even more rigorous and absurd years ago it was better then? I hope not. There comes a point after 36 hours on call that one cannot learn anything from patient contact. Rather, such exhaustion is antithetical to proper learning. I would remind the good doctor that medical training is supposed to teach. It should not be a test of one's ability to withstand torture. In short, I am saying that there is no valid educational reason for interns and residents to work such ridiculous hours. Unfortunately, a number of senior physicians in every hospital take the "old war horse" view of medical training: "We had to go through it, so you do too! (said with a note of triumph for effect). The logic of such an idea has always escaped me. Perhaps it is due to the kind of reactionary recalcitrance that has dogged the civil rights movement for so long in the southern United States. Just as some people still think of blacks as slaves, some staff people still think of house staff in a similar light. Tragic. The wrongs of the past do not excuse ongoing stupidity in the present. I quite agree with Hershfield that medical training should teach us that we are bound to fail. I certainly learned that lesson early on. In my article I was referring to the pedestal our entire profession has been put on; that is, we are considered "high priests" of our technocratic society. I have no delusions of grandeur in my own regard. And, yes, my neurosurgery rotation was a very humbling experience. Still, it is hard to unlearn the egotistic pride inculcated in medical students from their first day of classes and reinforced daily throughout early training. With regard to postponement of gratification, Hershfield misconstrues my meaning. I was not referring to postponing monetary or materialistic gratification. I meant that it takes years to get to the point of independent practice, 796
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when we can finally assume the duties of the profession for which we sacrificed so much. In other words, we must postpone being physicians for a very long time. Of course, this is right and proper: good training must come first. None the less, anyone going into medicine must by nature be a bit of a masochist to put up with the rigours of protracted training for a very distant goal. As for Hershfield's statement that I should be gratified at having more from the materialistic point of view than 99% of the world's population, I can only respond that I never entered medicine for such a mundane reason, and I do not embrace such an outlook now. In fact, the world could never pay me enough to be a physician if I did not already have a desire to put my gifts and talents to good work for my fellow human beings. No, Dr. Hershfield, I am a physician to serve God, not mammon. David G.C. McCann, MD 108 Circular Rd. St. John's, Nfld.
Should living wills be legalized? he primary point that should be at issue in this article (Can Med Assoc J 1990; 142: 23-26), by Drs. Rory H. Fisher and Eric M. Meslin and I do not think it is well stated - is the right of the individual to autonomy. This moral right, recognized in Canadian law, entitles the competent adult to decide which medical procedures may be performed upon his or her body. In my opinion this right should be extended so that individuals, while competent, may give legally enforceable direction on what may be done to them if they become incompetent. This is the "living will" situation, no-
where in Canada legalized. A possible alternative is the "durable power of attorney", which confers this decision-making authority upon another designated person. Among the Canadian provinces only Nova Scotia has legislation about this matter, and it was enacted so recently that its effect cannot yet be evaluated. Fisher and Meslin are correct that living-will legislation in the United States has been difficult to draft and to enforce and has not always achieved the desired effect. Canada is very different from the United States in its attitude to law, and the fact that a living-will law works poorly in the United States does not necessarily mean that it would not work in Canada. What we should be concerned with is ensuring that our right to individual autonomy does not cease when we become incompetent and that we are not forced into a situation of paternalism and of submission to procedures that we would reject were we competent. I do not think that the presumptively benevolent paternalism advocated by the authors addresses this principle. Harry E. Emson, MD Professor and head Department of Pathology University of Saskatchewan Saskatoon, Sask.
[Drs. Fisher and Meslin reply.] We agree wholeheartedly with Dr. Emson about the right of the individual to autonomy in deciding which medical procedures may be performed upon his or her body. However, this was not the primary point of our article. We were addressing whether the legalization of living wills would be a helpful move in respecting patient autonomy and improving the management of terminally ill patients. We note the advantages of living wills in permitting advance expression of a patient's wishes,
CAN MEDASSOCJ 1990; 142(8)
when we can finally assume the duties of the profession for which we sacrificed so much. In other words, we must postpone being physicians for a very long time. Of course, this is right and proper: good training must come first. None the less, anyone going into medicine must by nature be a bit of a masochist to put up with the rigours of protracted training for a very distant goal. As for Hershfield's statement that I should be gratified at having more from the materialistic point of view than 99% of the world's population, I can only respond that I never entered medicine for such a mundane reason, and I do not embrace such an outlook now. In fact, the world could never pay me enough to be a physician if I did not already have a desire to put my gifts and talents to good work for my fellow human beings. No, Dr. Hershfield, I am a physician to serve God, not mammon. David G.C. McCann, MD 108 Circular Rd. St. John's, Nfld.
Should living wills be legalized? he primary point that should be at issue in this article (Can Med Assoc J 1990; 142: 23-26), by Drs. Rory H. Fisher and Eric M. Meslin and I do not think it is well stated - is the right of the individual to autonomy. This moral right, recognized in Canadian law, entitles the competent adult to decide which medical procedures may be performed upon his or her body. In my opinion this right should be extended so that individuals, while competent, may give legally enforceable direction on what may be done to them if they become incompetent. This is the "living will" situation, no-
where in Canada legalized. A possible alternative is the "durable power of attorney", which confers this decision-making authority upon another designated person. Among the Canadian provinces only Nova Scotia has legislation about this matter, and it was enacted so recently that its effect cannot yet be evaluated. Fisher and Meslin are correct that living-will legislation in the United States has been difficult to draft and to enforce and has not always achieved the desired effect. Canada is very different from the United States in its attitude to law, and the fact that a living-will law works poorly in the United States does not necessarily mean that it would not work in Canada. What we should be concerned with is ensuring that our right to individual autonomy does not cease when we become incompetent and that we are not forced into a situation of paternalism and of submission to procedures that we would reject were we competent. I do not think that the presumptively benevolent paternalism advocated by the authors addresses this principle. Harry E. Emson, MD Professor and head Department of Pathology University of Saskatchewan Saskatoon, Sask.
[Drs. Fisher and Meslin reply.] We agree wholeheartedly with Dr. Emson about the right of the individual to autonomy in deciding which medical procedures may be performed upon his or her body. However, this was not the primary point of our article. We were addressing whether the legalization of living wills would be a helpful move in respecting patient autonomy and improving the management of terminally ill patients. We note the advantages of living wills in permitting advance expression of a patient's wishes,
