Informed Consent and Informed Consent and Truth-telling: Changing Truth-telling: Changing

Realities and Present Realities and Present Challenges Challenges

醫生、病人關係的世界性轉變醫生、病人關係的世界性轉變：病人私隱有否限制？：病人私隱有否限制？

譚傑志教譚傑志教授授JOSEPH THAM, MD, PHDJOSEPH THAM, MD, PHD

School of Bioethics, Regina Apostolorum, Rome, ItalySchool of Bioethics, Regina Apostolorum, Rome, Italy

Outline Outline 概要概要

Truth telling and Truth telling and Informed ConsentInformed Consent Historical BackgroundHistorical Background Principlism, AutonomyPrinciplism, Autonomy MulticulturalismMulticulturalism Implications for ChinaImplications for China

Advance DirectivesAdvance Directives

病情告知和知情同意 历史背景历史背景 原则主义，自主权原则主义，自主权 多文化主多文化主 在中国的应用在中国的应用

預設醫療指示 ( 遺囑 )

Case: "I can put the Case: "I can put the medicine in his soup, medicine in his soup,

Doctor!“ Doctor!“ 案例案例 : “: “ 医生，我能把药医生，我能把药放进他的汤里让他喝放进他的汤里让他喝 !"!"

J G W S Wong, Y Poon and E C Hui, “I can put J G W S Wong, Y Poon and E C Hui, “I can put the medicine in his soup, Doctor!” the medicine in his soup, Doctor!” Journal of Journal of Medical EthicsMedical Ethics 2005; 31:262-265. 2005; 31:262-265.

A young man with A young man with schizophrenia. schizophrenia.

His mother had been giving His mother had been giving him antipsychotic medication him antipsychotic medication covertly in his soup. covertly in his soup.

Should the doctor continue to Should the doctor continue to provide a prescription, thus provide a prescription, thus allowing this to continue? allowing this to continue?

Truth telling and the balance Truth telling and the balance between individual versus between individual versus family autonomy. family autonomy.

一个还有精神分裂症的一个还有精神分裂症的年轻患者 年轻患者

患者母亲长期将安定药患者母亲长期将安定药物放进患者所食用的汤物放进患者所食用的汤里里

在这种情况下，医生应在这种情况下，医生应该继续给患者家属开具该继续给患者家属开具处方吗？应该允许此类处方吗？应该允许此类情况继续发生吗？情况继续发生吗？

告知真相以及在个人和告知真相以及在个人和家庭自主权之间的平衡家庭自主权之间的平衡

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Case:Case:

65 y.o. Mexican woman, immigrant dx 65 y.o. Mexican woman, immigrant dx with aggressive late stage ovarian with aggressive late stage ovarian cancer. Poor prognosis.cancer. Poor prognosis.

Her family explicitly told MDs that she Her family explicitly told MDs that she would not want to hear any bad news. would not want to hear any bad news. It may cause too much trauma It may cause too much trauma

What should the MD do in this case?What should the MD do in this case?

Historical BackgroundHistorical Background历史背景历史背景

Modern MedicineModern Medicine Curing and treatment Curing and treatment

optionsoptions Better diagnosis, prognosisBetter diagnosis, prognosis

Paternalism to Patient’s Paternalism to Patient’s rightsrights Appearance of BioethicsAppearance of Bioethics Cultural changes in 1960sCultural changes in 1960s Scandals and abuses Scandals and abuses

became publicbecame public Right’s movements, distrust Right’s movements, distrust

with authority figureswith authority figures Legal casesLegal cases

现代医学现代医学 多种处理和治疗方式的多种处理和治疗方式的

选择选择 更好的诊断及预后更好的诊断及预后

家长式作风对患者权利家长式作风对患者权利的影响的影响 生命伦理学的出现生命伦理学的出现 在在 1960s1960s 年代出现的文年代出现的文

化改革化改革 医学丑闻和陋习公开化医学丑闻和陋习公开化 权利运动，对权威人士权利运动，对权威人士

的不信任的不信任 诉讼案件 诉讼案件

A bit of historyA bit of history

AbusesAbuses Patients’ rights Patients’ rights

to knowto know Legal challengesLegal challenges Ethics comes Ethics comes

before the law?before the law? Protect the Protect the

patients or patients or protect MDsprotect MDs

濫用濫用 患者的知情權患者的知情權 法律上的挑戰法律上的挑戰 倫理倫理置於置於法律面前法律面前

？？ 保障病人或保護醫保障病人或保護醫

生生 ??

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Principlism Principlism 原则主义原则主义 Product of modern philosophy Product of modern philosophy 现代哲学的产物现代哲学的产物

Analytic philosophy Analytic philosophy 分析性哲学分析性哲学 Normative ethics Normative ethics 规范伦理规范伦理

National Commission for the Protection of National Commission for the Protection of Human Subjects 1974-1978Human Subjects 1974-1978 Abuses Abuses 滥用滥用 National Research Act 1974: 12 commissioners to National Research Act 1974: 12 commissioners to

identify ethical principles (Engelhardt's sin of his youth) identify ethical principles (Engelhardt's sin of his youth) Belmont Report 1978Belmont Report 1978 Principles Principles 原则原则

Respect for persons Respect for persons 对人的尊重对人的尊重—— informed consent informed consent 知情同知情同意 意

BeneficenceBeneficence 行善原则行善原则—— risk-benefit ratio risk-benefit ratio 风险风险 -- 利益比 利益比 Justice Justice 公平 公平 —— subject selection subject selection 受试者选择受试者选择

Quasi-official status Quasi-official status 似乎获得官方正式的地位似乎获得官方正式的地位

Principlism Principlism 原则主义原则主义

Beauchamp and Beauchamp and Childress: Childress: Principles of Principles of Biomedical EthicsBiomedical Ethics Autonomy, beneficence, Autonomy, beneficence,

nonmaleficence, justicenonmaleficence, justice Prima faciePrima facie principles principles Popularity and Popularity and

practicability: clinics, practicability: clinics, public policy, doctor-public policy, doctor-patient relationshippatient relationship

Presumes common Presumes common moralitymorality

Intuitionism or emotivismIntuitionism or emotivism

Beauchamp Beauchamp 和 和 Childress: Childress: 生命医学生命医学伦理学原则伦理学原则 自主权，行善，不作恶自主权，行善，不作恶

，公平，公平 初次印象初次印象原则原则 普及性和实用性：临床普及性和实用性：临床

，公共卫生政策，医患，公共卫生政策，医患关系关系

假定拥有共同的道德标假定拥有共同的道德标准准

直觉主义，动感情主义直觉主义，动感情主义

Challenges to PrinciplismChallenges to Principlism原则主义面临的挑战原则主义面临的挑战

Tyranny of autonomyTyranny of autonomy Trumping all other Trumping all other

principlesprinciples No consensusNo consensus Law (Patient Self-Law (Patient Self-

determination Act 1990) determination Act 1990) Anti-paternalism, anti-Anti-paternalism, anti-

authorityauthority IndividualismIndividualism Inadequate: not all Inadequate: not all

choices are goodchoices are good

自主权的 “独断专行”自主权的 “独断专行” 以其他所有原则为幌子以其他所有原则为幌子 无法达成一致意见无法达成一致意见 法律法律 (( 患者自主决策法患者自主决策法

案 案 Patient Self-Patient Self-determination Act determination Act 1990) 1990)

反家长主义，反权威主反家长主义，反权威主义义

个人主义个人主义 不足之处：并不是所有不足之处：并不是所有

的选择都是有好处的的选择都是有好处的

Challenges to PrinciplismChallenges to Principlism原则主义面临的挑战原则主义面临的挑战

Autonomy and informed Autonomy and informed consentconsent Signing a paperSigning a paper Reasonable and prudent Reasonable and prudent

person standard.person standard. Patient’s right NOT to know? Patient’s right NOT to know?

Autonomy and truth-tellingAutonomy and truth-telling Never lie to patient.Never lie to patient. Truth could never be harmful?Truth could never be harmful?

Autonomy and family Autonomy and family decisionsdecisions

Ambiguity of 4 principles Ambiguity of 4 principles and their secularized and their secularized contextcontext

自主权与知情同意自主权与知情同意 签署某种文件签署某种文件 合适而谨慎的个人标准合适而谨慎的个人标准 患者拥有“不知情”的患者拥有“不知情”的

权利吗权利吗 ? ? 自主权与告知真相自主权与告知真相

永远不向患者撒谎永远不向患者撒谎 难道真相永远都不会造难道真相永远都不会造

成伤害吗成伤害吗 ?? 自主权与家庭决策自主权与家庭决策 44 项原则的模糊表述以项原则的模糊表述以

及各自的俗世语境及各自的俗世语境

Challenges to PrinciplismChallenges to Principlism原则主义面临的挑战原则主义面临的挑战

PrinciplismPrinciplism Neo-casuistryNeo-casuistry Consensus ethicsConsensus ethics

Engelhardt’s Engelhardt’s content-less content-less consensus ethicsconsensus ethics

Contextual ethicsContextual ethics Pragmatic ethicsPragmatic ethics Utilitarian ethicsUtilitarian ethics Liberalism and Liberalism and

nihilismnihilism

原则主义原则主义 新诡辩论新诡辩论 共识伦理学共识伦理学

EngelhardtEngelhardt 無內無內容的共识伦理学容的共识伦理学

背景性背景性伦理学伦理学 实用主义伦理学实用主义伦理学 功利主义伦理学功利主义伦理学 自由主义和虚无主自由主义和虚无主

义义

Challenges to PrinciplismChallenges to Principlism原则主义面临的挑战原则主义面临的挑战

ControversialControversial Inhuman and unrealisticInhuman and unrealistic Ignores the fact hat the Ignores the fact hat the

person is not just an person is not just an isolated individual, but isolated individual, but has ties to family, has ties to family, friends, religion, society.friends, religion, society.

Immigrants and Immigrants and multurculturalism: multurculturalism: importance of family in importance of family in healthcare decision-healthcare decision-makingmaking

富有争议的富有争议的 不人道而且不现实不人道而且不现实 忽略了人不是一个忽略了人不是一个孤立的个体，而是孤立的个体，而是与家庭、朋友、宗与家庭、朋友、宗教、以及社会等紧教、以及社会等紧密相连这一事实。密相连这一事实。

移民和多文化主义移民和多文化主义 ::家庭在医疗决策中家庭在医疗决策中的重要性的重要性

AutonomyAutonomy

Autonomy = self-Autonomy = self-determinationdetermination

No more No more “paternalism”“paternalism”

Tyranny of Tyranny of autonomy?autonomy?

Must MD do Must MD do everything patients everything patients request? Eg. female request? Eg. female circumcision, etc. circumcision, etc.

自治 = 自決 沒有更多的“家長

式“ 自主權暴的政？ 醫師必須盡一切病

人要求？例如。女性割禮等

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ChallengesChallenges

Becomes a piece Becomes a piece of paperof paper

How much How much information is information is needed?needed?

Can informed Can informed consent be truly consent be truly informed?informed?

變成了一張紙 需要多少信息？ 知情同意是真正可

以告知情況？

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Relational Self Relational Self 關係性自我關係性自我

The enhanced patient The enhanced patient autonomy approach autonomy approach requires the inclusion of requires the inclusion of family members in the family members in the decision making process. decision making process. (Surbone, 2006) (Surbone, 2006)

Patient autonomy = Patient autonomy = complex concept referring complex concept referring to both one’s capacity to to both one’s capacity to choose and to one’s ability choose and to one’s ability to implement one’s to implement one’s choices choices

得到提升的患者的自得到提升的患者的自主权需要将家庭成员主权需要将家庭成员纳入到决策制定过程纳入到决策制定过程中来中来 (Surbone, (Surbone, 2006) 2006)

患者的自主权 患者的自主权 = = 与与个人的选择能力以及个人的选择能力以及执行个人选择的能力执行个人选择的能力相关的复杂概念相关的复杂概念

New paradigmNew paradigm

Autonomy as Autonomy as individual self vs individual self vs relational selfrelational self

Family, other Family, other members, etc.members, etc.

Decision makingDecision making Truth tellingTruth telling Breaking bad Breaking bad

newsnews PlaceboPlacebo

自治 自治 = = 個人自我個人自我還是還是關係自我關係自我

家庭其他成員等家庭其他成員等 決策決策 病情告知病情告知 壞消息壞消息 安慰劑安慰劑

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New ParadigmNew Paradigm

Do patients want to Do patients want to know bad news?know bad news?

Fear from MD > patientFear from MD > patient Not to let hope die? Not to let hope die?

Deception to maintain Deception to maintain hope?hope?

When to tell, how to tell When to tell, how to tell (sequence), who to tell… (sequence), who to tell…

Family involvement can Family involvement can soften the impactsoften the impact

Rights to refuse to Rights to refuse to know?know?

病人想知道壞消息？病人想知道壞消息？ 醫師醫師 >> 病人害怕病人害怕 不要讓希望死嗎？騙不要讓希望死嗎？騙

保持希望？保持希望？ 當告之，如何辨別真當告之，如何辨別真

假（序列），誰告假（序列），誰告訴訴 ......

家庭的參與可以軟化家庭的參與可以軟化影響影響

有權拒絕知道嗎？有權拒絕知道嗎？04/21/23 17

MulticulturalismMulticulturalism

Challenging the Challenging the individualist individualist approachapproach

Patient’s culture, Patient’s culture, religion, values religion, values system, etc.system, etc.

MD’s knowledge MD’s knowledge of these of these systems, systems, strategies to be strategies to be culturally culturally sensitivesensitive

挑戰個人主義方法 病人的文化，宗教

，價值觀系統等值觀系統等 醫師對這些系統的

知識，在文化識相識相的戰略

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In China In China 對於中国對於中国

家庭主义為成在中国的家庭主义為成在中国的初初次印象次印象 家庭，村，县 ，省，国家，家庭，村，县 ，省，国家，民族民族……

原则主义的知情同意以及原则主义的知情同意以及告知真相在实践中所遇到告知真相在实践中所遇到的困难的困难

家庭主义与西方的關係性家庭主义与西方的關係性自我概念的趋同自我概念的趋同

挑战：逐渐缩小的家庭规挑战：逐渐缩小的家庭规模，个人主义模，个人主义

Familism as Familism as prima facieprima facie in Chinain China Family, village, province, Family, village, province,

nationnation Difficulties with informed Difficulties with informed

consent and truth telling consent and truth telling practices of principlismpractices of principlism

Convergence of familism Convergence of familism with the relational self with the relational self concept in the Westconcept in the West

Challenges: smaller Challenges: smaller family units, family units, individualismindividualism

保持信任保持信任

尊敬他人尊敬他人

維持联络維持联络的价值的价值

避免强迫或操縱 避免强迫或操縱

真相真相

Advanced Directives Advanced Directives from a Catholic from a Catholic

PerspectivePerspective Francisco de Vitoria Francisco de Vitoria

ordinary vs. extraordinary means ordinary vs. extraordinary means 普通 vs. 特殊的手段

Medical advances now gave doctors much Medical advances now gave doctors much more options to cure and prolong life, and more options to cure and prolong life, and even prolong the dying process. even prolong the dying process.

Pope Pius XII in 1957. Pope Pius XII in 1957.

Ordinary vs Ordinary vs extraordinary meansextraordinary means

Ordinary (proportionateOrdinary (proportionate 相稱 ) means are ) means are those basic care and treatments which those basic care and treatments which doctors are obligated to provide and which doctors are obligated to provide and which under normal circumstances, patients should under normal circumstances, patients should not refuse—run of the mill medical not refuse—run of the mill medical treatment, hygiene, antibiotics, etc. treatment, hygiene, antibiotics, etc.

Extraordinary (disproportionate Extraordinary (disproportionate 不相稱 ) ) means are those medical measures that can means are those medical measures that can cause undue burden on the patients and the cause undue burden on the patients and the family, and therefore patients are not obliged family, and therefore patients are not obliged to undergo these (experimental) treatments, to undergo these (experimental) treatments, or if they have been started could ask for or if they have been started could ask for their withdrawal. their withdrawal.

Ordinary vs Ordinary vs extraordinary meansextraordinary means

There are objective and subjective elements that There are objective and subjective elements that the patients and doctors must weigh the risks the patients and doctors must weigh the risks and benefits in each case. and benefits in each case. Objective elements such as the difficulties, pain risk, Objective elements such as the difficulties, pain risk,

cost and success rates, etc. cost and success rates, etc. Subjective elements include fear, anxiety, physical or Subjective elements include fear, anxiety, physical or

psychological suffering, shame, the desire to live on, the psychological suffering, shame, the desire to live on, the time to settle affairs, etc.time to settle affairs, etc.

Preferred term is proportionality, since some Preferred term is proportionality, since some ordinary means can become disproportionate in ordinary means can become disproportionate in very ill patients, and some extraordinary means very ill patients, and some extraordinary means can be proportionate to patient needs when the can be proportionate to patient needs when the risk and benefits are weighed.risk and benefits are weighed.

  Therapeutic obstinacy Therapeutic obstinacy and Euthanasiaand Euthanasia

Two extremes to be avoided. Two extremes to be avoided. Therapeutic obstinacy Therapeutic obstinacy 治療頑固 : When all : When all

available treatments have been tried and available treatments have been tried and patient is dying, doctors should accept this patient is dying, doctors should accept this rather than employing all technology to rather than employing all technology to prolong the dying process, thus causing more prolong the dying process, thus causing more suffering and does not respect the dignity of suffering and does not respect the dignity of the person. (Unrealistic expectations from the person. (Unrealistic expectations from patients, family and doctors: Medicine or patients, family and doctors: Medicine or doctors seen as saviors, failure). Pius XII: doctors seen as saviors, failure). Pius XII: extraordinary means can be withheld or extraordinary means can be withheld or withdrawn. withdrawn.

  Therapeutic obstinacy Therapeutic obstinacy and Euthanasiaand Euthanasia

CCC 2278 Discontinuing medical procedures that CCC 2278 Discontinuing medical procedures that are burdensome, dangerous, extraordinary, or are burdensome, dangerous, extraordinary, or disproportionate to the expected outcome can disproportionate to the expected outcome can be legitimate; it is the refusal of “over-zealous” be legitimate; it is the refusal of “over-zealous” treatment. treatment. ““ 過分熱心過分熱心” ” 治療 治療 Here one does Here one does not will to cause death; one's inability to impede not will to cause death; one's inability to impede it is merely accepted.it is merely accepted.

The decisions should be made by the patient if The decisions should be made by the patient if he is competent and able or, if not, by those he is competent and able or, if not, by those legally entitled to act for the patient, whose legally entitled to act for the patient, whose reasonable will and legitimate interests must reasonable will and legitimate interests must always be respected.always be respected.

  Therapeutic obstinacy Therapeutic obstinacy and Euthanasiaand Euthanasia

Euthanasia: to end someone’s Euthanasia: to end someone’s suffering by intentionally suffering by intentionally ending his or her life. ending his or her life.

““By euthanasia is understood By euthanasia is understood an action or an omission an action or an omission which of itself or by intention which of itself or by intention causes death, in order that all causes death, in order that all suffering may in this way be suffering may in this way be eliminated.” (Declaration on eliminated.” (Declaration on Euthanasia 1980, EV, CCC) Euthanasia 1980, EV, CCC)

Level of intention, includes Level of intention, includes omission if the intention is omission if the intention is there to provoke death. Could there to provoke death. Could be voluntary or non-voluntary. be voluntary or non-voluntary.

安樂死：結束一個安樂死：結束一個人的痛苦，故意結人的痛苦，故意結束她的生命。束她的生命。

意向的意向的層次層次 包括不行動故意造包括不行動故意造

成死亡成死亡 可能是自願或不自可能是自願或不自

願的。願的。

PVS and ANH PVS and ANH 植物人 , 人工營養與水分

Water and nutrition are basic Water and nutrition are basic needs, not therapy.needs, not therapy.

Withdrawal with the intention to Withdrawal with the intention to cause death, since PVS patients cause death, since PVS patients could live on indefinitely. That is, could live on indefinitely. That is, cause of death is starvation and cause of death is starvation and dehydration. dehydration.

Recent report form NEJM—some of Recent report form NEJM—some of them can have thought processes.them can have thought processes.

Historical Background on Historical Background on Advanced directives Advanced directives

Quinlan Case: Natural Death Act 1979Quinlan Case: Natural Death Act 1979 Karen Ann Quinlan, PVS and on ventilator. Parents Karen Ann Quinlan, PVS and on ventilator. Parents

petitioned for withdrawal of respirator, but doctors petitioned for withdrawal of respirator, but doctors refused. Court decided that ventilator is an refused. Court decided that ventilator is an extraordinary means, and can be withdrawn, citing extraordinary means, and can be withdrawn, citing Pius XII. Pius XII.

Natural Death Act: There is a right to express one’s Natural Death Act: There is a right to express one’s will regarding life sustaining treatments, and the right will regarding life sustaining treatments, and the right to withdraw or withhold them. In the case of mental to withdraw or withhold them. In the case of mental incapacity, these rights can be expressed by either incapacity, these rights can be expressed by either Advanced Directives (written document) or durable Advanced Directives (written document) or durable power of attorney (proxy) by naming someone who power of attorney (proxy) by naming someone who could make the decision on behalf of the patient.could make the decision on behalf of the patient.

Historical Background on Historical Background on Advanced directivesAdvanced directives

Cruzan Case: Patient Self-determination Act Cruzan Case: Patient Self-determination Act 19911991

Nancy Cruzan also PVS, on artificial nutrition Nancy Cruzan also PVS, on artificial nutrition and hydration (PEG). Family wanted removal and hydration (PEG). Family wanted removal of tube feeding against doctor’s judgment. of tube feeding against doctor’s judgment. They were able to demonstrate They were able to demonstrate retrospectively that this was the patient’s retrospectively that this was the patient’s desire. desire.

Patient Self-determination Act requires all Patient Self-determination Act requires all health care institutions to advise all patients health care institutions to advise all patients admitted to their facilities the availability of admitted to their facilities the availability of advanced directives.advanced directives.

Terri Schiavo Terri Schiavo

Context of the Living Will Context of the Living Will movement movement

Fear of technology: hooked up to machine Fear of technology: hooked up to machine and living an undignified existenceand living an undignified existence

Euthanasia movement in the 1980s found Euthanasia movement in the 1980s found it difficult to change the laws to permit it difficult to change the laws to permit euthanasia.euthanasia.

More emphasis on who decides rather More emphasis on who decides rather than what is best for the patient. than what is best for the patient.

Individualism: Self-determination often Individualism: Self-determination often becomes the only criteriabecomes the only criteria

CritiquesCritiques

Difficulties in explaining to patients the medical conditions, Difficulties in explaining to patients the medical conditions, and they could be subject to manipulation, undue fears and they could be subject to manipulation, undue fears and ideological pressures. Not truly informed consent.and ideological pressures. Not truly informed consent.

Difficulty in foreseeing all possible future situations which Difficulty in foreseeing all possible future situations which can be complex. When circumstances change, people can can be complex. When circumstances change, people can change their minds (eg. Charles Kao)change their minds (eg. Charles Kao)

Damaging relationships between doctors and patients: Damaging relationships between doctors and patients: Doctors just execute the patient decision as a robotDoctors just execute the patient decision as a robot

Tyranny of Autonomy: Respect of the person includes Tyranny of Autonomy: Respect of the person includes looking for what is best for the patient. looking for what is best for the patient. Not all decisions are wise and good. One can choose the Not all decisions are wise and good. One can choose the

wrong thing. “No man is an island”—recent shift of emphasis wrong thing. “No man is an island”—recent shift of emphasis that decision making is best when made in a wider that decision making is best when made in a wider “relational” context including family, friends, and co-“relational” context including family, friends, and co-religionists. Familism in Asia.religionists. Familism in Asia.

Legal frameworksLegal frameworks

Legally binding (USA, Australia, UK, Legally binding (USA, Australia, UK, Holland, Belgium) or just consultative Holland, Belgium) or just consultative and indicative (Italy, Germany, and indicative (Italy, Germany, Austria)Austria)

Existence of Catholic versions of Existence of Catholic versions of “Advanced Directives” that respect “Advanced Directives” that respect the Catholic teaching (e.g. NCBC). In the Catholic teaching (e.g. NCBC). In general, resistance to its use because general, resistance to its use because of these problems.of these problems.

Introduction of the Concept of Introduction of the Concept of Advanced Directives in Hong Advanced Directives in Hong

KongKong Terminal illness / irreversible coma / PVS, are very different conditions. Terminal illness / irreversible coma / PVS, are very different conditions.

Different principles apply here—for eg., any treatment in truly Different principles apply here—for eg., any treatment in truly irreversible coma would be wrong, even ANH. Whereas in the case of irreversible coma would be wrong, even ANH. Whereas in the case of PVS, withdrawal of ANH would be euthanasia.PVS, withdrawal of ANH would be euthanasia.

Euthanasia defined as “direct intentional killing of a patient as a part of Euthanasia defined as “direct intentional killing of a patient as a part of the medical care being offered.” Omission can also be a means of the medical care being offered.” Omission can also be a means of intentional killing.intentional killing.

Artificial vs. natural rather than proportionality the criteria. That is, Artificial vs. natural rather than proportionality the criteria. That is, artificial means are always inappropriate or burdensome… Definition of artificial means are always inappropriate or burdensome… Definition of life-sustaining treatment includes ANH. (Catholic hospitals should not life-sustaining treatment includes ANH. (Catholic hospitals should not cooperate with this)cooperate with this)

Family or relatives seen as enemies to patient self-determination. Family or relatives seen as enemies to patient self-determination. Elimination of proxy as an option. This is absurd in the Asian context, Elimination of proxy as an option. This is absurd in the Asian context, especially in view of the recent shift of opinion coming from the especially in view of the recent shift of opinion coming from the Western experience.Western experience.

Options only to withdraw or withhold treatments, no mention of desire Options only to withdraw or withhold treatments, no mention of desire to continue treatments under these conditions. Doubt: cost saving to continue treatments under these conditions. Doubt: cost saving measures?measures?