MEDicine or MADness

To the Editor: In his recent Commentary on hastening death in terminally ill patients,1 Hunt may not have fully appreciated a very cogent point made in the research by Douglas and colleagues.2 The surgeons surveyed clearly reported the intent of their prescribing. This is contrary to Hunt's assertion that "Intention is inherently subjective . . . complex [and] ambiguous". Some surgeons gave a dose appropriate to the symptoms, others deliberately increased the dose beyond direct symptomatic control, and a few deliberately ended life, at times with no explicit request. As Douglas points out, the dose of a medication given will be an important clue in this. Good clinical practice is about minimum effective dose (MED), not maximum administrable dose (MAD). This is the case for all patients, whether they are near the end of life or not.