lose viability, but it's unclear what David's wishes were.

The ethics consultants authorized the harvesting to preserve the option of using the sperm and then they deliberated. They ultimately decided that since David had never expressed his wishes in writing, his wife did not have a right to use his sperm. Since then, the committee has helped the ob-gyn department craft a policy that addresses such issues ahead of time.

Caroline, a 67-year-old woman, is dying of cancer. Her caregivers have recommended stopping aggressive treatment and providing only comfort care. Caroline had signed both a durable power of attorney for health care and a power of attorney for financial matters, naming her husband as her proxy in both. Her husband understands her status but would like to have her kept alive a few more days so he can finish some financial transactions.

The ethics team ended up advising Caroline's husband that it wasn't in her best interest to be kept alive for such a purpose. Her husband agreed, and aggressive treatment was discontinued.

Simon, an 85-year-old man, has had a major stroke and is unconscious. He has "DNR" tattooed on his chest. His caregivers aren't sure whether that serves as an adequate reflection of his wishes.

The ethics team, too, felt it was unclear, in case Simon had changed his mind since getting the tattoo. So, because Simon had a durable power of attorney for health care, they recommended that his caregivers confirm the decision with his health-care proxy. Simon's proxy agreed

Marie Bakitas: There's no mandated training about end-of-life care

Ronald Green, an adjunct DMS professor and faculty director of the Dartmouth Ethics Institute, was on a 1994 blue-ribbon panel convened by the National Institutes of Health to study human embryo research.

Ethics consults have helped many people, but the team isn't called in as often as it might be—in part because some health-care providers are so focused on curing illness and fixing injury, at any cost, that they can't face offering less than the most aggressive treatment.

that the DNR order, as unorthodox as it was, should stand.

Peter, an infant who'd suffered severe abuse, is near death in the pediatric intensive care unit. One of his parents, the alleged abuser, wants a say in Peter's care. If the baby dies, the parent could be charged with murder. But if he's kept alive, the parent might be charged only with assault. Should someone whose judicial fate hangs on a patient's survival be involved in making decisions about that individual's care?

There is still the very occasional perplexing case that cannot be decided by the parties involved, even with the help of an ethics consult. This was one of the few that ended up in the courts. In the end, however, the baby died before a judicial opinion was rendered.

None of the members of the DHMC Ethics Committee have formal degrees in ethics; it is a new enough field that degree-holding practitioners are only beginning to populate the nation's hospital ethics committees. But most of the DHMC committee members have taken advanced training in ethics or have been mentored in the discipline by others on the committee.

Committee members are concerned, however, that few in the medical profession have any training at all in ethics. Medical staff are rarely taught in any systematic way how to help patients and families deal with end-of-life issues—although they are required to learn CPR and other techniques used to extend life.

"I think that's great," says Marie Bakitas, agreeing it's appropriate for doctors and