ETHICS ON CALL

A practical primer on how to safeguard your right to make your own decisions about medical care. With the assistance of health-writer Nimmons, Dubler, a Harvard-trained lawyer and clinical ethicist at N.Y.C.'s Montefiore Medical Center, shares her knowledge of how hospitals operate and what powerful forces influence health-care decisions today. To avoid dependency on ``the uncertain kindness of strangers,'' she recommends that patients use the procedure developed by her ``ethics SWAT team'' to help resolve issues: first, clarify the medical facts; next, find out the possible options and their consequences; then, understand how the options fit one's own personal values. Ideally, decisions are made by the patient, but, as Dubler stresses, in the real world of modern medicine this is often not the case. In fact, life-and-death decisions may be made by concerned but uncertain and confused family members, by professional caregivers whose priorities are not the same as those of the patient, or even by courts and bureaucrats. The issues in many of the case studies Dubler describes are familiar—the right to refuse care, the right to die, the rights of parents over the care of their children, the right of access to scarce resources, such as organs for transplant or beds in an ICU—but Dubler presents them with a rare clarity. A staunch advocate of planning, she offers suggestions on how to gather needed information, how to examine your values with the help of a value-history form, how to document wishes in a living will and a videotape, and how to designate a proxy decision-maker. A superb guidebook to issues most of us would rather not think about—but should.