Dr. Mitchell T. Rabkin '51, general director of Beth Israel Hospital and associate professor of Medicine, says, unlike most of his colleagues, that "the Saikewicz decision was a wise one." But he, too, feels that doctors read the ruling too strictly--that every time one wants to withhold treatment from incompetents, one must seek the court's approval. Rabkin feels this is not appropriate for a dying patient.

A lower court has gone ahead and clarified the Saikewicz case in last year's Shirley Dinnerstein decision. On June 30, 1978, the Massachusetts Appeals Court ruled that Saikewicz dealt with a case where there was a reasonable chance of prolonging or saving life; in the case of Dinnerstein, however, treatment would have been "a mere suspension of the act of dying," the court said. The case of a patient near death such as Dinnerstein presented "no significant treatment choice or election" because "attempts to apply resuscitation, if successful, will do nothing to cure or relieve the illnesses which will have brought the patient to the threshold of death."

The court became the first in the nation to uphold the withholding of emergency treatment from irreversibly, terminally-ill in-competent patients who suffer caridac or respiratory failure. The decision held that doctors have the final say on the right-to-die of these patients.

As Rabkin comments, "It said, 'look fellows, you practice medicine.'" Doctors now feel free to treat terminally-ill incompetents without court interference and they are relatively free to define irreversible terminal illness. Yet, a survey of practices in local hospitals reveals that the Saikewicz experience has served its purpose in making hospitals and doctors more careful about the right-to-die decisons.

Beth Israel Hospital is working on "articulation of our own policy," according to Rabkin. It is trying to determine criteria for competence, and incurable illness. And the hospital staff is closely examining the decision process, "bending over backwards" to preserve the rights of patients and to consider opinions which "cannot be dismissed." In most cases the hospital will respect the wishes of the family, except when "the family asks for something medically unrealistic," Rabkin says.

Massachusetts General Hospital (MGH), according to Martin S. Bander, deputy to the general director, has established two categories of incompetent patients--those who are "imminently, terminally ill" and those who are terminally ill but for whom death is not imminent. The definition of imminence is dependent on a "combination of circumstances depending on the illness," Bander says.

For the first type of patient, for whom death is thought to be imminent, it is possible to stop treatment if the family wishes. For the other type of patient, MGH still resorts to the courts if the doctor and family feel the patient should be "treated selectively rather than aggressively." In all situations, the family's wishes are respected and heeded despite disagreement with a doctor.

So, it now seems that doctors are using the court rulings as guidelines in making their decisions. But not everybody is satisfied. The suspicions of lawyers and doctors are still apparent. "The better solution is to have a system of review which involves some people other than those involved in the case," Stone says.

And Relman adds, "I think in this whole series of court cases, doctors have been made more cautious, and that is not necessarily a good thing." He adds that "the emphasis is in the wrong place here." He feels courts can play a role in ensuring that doctors act responsibly, by maintaining high standards in performance and education. "Doctors are the people whom society ought to be able to count on to consider the welfare of the patient. And if not, they ought to be held accountable," Relman says.

The debate between doctors and lawyers threatens to heat up once again as a more significant case looms on the Supreme Judicial Court's docket. The court is scheduled to hear oral arguments in September in Hall v. Myers, a case that deals with the appropriateness of euthanasia for any patient, competent or incompetent. It involves a prisoner on renal dialysis who wanted to stop his treatments and be allowed to die. The Suffold Superior Court has ruled that the prison commissioner could force the prisoner to keep taking his life-saving treatment.

The Supreme Judicial Court will now have to develop a balancing test to determine when the individual's right to privacy outweighs the state's interest in preserving the sanctity of human life. And the court must once again address the prickly question, who should pull the plug? Should the court provide doctors a guideline for dealing with patients who refuse treatment, or should it require adjudication of all right-to-die cases? The court's answer could lead to another stormy chapter in the effort to resolve the dilemma that Karen Ann Quinlan first triggered.