition of the child deteriorated. Pneumonia set in. His reflexes became impaired and because of poor circulation, severe brain damage was suspected. The tracheal esophageal fistula,

To save or let die. The dilemma of modern medicine.

Standard bioethics textbooks present the field to students and non-experts as a form of "applied ethics." This ahistoric and rationalistic presentation is similar to that used in philosophy of science textbooks until three decades ago. Thomas Kuhn famously critiqued this self-conception of the philosophy of science, persuading the field that it would become deeper, richer, and more philosophical, if it integrated the history of science, especially the history of scientific change, into its self-conception. This essay urges a similar reconceptualization for bioethics, arguing that the analysis of moral change ought to be integral to bioethics (and to ethics generally). It proceeds by suggesting the sterility of the ahistoric, rationalist applied ethics model of bioethics embraced by standard bioethics textbooks. It also suggests the fecundity of alternative conceptions of the bioethics that focus on the history of successful and failed attempts to negotiate moral change, and the history of multifaceted relations between moral philosophy and practical ethics.

Bioethics and History

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Synthetic conception: artificial insemination and the transformation of reproduction and family in nineteenth and twentieth century America

Background: Indication for home parenteral nutrition (HPN) in cancer patients is controversial because intestinal failure and malnutrition are often only two of the many problems found in such patients that may deserve priority of treatment. Methods: This was a retrospective study of 75 cancer patients from nine institutions included in the Italian HPN Registry. The patients had a mean weight loss of 12.5%, serum albumin of 3.1 g/dL, lymphocyte count of 1150/mm3, and serum total iron-binding capacity of 190 μg/dL. The main indication for HPN was intestinal obstruction (66%); 72% of the patients had metastatic disease. A series of demographic, oncologic, and nutritional characteristics were analyzed in an attempt to predict a possible benefit of HPN. Results: A total of 9897 days of HPN were delivered to 75 cancer patients, for a median of 4 months (range 1 to 15 months) per patient. Sixty-nine patients died while receiving HPN, five had a remission of their intestinal failure, and one chose to stop the tr...

Outcome of Cancer Patients Receiving Home Parenteral Nutrition

Some time ago I published an article entitled \"The Duty of Using Artificial Means of Preserving Life.\" Though the entire article was intended to stimulate discussion, the conclusion indicated two points that seemed to merit special consideration: namely, that even ordinary artificial means might not be obligatory for the patient when they are relatively useless, and that a physician's professional standards might call for efforts to preserve life that exceed his strict duty to his patient. My present purpose is to give briefly some of the reactions to my suggestions, as well as some further observations of my own, particularly with reference to the physician's duty. My intention is still to promote discussion, not to draw final conclusions.

The Duty to Preserve Life

Medico-moral problems

APRELIMINARY draft of the revised ethical code for Catholic hospitals contained this statement: \"The failure to supply the ordinary means of preserving life is equivalent to euthanasia/' When this draft of the code was submitted to a group of theologians for criticism, they were asked whether this general statement should be made more particular by the addition of a note specifying what means should be considered ordinary and what extraordinary. To this question one theologian replied: \"I don't believe in being more specific on points like this because you will immediately get into the field of mere opinion, not binding on anyone. Leave something to the doctor's conscience. After all, it is about as good as anything we have to offer on this point.\" There was general agreement with this criticism; hence the published revision of the code contained only the general statement. One can hardly question the prudence of the decision concerning the code. Yet a problem does exist which calls for solution. Our age abounds in artificial means of preserving life: e.g., incubators, blood transfusions, oxygen tents and masks, iron lungs, highly technical operations, insulin, and various other stimulants and medications. The formulation of some definite rules concerning the duty of using these artificial means is not merely intriguing speculation; it is also—if I may judge from the many questions asked me—a practical necessity. For two or three years I have been gathering material on this problem and attempting to solve pertinent questions. The results of my study are not yet satisfying. However, it seemed to me that if I could present a survey of the literature I have read, together with my own criticisms and conclusions, it might serve as the basis for a constructive discussion. My plan includes four divisions. I shall first present a digest of per-

The Duty of Using Artificial Means of Preserving Life

IN RECENT years I have heard many moral theologians express the opinion that the treatise on mutilation, as usually given in the manuals, needs extensive revision. Needless to say, a satisfactory revision could hardly be the work of one man. The purpose of the following pages is merely to suggest, for constructive criticism, a number of points that ought to be considered in making the revision. I have found it difficult to arrange these points in a perfectly logical order. I believe, however, that most of the ideas can be conveniently grouped as follows: (1) the doctrinal value and use of papal pronouncements; (2) the main definitions and divisions; (3) other divisions; and (4) the moral principles. A concluding section can be devoted to a discussion of some concrete problems.

The Morality of Mutilation: Towards a Revision of the Treatise

F many years there has been a world-wide concern over moral questions pertaining to the production of and attendance at motion pictures. As regards the United States, these moral questions can hardly be considered without some reference to the work and the objectives of the Legion of Decency. It is not the purpose of the present article either to propose or to solve all possible moral questions; the main purpose is rather to give more information about the Legion than is usually available to theologians, so that some of the more practical of the moral problems can be reasonably discussed, if not perfectly solved.

Gerald Kelly

Papers

The Duty to Preserve Life

Medico-moral problems

The Duty of Using Artificial Means of Preserving Life

The Morality of Mutilation: Towards a Revision of the Treatise

The Legion of Decency