This report addresses the ethical issues involved in decisions to initiate and terminate treatment. A general framework is constructed and then two illustrative cases are discussed. The framework is developed in three stages. First, the issue of guiding ethical principles is examined, with a multiple-principle approach being adopted. Second, common models of the care-giver/patient relationship (warrior, parental, contractual, covenantal) are identified, and their varying impacts on treatment decisions are explained and assessed. Third, specific criteria for determining when to initiate and terminate treatment are introduced. Two criteria (willingness and medical benefit) are commended in the context of initiating treatment, while three distinctions (willing v unwilling, passive v active, and terminal v nonterminal) are found to be particularly helpful when deciding if treatment should be terminated. Two illustrative cases involve end-stage renal disease (ESRD). The first describes a noncompliant and abusive intravenous (IV) drug user on hemodialysis who wants to continue on dialysis and eventually receive a living-related donor kidney transplant. The second describes a patient's decisions to refuse feeding gastrostomy and jejunostomy, any further surgical or diagnostic intervention, and eventually dialysis—though only after a period of time when he wants dialysis alone to continue. © 1990, National Kidney Foundation, Inc.. All rights reserved.
