My comment to Johannes and may I add a bit more to the case:

Case 1: Suppose the man on a ventilator for life support is actually a quadriplegic (which would not be a rare coincidence!!) and requests the attending physician to turn off the ventilator because his life was continuing to be intolerable to him. He is physically unable to perform the act himself. The quadriplegic understands that this action would cause his death. What if the attending physician is unwilling to "pull the plug" since the physician would consider this action as, if not assisted-suicide, virtually euthanasia (killing instead of "letting die") for which the physician finds morally abhorrent and not, for him, an establish professional responsibility? For the same reason, the physician is unwilling to write an order for someone else to shut off the ventilator since he considers that order aiding and abetting. Also he knows that before the ventilator is turned off, he would be responsible for ordering or administrating a sedative to reduce any terminal symptoms, again being part of the act. If the physician came to you as a clinical ethicist and asked you if the physician's decision to say "no" to the patient's request was ethical and legal and then asks you "what can I do?" How would you respond? ..Maurice.

With regard to case 1, I would agree that the attending physician can be presented with the option to terminate the doctor-patient relationship if what the patient is asking the physician to do the physician considers morally wrong. California law would support such an action and the moral basis for the action. However, every physician leaving a case must make an active and honest attempt to find another physician to take over the case and respond to the patient's request. Otherwise, leaving the patient without that could represent abandonment.

In case 2, I doubt that an anencephalic infant with zero cortical brain tissue can be compared to an infant with hydrocephalus whose cortical tissue, as I understand it, is compressed but present. I am not sure how their potential for brain function can be compared. But let's say that the infant's pathology is such that no awareness nor intellectual brain function will ever be present and that, as with anencephalics, the infants life span is severely limited. How does the ethicist resolve the conflict between the mother's and father's separate philosophy and needs? What does the clinical ethicist have to do? What options are available? ..Maurice.

With regard to Case 1, of course a patient can discharge a physician anytime the patient desires. No physician will continue treatment without the patient's consent since that could represent legal battery. But when the patient initiates the break in the relationship because the physician will not act as the patient desires, the physician would not be expected to continue the relationship against the patient's will. The physician's leaving in this situation does not represent abandonment. In this case, however,I still would expect the physician to be humanistic enough to attempt to help to find the patient a replacement physician though the physician wouldn't be required by law to do so.

I also must point out in Case 2 and all the cases, if one is playing the role of a clinical ethicist, a clinical ethicist faced with a clinical ethical conflict, the personal biases or personal moral or religious views of the ethicist must not be an element in the mediation of the conflict between stakeholders or in the facilitation of the decision to be made by the stakeholders themselves. What I am saying is that whether the ethicist personally agrees or disagrees about issues such as abortion, euthanasia, homosexuality or any other controversial issues has no part in the consultation effort by the ethicist. The responses of the ethicist must be based on the facts provided and the principles of ethical analysis, ethical consensus and the current laws. Ethicists are not physicians (even if they have an M.D. degree) nor are they one of the stakeholders in a conflict. They cannot make their own medical diagnosis or prognosis but listen to physicians who have that capacity. They cannot be a patient advocate as may be the physician, nurses or family. In answering the challenge of this Medpedia question, in each of the 4 cases, this understanding of the capacity and role of the ethicist should be kept in mind. ..Maurice.

In response to Johannes last comment regarding treating or not treating the anencephalic child, to some, the decision to watch death to occur is a severe emotional pain and to others it represents a great relief. But for the clinical ethicist, the duty is not to weigh one feeling above the other as more ethical but to understand that both feelings are worthy of attention and that the goal of the ethicist is to help the parties with conflicting feelings to arrive at some decision they can live with. For example, the mother and father, after meeting with the ethicist, might decide to have the infant treated energetically for a week but if there is no improvement to stop and let nature take it's course. Thus, despite whether the ethicist has one feeling or the other regarding watching the infant die, the ethicist will have performed his or her duty by bringing the surrogates closer together so that they, not the ethicist, can exercise their responsibility to make the final decision. ..Maurice.

Johannes, your conclusion to Case 3 ("no one knows if a life, limited in advance to 15 years, is less meaningful") is certainly valid. Without additional information regarding the genetic characteristics of the disorder nor whether the current fetus is even affected, it is hard to respond to this made-up case. This is an example where in a clinical situation the ethicist really can't advise the physician unless the physician as well as the ethicist knows all the pertinent clinical facts. If the parties involved have inadequate information regarding the disorder itself and no information regarding the genetic status of the fetus, the ethicist cannot provide answer the physician's concerns regardless of the physician's views about abortion. One of the facts would be what the woman was told and then understood as the nature of the genetic disorder affecting both her living children. What information gave her comfort or motivation for a second pregnancy and then with the resultant two children with the disorder led her to a third pregnancy? Ethical decision making is not automatic and still requires facts. ..Maurice.