Dying made legal: New challenge for advance directives

l i e CFORUM, Vol. 3, No. 4, pp. 187-199, 1991. 0956-2737/91 $3.00+.00 Printed in the USA. All rights reserved, Copyright © 1991 Pergamon press plc

D Y I N G M A D E L E G A L : N E W C H A I J . E N G E

F O R A D V A N C E D I R E C T I V E S

NANCY M. P. KING, J.D.

Overview

As more and more courts, legislatures, healthcare institutions, and patients concern themselves with end-of-life decisionmaking, advance directives continue to grow more popular. HEC's should expect to be called upon to assist in the interpretation and implementation of advance directives and in institutional policymaking about them. In order to do so fairly, HEC's must resist the increasing tendency to regard advance directives as purely legal documents. Despite current emphasis on state statutory living wills and healthcare proxy designations, advance directives do not have to conform to these statutes in order to be valid. Once advance directives are understood to be expressions of patients' common-law and constitutional rights to make treatment decisions, directives in any form may be interpreted and implemented in good faith by the patient's community of decisionmakers.

With Nancy Beth Cruzan's death on Dec. 26, 1990 (1), her story has come full circle: The state of Missouri has now acknowledged that oral declarations expressing an aversion to life in a diminished condition can meet the "clear and convincing" evidentiary standard it requires to authorize the withholding or withdrawal of artificial nutrition and hydration (2). As a result, some might speculate that the frantic rush to advance directives spawned by the Cruzan case's earlier episodes (3) should diminish. After all, the case has demonstrated that even under the severest constraints permitted by the Constitution of the United States, it is unreasonable to expect everyone to have prepared an explicit and comprehensive written document, witnessed, notarized, and vetted by attorneys. Shouldn't we all be able to relax now, and treat advance directives as they were meant to be treated - as guidance for persons ready and willing to honor our choices, so long as they know what we choose?

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Advance directives can be instruction directives, containing lists of refused and requested treatments; proxy directives (such as the durable power of attorney) naming substitute decisionmakers; or a combination of the two. They derive their authority not from their own terms but from the common-law doctrine of informed consent (4) and from the constitutional liberty interest acknowledged by the United States Supreme Court in Cruzan (5). For a variety of reasons, however, advance directives have often been viewed by caregivers and their institutions with caution, or even with suspicion. As a result, the rights and interests of their authors have often been squeezed within narrow boundaries of state 'living will' statutes and the spare language of the statutory model advance directives they contain. Paradoxically, as advance directives have become more common, caregivers and courts have increasingly become entangled in their form, rather than their substance.

Healthcare ethics committees (HCECs) function as advisors not only to physicians faced with interpreting and implementing their patients' advance directives but also to institutions faced with drafting policies regarding the writing, interpretation, and implementation of patients' advance directives. As such, HCECs have a potentially pivotal role in shaping their institutions' understanding of advance directives - a role likely to increase greatly in importance with the passage of the Patient Self-Determination Act of 1990 (6).

This "Act", which takes the form of amendments to Medicare and Medicaid, appears destined to ensure that the heightened popular interest in advance directives created by the case of Nancy Cruzan will continue for awhile longer, despite the reassurances the Cruzan decision presents to the careful reader (7). Because the Act requires health care organizations receiving federal Medicare funds to inform their residents about advance directives, it is likely to cause many more advance directives to be written, and may even result in many institutions' essentially requiring all their residents to have one. Understanding advance directives properly is thus an even more critical imperative for physicians, patients, institutions, and HCECs, in order to reduce the growing risk that directives will be dictated exclusively, or even primarily, by legal imperatives that fail to take sufficient account of their true nature.

The Patient Self-Determination Act of 1990, passed as part of the Omnibus Budget Reconciliation Act on November 5, 1990, has been hailed by many as a breakthrough in the acceptance of advance directives. The Act amends Medicare law to require hospitals, skilled nursing facilities, home health agencies, and hospice programs having Medicare provider agreements to maintain written policies and procedures for informing patients, residents, and clients about advance

Dying Made Legal: New Challenge for Advance Directives 189

directives. The language of the amendments is likely to be critical to institutions' understanding, not only of how much freedom and flexibility they have in policymaking, but also of how much their patients, residents, and clients have in directive-writing. Institutional policies must provide written information to patients, residents, and clients concerning

"an individual's rights under State law (whether statutory or as recognized by the courts of the State) to make decisions concerning...medical care, including the right to accept or refuse medical or surgical treatment and the right to formulate advance directives."

'Advance directive' is defined as follows:

"a written instruction, such as a living will or durable power of attorney for health care, recognized under State law (whether statutory or as recognized by the courts of the State) and relating to the provision of such care when the individual is incapacitated."

There is only one problem with this language, and it is a big one: Institutions are likely to read it as requiring the use o f the statutory model directives included in state statutes. In fact, the quoted language does not require their use; such a statutory directive is, of course, "a written instruction...recognized under State law", but many other forms of directives, including oral statements, have also been recognized by legislatures and courts in nearly all of the states. Nonetheless, institutional administrators and their attorneys, understandably already predisposed to focus on statutory directives both because they believe them to be required by state statutes and because dealing with one standard document is a lot less complicated than interpreting and implementing many, are unlikely to linger over the subtleties of statutory interpretation.

Even more significant, however, is the fact that the Act requires discussion of individuals' rights under state law, but omits mention of their constitutional rights. Because the Constitution limits the states' power to curtail the rights of individuals by statute or court decision, the failure to mention the Constitution may reinforce institutions' mistaken propensity to treat state statutes as defining advance directives, though it cannot alter the Constitution's power to correct the error.

The tendency to conceive of advance directives in primarily legal terms results from three common misconceptions about them - misconceptions arising from understandable, indeed, admirable efforts to make the decisions that directives face a little less difficult and troubling for those involved. Misconceptions result when what is

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advisable comes to be seen as required, and when it is believed that the difficult and troubling character of end-of-life decisions can be eliminated, rather than merely reduced. It is necessary to examine more closely the misconceptions about advance directives, in order to begin to correct them.

Misconception #1: It Bet ter Be in Writing

Written directives are desirable. Because they do not depend upon the recollections of others, they provide more certainty for the author that his or her choices will be known and correctly understood. Written directives also demonstrate that the author was serious enough in his or her choices to commit them to writing. All individuals with serious concern about their health care decisions should state them in written form.

Recognizing that written directives are preferable, however, is a long way from holding that they are required. To require them would greatly disadvantage those who did not write directives in time, particularly those whose need for end-of-life choices arises as a result of an emergency. Nancy Cruzan provides the paradigmatic example: a young woman with no health problems, who holds decided views but cannot anticipate the accident that will place those views in critical issue. If orally expressed preferences were to be devalued because they have not been committed to paper, young people, accident victims, and those whose disability is unexpected or takes an unanticipated form would be treated differently even though their settled views might be just as strongly held and almost as readily determinable as the views of those who were able to put them in writing.

Moreover, there is no legal basis for any such requirement. It is vital to understand that the right to refuse treatment is derived from the common law doctrines of informed consent and battery and from the fourteenth amendment liberty interest derived from the Constitution. This means that written directives provide evidence of the author's choices, but are not necessary to establish the right to make them. The right already exists, independent of the form in which it is exercised (8).

According to the common law, intentional physical contact between people must be consensual or it is unlawful. Physicians make intentional contact with patients, in order to benefit them medically; despite their good intentions, they must obtain their patients' permission to do so. Physician defendants in early cases argued that this permission was implied whenever patients sought medical care (9); however, the developing doctrine of informed consent recognized that patients yield their bodies to the medical profession for specific


purposes and to gain specific ends, and that they consciously weigh the risks, costs, and discomforts of treatment against the chances of improvement. Because they consent to the intrusions of medicine on the basis of their understanding of the purposes for and the value of those intrusions, patients must be given the information necessary to decide whether those intrusions are desirable as well as the power to decide. If they are denied this information, their decisions cannot be valid (10).

By the same token, if patients are denied the power to refuse an undesired medical intrusion, their consent to it cannot be valid. The constitutional right to refuse unwanted medical treatment, incorrectly characterized by the Supreme Court's Cruzan majority as "the right to die" (11), enshrines the same reasoning in constitutionally protected terms.

Advance directives are different, of course, from the contemporaneous treatment refusals of informed and decisionally capable adults. Advance directives express decisions that will be carried out in the future, when the decisionmaker is not able to make contemporaneous choices.

Currently incapable persons must exercise their rights differently from decisionally capable persons, either through a surrogate or by prior expression; neither of these means, however, requires a writing. Written directives are more likely to be specific and detailed than prior oral statements, and therefore more easily implemented by caregivers in some cases. The naming of a surrogate decisionmaker, in contrast, need provide no detail at all, and is even easier for caregivers to implement. In short, writings are desirable for many reasons, but cannot be reasonably required. As the Cruzan case and others have shown, even when a state, to protect the rights and interests of its decisionally incapable citizens, requires that their treatment refusals be proven by "clear and convincing" evidence (the highest evidentiary standard permitted in a civil case), oral rather than written evidence of the patient's t reatment refusal may be found to meet that standard (2).

Misconception #2 : You Have to Use the Statute

Even if neither the Constitution nor the common law requires written directives, most states have passed "living will statutes" that provide model advance directives whose form and substance have been deemed acceptable by the legislature. Many caregivers, and a considerable number of lawyers as well, believe that the existence and availability of the statutory model directive establishes its necessity. This conviction is wrong.

Most living will laws were not intended to supplant the common

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law's recognition of the right to refuse treatment. Many of them say so explicitly in their legislative preambles and general purpose clauses. North Carolina's Natural Death Act, for example, begins this way:

"The General Assembly recognizes as a matter of public policy that an individual's rights include the right to a peaceful and natural death and that a patient or his representative has the fundamental right to control the decisions relating to the rendering of his own medical care, including the decision to have extraordinary means withheld or withdrawn in instances of a terminal condition. This Article is to establish an optional and nonexclusive procedure by which a patient or his representative may exercise these rights .... Nothing in this Article shall impair or supersede any legal right or legal responsibility which any person may have to effect the withholding or withdrawal of life- sustaining procedures in any lawful manner..." (12).

Even if no such explicit recognition of the patient's non-statutory rights is given in a particular statute, the history of the living will laws supports their continuing recognition of nonstatutory advance directives. These statutory schemes were enacted, beginning in the 1970s, primarily to protect the interests of physicians concerned that they could be held legally responsible for withholding or withdrawing treatment at the request of the patient. Protecting the patient's right to make medical treatment decisions was a secondary and poorly enforced goal. Beginning with the Quinlan decision (13), which was brought to court initially because Karen Quinlan's caregivers were unsure of their legal responsibilities and liabilities in extremely ambivalent moral and legal circumstances, physicians and lawyers have been understandably uncertain regarding both the civil and criminal liability of caregivers who withhold or withdraw life-sustaining treatment from patients.

Fifteen years since Quinlan and many court decisions later, the absence of liability is generally clear (8); but in the interim, living will statutes carved out a category of treatment refusal decisions that seemed relatively uncontroversial, and offered physicians a small degree of legal protection for implementing the decisions of their patients when expressed in the model directives contained in the statutes. The "preapproved" character of the statutory directives does not imply, however, that directives not conforming to these statutes are invalid. Rather, "nonconforming" directives continue to be evaluated according to the precepts of the common law. Though not presumed valid like statutory directives, nonconforming directives can thus be proven valid to the satisfaction of a court, and therefore may be reasonably relied upon by physicians and others.

There are two types of "nonconformance" that directives can exhibit. A directive may be either formally or substantively


nonconforming; that is, it may deviate from the statutes prescribed indicia of reliability, or it may state treatment decisions that deviate from those presumed acceptable by being encompassed in the statutory form.

Directives that fail to conform in the formal sense might not meet the statutory directive's specifications regarding the number of witnesses and their qualifications; the requirement of certification by a notary or other official; attestations as to the patient's physical condition by the requisite number of physicians having the prescribed relationship to the patient; and other similar requirements. These requirements are intended to ensure that the authors of advance directives take seriously the task of preparing their directives, and recognize their importance and their implications.

Should the requirements not be satisfied in every respect in a given directive, their purpose may be accomplished if that directive contains other comparable indicia of reliability and seriousness in its form and contents, or if evidence external to the directive demonstrates its reliability and the seriousness of its author. If this were not so, a directive executed according to the statutory requirements of one state would be invalid in a state whose statute contained different requirements, making it impossible for most directives to cross most state lines. As even oral statements of treatment preference may be found valid under the stringent "clear and convincing" civil evidentiary standard, so may witness testimony about the content and seriousness of the patient's previously expressed choices be valid by that standard, making it possible to meet the formal requirements of statutory directives in spirit as well as in letter.

Substantive nonconformance presents a more difficult problem. Statutory directives are granted their 'preapproved' status not only because of their indicia of reliability, but also because they address choices about which there is sufficient consensus to earn legislative approval. Living will statutes were originally drafted to permit refusal of "extraordinary" treatments in the face of "terminal" conditions, when death could not be prevented but at best postponed - circumstances in which few would argue with a patient's choice of a peaceful death over a few more hours or days of mechanically maintained existence. Before long, however, patients in persistent vegetative states (PVS) began to present a problem for the implementation of advance directives.

PVS patients cannot easily be described as terminally ill, because they often have the capacity to live out nearly normal lifespans. Karen Quinlan, who was expected to die after she was removed from her respirator in 1976, lived for over ten years longer. More importantly, PVS patients are not supported by what were conventionally considered "extraordinary means": they breathe on their own, have healthy hearts,

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and require only custodial care and food and water by tube (14). "I don't want to become another Karen Quinlan" soon became a short- form oral advance directive for many patients, but one that fell outside the scope of all state living will statutes.

The first response of a number of state legislatures to the problem of PVS patients was to amend their statutes to preclude the refusal of artificial nutrit ion and hydration by statutory directive (15). Insofar as they sought thereby to discourage or prevent the refusal of artificial nutrit ion and hydration in any directive, such restrictions ran afoul of the Constitution, as was repeatedly confirmed in state and federal courts and ultimately by the United States Supreme Court in Cruzan (16).

Just as significantly, perhaps, these new restrictions began to run afoul of public opinion as well. Soon state legislatures were amending their statutory directives yet again - this time to permit refusal of artificial nutrit ion and hydration, usually by adding a specific notation to the effect that they must be separately initialed by the directive's author. While more states may be expected to amend their statutes in this way, it should also become clearer that refusing nutrition and hydration, under at least some circumstances, is permissible regardless of the language of statutory directives.

Misconception #3: The Perfect Document

Unlike the first two misconceptions, which may be ascribed largely to the concerns of those charged with interpreting and implementing advance directives, the third misconception is commonly held by the authors of advance directives as well. Recognizing that many physicians and health care institutions are nervous about advance directives, and highly concerned that their decisions be understood and implemented, many authors of advance directives attempt to write the Perfect Document. The Perfect Document is crystal clear, covers all contingencies, contains no ambiguities, and gives rise to no questions. It protects its authors and its implementers from any and all untoward consequences, and therefore commands obedience in its every particular. The authors of Perfect Documents believe that perfecting their directives is possible; more importantly, they believe that their directives, thus perfected, constitute orders to their doctors - orders that their rights as patients require their physicians to carry out.

Like the others, this misconception also grew from a good planting - the desire for clarification of some of the more confusing and troublesome aspects of advance directives. By way of illustration, let us examine a well-known model directive devised by Concern for Dying, a nonprofit advocacy organization devoted to public education


about advance directives and the right to refuse treatment. Concern has been issuing model 'living wills' to interested persons throughout the United States for decades; it also supplies copies of statutory living wills and durable powers of attorney for all jurisdictions.

Concern's model directive is well-known and has been extensively disseminated. It has profoundly influenced thousands of individuals, as well as affecting scholarship and public policy. For many years, it took the form of an exhortatory, philosophical document, reading, in its entirety, as follows (17):

"To my family, my physician, my lawyer and all others whom it may concern: Death is as much a reality as birth, growth, maturity and old age - it is the one certainty of life. If the time comes when I can no longer take part in decisions for my own future, let this statement stand as an expression of my wishes and directions, while I am still of sound mind.

If at such time the situation should arise in which there is no reasonable expectation of my recovery from extreme physical or mental disability, I direct that I be allowed to die and not be kept alive by medications, artificial means or 'heroic measures'. I do, however, ask that medication be mercifully administered to me to alleviate suffering even though this may shorten my remaining life.

This statement is made after careful consideration and is in accordance with my strong convictions and beliefs. 1 want the wishes and directions here expressed carried out to the extent permitted by law. Insofar as they are not legally enforceable, I hope that those to whom this Will is addressed will regard themselves as morally bound by these provisions".

Notice how "unofficial" ~he language of this model directive is. Terms are not minutely defined, but made clear by context. Although there is certainly vagueness, there is also conviction and emotional sincerity in these words; this is a document that invites the engagement of caregivers and family in honoring its terms. In particular, the last paragraph is remarkable, looking not to legal enforceability but to the conscience and understanding of those charged with the patient's care.

Concern for Dying is headquartered in New York, a state that has done even more than Missouri to engender fear of the courts when it comes to treatment refusal and end-of, life decisionmaking, New York is one of the few states that still does not have a 'living will' law, although it recently passed a Health Care Proxy Act (18) in reaction to the Cruzan decision, and its courts have been exceedingly conservative in interpreting and implementing advance directives (19). Perhaps as a result of bitter experience, Concern's model directive currently has a new, and newly legalistic, sound (20).

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"Death is as much a reality as birth, growth, and aging - it is the one certainty of life. In anticipation of decisions that may have to be made about my own dying and as an expression of my right to refuse treatment, I , being of sound mind, make this statement of my wishes and instructions concerning treatment.

By means of this document, which I intend to be legally binding, I direct my physician and other care providers, my family, and my surrogate designated by me or appointed by a court, to carry out my wishes. If I become unable , by reason of physical or mental incapacity, to make decisions about my medical care, let this document provide the guidance and authority needed to make any and all such decisions.

If I am permanently unconscious or there is no reasonable expectation of my recovery from a seriously incapacitating or lethal illness or condition, I do not wish to be kept alive by artificial means. I request that I be given all care necessary to keep me comfortable and free of pain, even if pain-relieving medications may hasten my death, and I direct that no life-sustaining treatment be provided except as I or my surrogate specifically authorize.

This request may appear to place a heavy responsibility upon you, but by making this decision according to my strong convictions, I intend to ease that burden. I am acting after careful consideration and with understanding of the consequences of your carrying out my wishes".

In addition, this model directive now contains a proxy designation clause, which spells out the decisional standards the proxy is to use and concludes: "I release and agree to hold harmless my health care surrogate from any and all claims whatsoever arising from decisions made in good faith in the exercise of this power." Finally, this closing language has been added: "This Living Will expresses my personal treatment preferences. The fact that I may have also executed a declaration in the form recommended by state law should not be construed to limit or contradict this Living Will, which is an expression of my common-law and constitutional rights."

What is the effect of this change in language? First, there is a great increase in explicitness and specificity regarding the purpose of the directive, the author's understanding of its meaning, and its interpretation and consequences. Obviously, such changes may make it easier for many caregivers to honor patients' choices. Perhaps not so obviously, the tone of the directive has also been substantially changed. It is more formal, more at arm's length, more responsive to legal than to moral concerns. Indeed, it spells itself out with such dry clarity that it appears intended to cover any and all contingencies. Should a decision arise that is not addressed in such a directive, a


caregiver might even be at a loss as to how to proceed. By contrast, this model directive in its earlier form seemed somehow more capable of offering general guidance to caregivers seeking support for their good-faith efforts, and of encouraging a broader, more exploratory viewpoint.

Concern for Dying's new model directive will no doubt prove reassuring to many charged with the implementation of advance directives cast in its mold. Nonetheless, the authors of directives are wrong to believe that good directives can or should command unquestioning obedience. Yes, it is true that the autonomy of patients requires that they not be treated against their will. But it is also true that the doctrine of informed consent, whereby permission for treatment is granted or withheld, describes a process of communication and decisionmaking that is shared by physician and patient as a central part of their relationship. The final decisionmaking authority is the patient's, but the process leading up to it is inescapably mutual (21).

As one kind of treatment decision by a patient, an advance directive is therefore properly the culmination of a shared process of communication and decisionmaking. When a long-standing physician- patient relationship exists, the document can be exactly that. When the patient comes to the physician with the desire to write, or to discuss the writing of, an advance directive, that desire triggers the mutual process. But when the author of a directive presents it to the physician as a fait accompli, it becomes a conversation-stopper rather than a conversation-starter. The opportunity to understand the author's wishes fully may be lost if the author does not acknowledge the possibility that more than the document itself may be needed in order to do so.

The third misconception can cause opportunities for discussion and understanding to be lost, because it fails to acknowledge that such opportunities are beneficial and sometimes necessary. Correcting this misconception does not mean, however, that discussion is required in order for a directive to be valid. Too many physicians are wary of implementing directives that they themselves have not discussed with their authors - a concern that could far too easily result in the invalidation of many (if not most) advance directives. Instead, correcting this misconception is a great deal simpler. It requires only that advance directives be understood as documents that invite the engagement of the author's moral community in understanding the decisions contained within them and their implications (8).

As a result, the authors of directives will find it natural to consider not only what their choices are, but how to explain them clearly to their families and to caregivers, thus producing documents that have been thoughtfully drafted in every case, discussed whenever possible, and therefore likely to be more easily understood and

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implemented. Moreover , the physicians and others who are called upon to in terpret and implement directives will be bet ter prepared to recognize when their authors were thoughtful and took their decisions seriously, part icularly when those directives do not conform with the models provided by state statutes.

Hea l thcare Ethics Commit tees and Advance Directives

H C E C s should prove exemplary at dispelling the three misconcept ions about advance directives, both when they are called upon to assist physicians in considering part icular directives, and when drafting inst i tut ional policy regarding directives. The reason is simple: H C E C s are mora l communit ies , const i tuted specifically to ensure that their considera t ion o f any mora l p rob lem within their insti tution is full, fair, and mindful no t only o f the rights, duties, and interests o f those concerned, but also o f the richness and complexity o f the problem's human character (22).

Like the o ther problems considered by HCECs , advance directives cannot be reduced to a set o f requirements , as the three misconcept ions seem to suggest. The decisions that directives encompass are inherently difficult and inherent ly painful, and the burdens o f interpret ing and implement ing them can be borne bet ter but never cast aside. If H C E C s bring their own humani ty to the tasks o f advising caregivers and making policy about advance directives, dying by directive can become more than just a legal exer_cise.

R E F E R E N C E S

1. Gianelli D. Right-to-die debate persists after Nancy Cruzan's death. American Medical News, Jan 14, 1991; p. 1.

2. Cruzan v. Mouton, estate no. CV384-9P, Jasper Co. (Missouri) Circuit Court, Probate Div. at Carthage, Dec. !4, 1990.

3. Cruzan v, Harmon, 760 S.W.2d 408 (Mo. 1988), tlffd sub nora. Cruzan v. Director, Missouri Dep't of Health, 110 S.Ct. 2841 (1990).

4. Faden R, Beauchamp T, King NA. History and theory of informed consent. New York: Oxford University Press;1986: 25-39, 114-50.

5. Cruzan v. Director, 110 S.Ct. at 2851. 6. Omnibus Budget Reconciliation Act, P.L. 101-508, §4206 (Nov. 5, 1990). 7. Annas G. Nancy Cruzan and the right to die. New England Journal of Medicine.

323:670-73; 1990. 8. King N. Making sense of advance directives. Dordrecht, The Netherlands: Kluwer

Academic Publishers; 1991. 9. Pratt v. Davis, 79 N,E. 562, 565 (IlL 1906).

10. Canterbury v. Spence, 464 F.2d 772(D.C, Cir 1972). 11. Cruzan v. Harmon, 110 S,Ct. at 2852. 12. N.C. Gen. Stat. Ann. §90-320 (1985). 13. In re Quinlan, 70 N.J. 10, 355 A,2d 647 (1976). 14. Cranford R. The persistent vegetative state: The medical reality (getting the facts


straight). Hastings Center Report. 18(1):25-32; 1988. 15. Society for the Right to Die. Tube feeding law in the United States (chart). 250

West 57th Street, New York, NY, 10107; 1989. 16. In re Guardianship of Browning (State v. Herbert), No. 74,174 (Fla. Sept. 13,

1990). 17. Concern for Dying. A living will (pamphlet). 250 West 57th Street, New York,

NY, 10107; 1985. 18. New York Health Care Proxy Act, NY Pub. Hlth L. §§2980-2994 (S.B. 6176-A

signed July 22, 1990). 19. In re Westchester County Medical Center (O'Connor), 72 N.Y. 2d 517, 534

N.Y.S.2d 886, 531 N. E. 2d 607 (1988). 20. Concern for Dying. A living will and appointment of a surrogate decision maker

(250 West 57th Street) New York, NY;1990. 21. Katz J. The silent world of doctor and patient. New York: Free Press; 1984. 22. King N. Ethics committees: Talking the captain through troubled waters. In: King

N, Churchill L, Cross A, eds. The physician as captain of the ship: A critical reappraisal. Dordrecht, The Netherlands: D. Reidel Publishing Company; 1988:223- 41.