I read the case and response with great interest. I think the problem is real and one that is often dismissed by what I have come to call " moral numbness". You allude to it in your comments about a lack of insight and adaptation to what has become a "normal" event in the life of health care providers. It is not a "normal" event in the life of the patient forced to participate in an event that was, for him, traumatic. The current health care system perpetuates the problem. Staff is often short and the focus has become more one of completing an overwhelming load of care "tasks" in a cost and time efficient manner. The holistic care of the patient has become more rhetoric than fact. Certainly, to transfer the dying patient to a private room would be ideal. However, in the current institutional climate, it would be unlikely to occur. The cost of a private room is higher - it requires paper work both for the shift and for billing - insurance may not cover a private room - moving patients around as was once the norm, is now considered a costly and inefficient process. Justice is focused more on distribution of goods than what is fair for the individual involved.

I was struck by the fact that there is no mention of any family member being with the dying patient. Patients in the past have told me that they were less stressed by the fact that a roommate was dying than that he/she was dying alone. No family member was present and nurses tended to shy away from the room of dying patients. The living patient felt isolated from care and trapped in a vigil with one who had to die alone without the ability to even get up and go hold the person's hand. I often wonder if older patients are less afraid of death than of dying - dying in a strange place, among strangers, isolated from loved ones. To witness that is to fear for the circumstances of one's own demise.

I would like to see nurses enter the room of the dying more often to offer comfort, and support both to the dying and to the living. We cannot be sure that the dying person does not sense the presence and compassion of another even when he/she seems to be unresponsive. Surely the caring behavior is communicated to the living and offers beneficent hope that they may look forward to the same compassion.

I believe autonomy is lost in many ways in the hospital, some that affect this patient as well. William May discusses the fact that in past times, health care went to the domain of the patient - that is, care was delivered primarily in the home and only the poor went to hospitals. Now the reverse is true (though that is changing, too). Now the patient comes to our domain where she/he is often instrumentalized and certainly is placed in an environment where decisions are often made for the convenience/efficiency of the institution rather than based on the needs of the patient. It is Kant who reminds us to avoid this instrumentalization. So treat every person as an end in himself, never as a means to an end. Do not expect the patient to hand over all control of his/her destiny to others; do not remove choice and decision making; do not baffle and confuse them with the events of the institution suffered in isolation and without adequate explanation. As May puts it, the patient's world has already been diminished to one room - and that room has been visited by death and both patients left to deal with it in isolation.

I certainly applaud the option of spending time with the living patient to deal with the events and would tend to call the chaplaincy to seek spiritual support for both patients. I don't believe we attend to the spiritual aspects of patient care as well as we might.

I was unable to follow the connection between the euthanasia reading and this case. It seemed a stretch to me while the Chambliss link was interesting. The reference to individual vs social moral issues was especially important. I believe this case has overtones of both. It was certainly individual for the two patients. But perhaps we have become too individual in our pursuit of rights and entitlements; we have lost the spirit of community. The sense that we are all a part of a larger group that must care about and look to the good of the whole and of the individual members of the whole. Certainly there was nothing presented in this case that suggested a sense of community or commitment to a common good. The dignity of man should be a common good in my view both in the collective and at the individual level. Dignity, respect, beneficence, autonomy, and justice were all violated in this case in my view.