The interests of patients have changed dramatically through time. In the medieval period, the church proscribed medical treatment by Christians. Religious orders were involved with caring for the sick, but this was palliative care intended only to smooth the transition into heaven. Life was seen as a veil of tears to be passed through, not an end in itself. Modern notions of prolonging life would have been considered blasphemous. (As is usually the case, these prohibitions fell mostly on the poor. Wealthy individuals and the nobility often had Jewish or Muslim court physicians.)

During the period between the development of modern medicine and the advent of life-support technologies, patients’ interests shifted to curative, rather than merely palliative, care. After World War II, the U.S. government began to subsidize and otherwise encourage the construction of hospitals and the training of physicians. Technology became more important in medical practice, and private medical insurance companies proliferated as employers saw medical insurance as an attractive and inexpensive employee benefit. This trend continued through the 1950s, with technology-based medicine becoming the norm in the 1960s.

Two events in the 1960s had direct bearing on the problem of artificial prolongation of life. The first was the maturation of technology and its integration into routine practice. Ventilators, cardiac monitors, and other life- support devices were improved and became widely available. Physicians became comfortable with these devices and learned how to optimize their effectiveness through better infection control and nursing practices. The second event was the introduction of Medicare and Medicaid. Medicare was particularly important because it removed many of the cost constraints on the care of elderly patients, the class of patient most likely to need life support. This ushered in the era of patient demands for all possible medical technology.

The growth of technological medicine was accompanied by a developing concern for patient autonomy. The strongest force shaping demands for autonomy was the Nuremberg trials of the Nazi war criminals, which documented the medical experiments performed by physicians. Although directed at medical experimentation, the resulting Nuremberg doctrine set out the rights of patients to determine freely the course of their medical care. As discussed earlier in this section, the Nuremberg Code is the root of the informed consent doctrine. Patients’ concerns with the right to make an informed choice of care began to include a concern for the right to refuse care as the risk of being reduced to a persistent vegetative state became better publicized. [Cranford RE. The persistent vegetative state: the medical reality (getting the facts straight). Hastings Cent Rep. 1988;18:27; Brody BA. Ethical questions raised by the persistent vegetative state patient. Hastings Cent Rep. 1988;18:330; and, Wikler D. Not dead, not dying? Ethical categories and persistent vegetative state. Hast Cent Rep. 1988;18:41.]