The Cruzan decision and medical practice

Article Abstract:

This editorial reviews some points raised by the US Supreme Court decision in the case of Nancy Cruzan, a young Missouri woman injured in an automobile accident in 1983 who never regained consciousness. Cruzan's parents sought legal permission to remove their daughter's feeding tube (a means of delivering nutrition to patients who cannot eat) so that Nancy would die. The case raised fundamental issues concerning patients' rights to refuse treatment and the use of advance directives (instructions about desired medical interventions prepared by patients before they become incapacitated, sometimes called living wills). Several points in the Supreme Court decision are particularly relevant: (1) fluids and nutrition are considered medical treatment over which patients have rights of refusal; (2) states cannot restrict patients' refusal rights, but can only establish requirements for the kinds of evidence regarding patients' wishes that are acceptable; and (3) the family has less power in the modern health care setting than it previously did to decide about relatives' care. The Cruzan decision has implications for all gravely ill patients who confront technologies that could sustain them. It skirts a basic issue in modern medicine, its ''default mode'' - the assumption that, in lieu of other evidence, everyone wants all possible efforts made to save his or her life. Surveys have shown that this is not the case; most people do not want to live with severe, permanent neurological damage even if they are not dying. A more realistic approach to the issue of advance directives would be to assume that people with certain injuries do not want medical intervention unless their advance directives specify that they desire such intervention. Under such assumptions, advance directives would only be completed by those who wish their lives prolonged, and patients would not be maintained indefinitely on ''feeding wards''. Decisions should be made about patients' lives with maximal attention to private, not bureaucratic, considerations. (Consumer Summary produced by Reliance Medical Information, Inc.)

Advance directives (Medicine), Right to refuse treatment, Treatment refusal, editorial, Cruzan, Nancy

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A review of public policies to procure and distribute kidneys for transplantation

Article Abstract:

The current policies for obtaining and distributing donor kidneys for transplantation are reviewed. Issues related to the procurement of donor kidneys include: the Uniform Anatomical Gift Act; criteria for brain death; the use of living kidney donors; and routine inquiry-required request policies, in which hospitals must give the next of kin the opportunity to donate the organs and tissues of the deceased. The Uniform Anatomical Gift Act, drafted in 1968, granted authority to persons over age 18 years to donate their body parts for organ transplantation, introduced the use of donor cards attached to the driver's license, and recognized the authority of the next of kin to donate the organs of the deceased. Concerns involving the distribution of donor organs include access to the transplant waiting list and use of a new national point system to select recipients from the list. In 1987, the United Network for Organ Sharing (UNOS) introduced a point system that assigns a numerical priority score to each patient on the transplant waiting list, based on quality of antigen match, waiting time on the list, and sensitized patients. These policies for the procurement and distribution of donor kidneys are particularly important for internists, who often care for potential organ donors and patients with advanced kidney failure. Because kidney transplantation is the model for organ transplant policy, these issues are pertinent to all policy-minded physicians. (Consumer Summary produced by Reliance Medical Information, Inc.)

Kidneys, Kidney transplantation, Transplantation of organs, tissues, etc., Organ transplantation, Tissue transplantation, Transplantation, Donation of organs, tissues, etc., Tissue donation

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