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Letters |

Palliative Options at the End of Life

Frédéric Pochard, MD; Marc Grassin, PharmD; Christian Hervé, MD, PhD
JAMA. 1998;279(14):1065-1067. doi:10-1001/pubs.JAMA-ISSN-0098-7484-279-14-jac80003.
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To the Editor.—Dr Quill and colleagues1propose safeguards for any medical action that may hasten death, including "obtaining informed consent" and "implementing reporting and monitoring processes." Their presentation emphasizes a vision of an autonomous patient-physician relationship, which is at high risk of denying other ethical values for all persons concerned by end-of-life decisions.

Autonomy, benevolence, nonmaleficence, and justice should be considered as equal ethical imperatives. A contextual approach supposes a "circular" vision, including proxies and medical staff in the foreseeable consequences of the decision. Deciding to hasten the death of a patient and considering his or her informed consent as a sufficient ethical shield may seem hypocritical and does not take into account the responsibility of the physician to protect all the persons concerned from the psychological consequences of the patient's death. Despite lack of specific studies, we suspect that proxy decision makers and health professionals (including nurses) are at risk of developing psychological stress if decisions to hasten death are considered as a contract between physician and patient. The prioritization of the patient's autonomy may lead to overlooking broader aspects of medical ethics. Moreover, reporting and monitoring processes have shown limitations in the Netherlands, despite explicit public policy about which practices are permissible, because of fear of procedural measures against physicians and the impossibility of obtaining the patient's informed consent in most situations.2

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