• ethics
• medical ethics
• palliative care
• communication

In this issue of the journal, philosopher Frances Kamm1 analyses and criticises in detail a set of highly influential US documents/guidelines and research studies relating to end-of-life care and advanced care planning. These documents, written by a diverse group of experts working in and around palliative care, were designed to address widely recognised problems in care of the dying in the USA. Writer and surgeon Atul Gawande2 has powerfully described what he calls the ‘modern tragedy’ of a ‘system of technological medical care [that] has utterly failed to meet the needs’ of dying patients.i

The documents analysed by Kamm are not the sort of thing that usually elicit ethical analysis. They are not endorsing withdrawal of artificial nutrition and hydration at the end of life. They do not delve into elective ventilation, terminal sedation or assisted suicide, or other controversial choices at the end of life. Instead, the various documents attempt to identify and recommend evidence-based initiatives in end-of-life care. Several of them focus on ways to encourage and improve patients’ conversations about their preferences for medical treatment towards the end of life. We might be tempted to wonder what could be wrong with that? What does philosophy have to contribute to these topics?

However, as Kamm makes clear in her paper, documents like these are sometimes ambiguous about the concepts that they invoke and they make assumptions that could be challenged. They also lead to (although they do not always appear to recognise) potential conflicts between different …