New York State Task Force on Life and the Law. 288 pages. Albany, New York: Health Research Inc., Health Education Services; 1992. $9.00.

A State Commission's goal is to identify and conserve a new mainstream consensus by proposing to amend laws. When Others Must Choose is the seventh report by an influential Task Force convened by Governor Cuomo in 1985 and is a notable event in this genre.

The report addresses the troubling public policy issues that guide and constrain health care decisions for incompetent persons. Its circumspect and well-referenced analysis outlines major features of the current consensus, emphasizes the dominant canon, and respectfully notes minority views that shape, but do not dictate, public policy. The Task Force claims a middle ground between prudence and principle, which it defines as protecting patients from "poor decisions ... (by) policies that work in the context of medical practice."

These innovative legislative proposals rely on supervision within health facilities to keep decisions out of state agencies or courts. Two clinicians determine when a patient lacks decisional capacity (a patient's objection takes the issue to court). Two doctors may manage patients who are in danger of imminent death. Ethics committees are authorized to approve decisions for persons without families; to ratify doctors' decisions to accept family requests to forgo treatment for incompetent, nonterminally ill persons; and to resolve disputes between surrogates. These safeguards would impose largely unreimbursed expenses on the health care system and would avert the cost and time involved in the use of courts or state agencies. No estimates of the extent to which these safeguards would change or improve current decision making, avert problems, or affect costs relative to present practices are given. None exist. The Task Force does not propose that they be determined, or how.

The report contains two laudable proposals for decision making for minors. The first would make parental surrogate authority equal that of surrogates for adults, thereby leveling the pre-emptive authority of neonatologists. The second would empower nonparental health care surrogates for foster children and fill a policy lacuna that otherwise defers to negligent or abusive parents.

The Task Force shies away from some ongoing controversies or uncomfortable topics. It skirts the illustrative debate about New York's O'Connor decision, in which a court dismissed previous statements about the "monstrous" use of life-sustaining technology by a woman hospital administrator who became demented. Obliquely referring to that verdict, the Task Force says that requiring "clear and convincing" evidence of the applicability of such preferences is "unworkable and inhumane, ... unrealistic and unfair." Its proposal, however, would subordinate the request by O'Connor's loving, middle aged, nurse daughter to forgo life-sustaining treatment to the judgment of an attending physician and an ethics committee, factors which precisely form the genesis of that dispute. The Task Force inexplicably fails to discuss the role of gay partners as surrogates for persons with the acquired immunodeficiency syndrome (AIDS). "Close friends" defer to family unless the family defers to them. Such examples suggest that the Task Force should seek broader community participation in its work.

This report has specialized appeal. This is not a text on medical ethics. The clinical cases are too thinly described, and students need to learn more about the foundations of our values. Its review of New York laws merits a reading in every health facility and ethics committee in that state. Outside New York, this report is a good model of ways in which to use experts and treatises to shape rational legislation.