Daniel Sulmasy

Unrealistic optimism is a bias that leads people to believe, with respect to a specific event or hazard, that they are more likely to experience positive outcomes and/or less likely to experience negative outcomes than similar others. The phenomenon has been seen in a range of health-related contexts—including when prospective participants are presented with the risks and benefits of participating in a clinical trial. In order to test for the prevalence of unrealistic optimism among participants of early-phase oncology trials, we conducted a survey with patients over 18 years of age who were enrolled in a phase I, phase I/II, or phase II clinical cancer trial in the New York City area between August 2008 and October 2009. Participants in our study were asked to compare their own chances of experiencing a range of risks and benefits related to the trial they were enrolled in with the chances of the other trial participants. We found a significant optimistic bias in their responses. Respondents tended to overestimate the benefits of the trial they were enrolled in and underestimate its risks. In addition, we found no significant relationship between respondents’ understanding of the trial’s purpose and how susceptible they were to unrealistic optimism. Our findings suggest that improving the consent process for oncology studies requires more than addressing deficits in understanding

The determination of brain death is challenging, and positions regarding its conceptual validity vary. Borrowing from the children’s story of Goldilocks, we classify the various positions regarding brain death into three categories. First, a complete acceptance of the current AAN guidelines, a position that does not adhere to the legal standard of whole brain death (too cold). Second, abandonment of the concept of brain death as a falsity concocted to permit access to organs for transplantation (too hot). We propose a middle ground (just right), clarifying why whole brain death is a biophilosophically sound standard for declaring death, offering critiques of the new guidelines, and making suggestions for increasing certainty that this standard has been met.

In 2023, the National Heart, Lung, and Blood Institute (NHLBI) organized a workshop to identify research gap areas in organ donation after circulatory determination of death (DCDD). We present the findings of the DCDD ethics working group. Heart DCDD, as all DCDD, may disrupt optimal end‐of‐life care. Irrespective of organ donation, research opportunities include identifying which processes of withdrawal of life‐sustaining therapy offer optimum patient comfort, how best to ensure patient comfort at the end of life, and how to better understand patients' preferences for end‐of‐life care. Whether heart DCDD breaches the Dead Donor Rule (DDR) depends on its interpretation, the validity and rationale of the determination of death, and the DCDD protocol used. Further research could clarify the interpretation of the DDR, the concept and determination of death, the time the cessation of brain function ensures that the patient is beyond neuro‐cognitive harm, the implications of thoracoabdominal normothermic regional perfusion on the determination of death and on brain functions, and the type of consent and level of information required for different DCDD techniques.

Towards the end of the last century, bioethics underwent an “empirical turn,” characterized by an increasing number of empirical studies about issues of bioethical concern. Taking a cue from the evidence-based medicine movement, some heralded this as a turn toward evidence-based ethics. However, it has never been clear what this means, and the strategies and goals of evidence-based ethics remain ambiguous. In this article, the author explores what the potential aims of this movement might be, ultimately arguing that, while the development of good empirical research can and should aid in ethical deliberation, one ought to avoid assuming or suggesting that empirical studies themselves determine normative prescriptions and proscriptions. The limits of the use of empirical studies in bioethics are explored in detail, and 10 potential ways that such studies can soundly contribute to bioethics are described. Good ethics depends upon sound facts, but ethics cannot be based on evidence alone.

Aim: Patients with advanced cancer need information about end-of-life treatment options in order to make informed decisions. Clinicians vary in the frequency with which they initiate these discussions.Patients and methods: As part of a long-term longitudinal study, patients with an expected 2-year survival of less than 50% who had advanced gastrointestinal or lung cancer or amyotrophic lateral sclerosis were interviewed. Each patient’s medical record was reviewed at enrollment and at 3 months for evidence of the discussion of patient wishes concerning ventilator support, artificial nutrition and hydration, resuscitation and hospice care. A Kaplan–Meier analysis was also performed and 2-year survival calculated.Results: 60 cancer and 32 ALS patients were enrolled. ALS patients were more likely than cancer patients to have evidence of discussion about their wishes for ventilator support, ANH, DNR and hospice care. At 6 months, 91% of ALS patients were alive compared with 62% of cancer patients; at 2 years, 63% of ALS patients were alive compared with 23% of cancer patients.Conclusions: Cancer patients were less likely than ALS patients to have had documented advanced care planning discussions despite worse survival. This may reflect perceptions that ALS has a more predictable course, that advanced cancer has a greater number of treatment options, or differing views about hope. Nevertheless, cancer patients may be less adequately prepared for end-of-life decision-making.

OBJECTIVES: To study the accuracy of reviewing ward notes (chart review) as a measure of the quality of care rendered to patients with "Do Not Resuscitate" (DNR) orders. DESIGN: We reviewed the charts of 19 consecutive, competent inpatients with DNR orders for evidence that the staff addressed a broad range of patient care needs called Concurrent Care Concerns (CCCs), such as withholding treatments other than resuscitation itself, and attention to patient comfort needs. We then interviewed the patient, consultant physician, house officer, and primary nurse and compared the ward notes with the understandings of these staff members. SETTING: The medical service of an urban university medical centre. RESULTS: The average number of documented CCCs addressed per DNR order was 1.1. The ward notes generally agreed with the perceptions of patients, house officers, and nurses (% agreement with notes = 79%, 77%, and 82%; kappa = 0.43, 0.40, 0.50). Consultant physicians' understandings were poorly reflected in the ward notes (% agreement = 59%; kappa = 0.18). They overestimated attention to CCCs compared with the notes (P < 0.0001) and with other observers (P < 0.0001). CONCLUSION: Chart review for attention to CCCs accurately reflects the understandings of patients, house officers, and nurses, but consultant physicians report more attention to CCCs than is recorded in the ward notes or understood by other observers. Better communication regarding end-of-life care plans should be encouraged

One major argument against prohibiting euthanasia and physician-assisted suicide (PAS) is that there is no rational basis for distinguishing between killing and allowing to die: if we permit patients to die by forgoing life-sustaining treatments, then we also ought to permit euthanasia and PAS. In this paper, the author argues, contra this claim, that it is in fact coherent to differentiate between killing and allowing to die. To develop this argument, the author provides an analysis of Saint Augustine’s distinction between martyrdom and suicide, highlighting the relevance of intention in the assessment of an agent’s actions. As a general matter of ethics, the intentions of agents, not just the outcomes of their actions, matter enormously for drawing distinctions between what is permissible and what is impermissible. Constructing an Augustinian account of this distinction between killing and allowing to die, the author argues that it is coherent to hold that assisted suicide is wrong, while also accepting that it is permissible to withhold or withdraw life-sustaining treatments.

Euthanasia and rational suicide were acceptable practices in some quarters in antiquity. These practices all but disappeared as Hippocratic, Jewish, Christian, and Muslim beliefs took hold in Europe and the Near East. By the late nineteenth century, however, a political movement to legalize euthanasia and physician-assisted suicide (PAS) began in Europe and the United States. Initially, the path to legalization was filled with obstacles, especially in the United States. In the last few decades, however, several Western nations have legalized euthanasia, and several US jurisdictions have now legalized PAS, giving state sanction to these once forbidden practices. With increasing social and political pressure to accept PAS, Christians need to understand how to think about this issue from an explicitly Christian perspective. Independent of the question of legalization, there are significant theological and ethical questions. This special issue aims to address those concerns, including: how does the practice of PAS or euthanasia impact our attitudes toward death, and what does it mean to “die well?” Should physicians, as healers, be involved in assisting patients who wish to bring about their own death? Are these methods significantly distinguished from other ethically justified practices in end-of-life care that also lead to a person’s death? Can Christians, both as patients and practitioners, justify the use of these methods to relieve suffering in this manner as compatible with the faith? Although these questions are not new to the debate, it is increasingly important that these controversies are addressed as the practice of PAS is popularized.

New Natural Law Theory and the Catholic medico-moral tradition often lead to similar conclusions in hard cases regarding end-of-life care. Considering the provision of artificial nutrition and hydration to patients suffering from post-coma unresponsive wakefulness, however, brings to light subtle ways in which NNL differs from the centuries-old natural law tradition. In this essay, I formalize the methodology embedded within the casuistry of the medico-moral tradition and show how it differs from NNL with respect to the role played by double-effect reasoning and the perspective for analyzing cases regarding care for those who cannot speak for themselves. Importantly, the ordinary/extraordinary means distinction has never historically been understood as an application of double effect and logically cannot be so understood. Given the outsized role that double effect plays in NNL, the theory leads to conclusions that deviate from the Catholic medico-moral tradition and creates additional burdens and duties for the sick.