End-of-life decision-making in the United States.

Decision-making at the end-of-life in the United States has evolved over the last 50 yr, beginning with the development of the concept of brain death as a criterion for permitting patients who are in a state of 'irreversible coma' to be considered as 'dead' for purposes of ventilator withdrawal and organ transplantation. Since then, a firm consensus has emerged in American law and ethics that 'Patients have a virtually unlimited right to refuse any unwanted medical treatment, even if necessary for life itself.' With regard to patients who are unable to make decisions for themselves, both Europe and the United States are converging toward a view that respects a role for surrogates in decision-making while recognizing the need to limit their authority. Beyond decisions to withdraw and withhold treatments, both the United States and Europe are experimenting with active hastening of the dying process through euthanasia and physician-assisted suicide. In the author's opinion, the next big question to be addressed in end-of-life decision-making is 'Just how bad does the neurological condition and prognosis need to be before it is acceptable to allow a decision to withdraw life support'? Although the practices described here have wide acceptance throughout the United States and Europe, the worldwide emergence of religious fundamentalism and the associated vitalistic view about the sanctity of life may result in significant changes over the next few decades.