Bloche on Managing Conflict at the End of Life
Professor Greg Bloche, Georgetown, has just published a perspective piece, “Managing Conflict at the End of Life”, in the New England Journal of Medicine. No abstract is available, but here are a couple of paragraphs from the article’s introduction:
Anger, denial, and other nonrational influences can lock family members into warring stances over whether to treat a devastating illness aggressively or discontinue life-sustaining measures. What is remarkable, given the intensity of the feelings at stake, is how rarely such conflicts make their way to court. It is a measure of how discreetly such squabbles are handled that we know little about how often they arise. And it is a measure of people’s character under this pressure that families usually come together to make these judgments or to honor the preferences their loved ones have expressed.
This is for the good: to rend families asunder at the end of a loved one’s life does spiritual violence to all concerned. Within wide boundaries, we are committed to honoring patients’ clearly stated wishes. This commitment not only safeguards patients’ liberty and dignity; it protects against family strife when a patient’s intentions are clear. When the patient’s wishes are unstated and illness precludes asking about them, it is important to limit the possibilities for family conflict and lasting anger. Enabling families to mourn and move on — and discouraging them from playing out old resentments as end-of-life battles — should be a clinical and social priority.
The law can help to pursue this goal by making it difficult for any one party to impose a decision when family members or others concerned disagree with it. Answers dictated by the law yield clear winners and losers, heightening long-term resentments and inviting further strife. A large literature suggests that solutions crafted by the parties to a conflict come with a sense of shared ownership that dampens discord.1 By making it harder to invoke a court’s final say, law can encourage conversation aimed at reconciliation or, at least, mutual accommodation. The proposition that law should promise quick, clear answers is a recipe for intensified family and social strife, since we are nowhere near national consensus on what the answers should be