In this issue, Quill and Cassel [1] propose to alter this traditional interpretation by expanding the obligation of nonabandonment in an idiosyncratic and problematic way. They believe that this is necessary to make medical care more humane, personalized, and ethically responsive. They would subsume under the rubric of nonabandonment a large part of medical ethics, including care of the whole person, attention to the details of each patient's life and illness, and integration of insights from so-called alternative theories of ethics now being discussed as antidotes to the excessive "abstractness" of principle-based ethics. This enlarged concept of nonabandonment, they argue, entails the physician's long-term commitment to care, especially when patients are terminally or chronically ill.

There is little to quarrel with in Quill and Cassel's call for medical care that is more ethically responsive to patient needs and that makes satisfaction of those needs a moral obligation. Many educators, clinicians, ethicists, behavioral scientists, and patients have justifiably lamented the neglect of these needs in contemporary care. The central questions are whether all the neglected dimensions of care can be subsumed under the rubric of nonabandonment, whether that rubric is sufficient as a primary moral imperative, and whether it helps in a practical or theoretical way to advance the kind of care that Quill, Cassel, and many others believe is owed to patients.

On closer scrutiny, Quill and Cassel's proposal is probably self-defeating for several reasons: 1) It dilutes the traditional interpretation of abandonment in a dangerous way; 2) it raises nonabandonment to the level of a principle and defeats Quill and Cassel's attempt to counter principlism; and 3) of itself, nonabandonment is an insufficient and confusing foundation for an ethics of the physician-patient relationship.

Quill and Cassel's proposal sweeps up so much of medical ethics that it would be hard, if not impossible, to say what could not be included. As a result, the moral force of the traditional legal and ethical interpretation of abandonment is diluted. As it now stands, abandonment is a clear and specific infraction of law and ethics that deserves both public and professional obloquy. In the expanded concept, abandonment would become one end of a spectrum of moral infractions of varying degrees of seriousness. What part of the spectrum would be morally obligatory, what part optional? Where would the line be drawn between the legal and the ethical obligations and culpability?

There is already a growing tendency to introduce the allegations of ethical misconduct into ordinary malpractice cases. Law does not usually require beneficence. How far into the proposed moral obligations would legal liability extend? Is the failure to include all significant details of a patient's life story in the physician's deliberations equivalent to refusing to respond to the call of a dying patient whose treatment is no longer clinically effective?

Is an elasticized conception of nonabandonment necessary in the first place? The traditional concept of nonabandonment already requires the long-term commitment that Quill and Cassel see as requisite once the physician and patient enter into a relationship. Frequently, the issue is not nonabandonment but rather the quality of caring and of sensitivity to the changing needs of patients and the will to help patients cope with their illness when they are beyond the powers of medicine.

Some of this is shown in the two cases the authors use to illustrate nonabandonment. In Cynthia's case, Dr. Quill's actions conformed with current models of medical ethics. He recognized the well-established rule that fully competent patients may refuse artificial nutrition and hydration and that physicians are bound to comply or withdraw from the case. In Mrs. K's case, Dr. Cassel did what a good physician should do. She addressed Mrs. K as a person. She recognized the limitations of medicine but was sensitive to the importance of personalizing her treatment to accommodate patient needs. Drs. Quill and Cassel responded as sensitive and beneficent physicians should.

Expansion of the concept of nonabandonment seems unnecessary. It adds nothing that is not deducible from traditional ethical principles [2-4]. What needs emphasis is that the ethics of medicine already demands the type of treatment Mrs. K and Cynthia received. Calling this nonabandonment is correct but superfluous and somewhat confusing.

Another problem is that nonabandonment, far from countering the abstractions of principles, must itself become a principle if it is to fulfill the many ethical obligations Quill and Cassel ascribe to it. A principle is that from which something proceeds. A moral principle is the most universal statement of moral obligation or the source of a moral obligation from which rules, duties, or other principles can be derived. The expansion of nonabandonment as described by Quill and Cassel would fit this definition. But by making nonabandonment a principle, they defeat one of their aims, which is to remedy the abstractness of principles.

Every moral act is a particular act, and as such the diversity of its concrete details is almost infinite. The issue is not the elimination of concreteness by resorting to principles. To be sure, alternative theories such as casuistry and narrative, hermeneutic, virtue, or caring ethics enrich ethical decisions and behavior through attention to intimate and concrete details. But these details cannot justify themselves. For that, they need the bedrock of a principle. The conceptual challenge in ethics is always to determine how to link the particular and the general, how to place principle-based theories into some ordered relation with the concrete details of individual cases. An ethic of nonabandonment does not do this. If nonabandonment becomes a principle, it shares the criticism levelled at all principles; if it remains an ethic of detail, it is descriptive but not normative.

Quill and Cassel treat nonabandonment as if it had the status of a prima facie trumping principle. As such, it faces the difficulties of any such principle: How is the principle itself justified? Is it derived from a more fundamental principle? Nonabandonment, like beneficence, autonomy, or justice, needs more fundamental grounding. For example, a physician could make a long-term commitment to care for a patient but could violate other principles such as beneficence or autonomy. Simply committing oneself to long-term involvement does not assure caring in the fullest sense. By itself, the idea of nonabandonment does not allow us to derive the rich content of obligations Quill and Cassel attribute to it. Some would argue that the source of these obligations must be grounded in the phenomenologic nature of the healing relationship [5].

The most serious objection to Quill and Cassel's formulation is to their suggestion that, in this interpretation of nonabandonment, assisted suicide and active euthanasia might be justified or even required. They find rule-based ethics "too rigid" to encompass the full meaning of beneficence and nonabandonment in certain dying patients. As a result, they recommend that physicians and patients face death "more boldly," "stretch the boundaries of rule-based ethics," and take "risks" when the clinical details demand it. By this, they open euthanasia and assisted suicide to the possibility of moral approbation.

Quill and Cassel assure us that the physician's conscience must be protected. But the fundamental place they assign to nonabandonment could be extended a step further to make hastening the patient's death a moral requirement. On the other hand, is it not a form of abandonment to intentionally cooperate in hastening death?

All of this is more moral freight than nonabandonment, as construed by Quill and Cassel, can carry. They define ethical principles by factual situation rather than seeing the principle as the justification for the moral quality of the act. This is part of a trend toward situational ethics that is gathering force in several of the alternative ethics theories now fashionable among certain bioethicists. It is a trend that threatens any notion of a moral structure other than the subjective notions of individual patients, physicians, or society.

In the end, nonabandonment is a derivative obligation. It is grounded in the nature of the physician-patient relationship. This relationship is based on a promise to act always in the interest of the patient, and it calls not only for technical competence but also for advocacy of the well-being of the patient as perceived by the patient. Here, the techniques of casuistry and hermeneutics and the ethics of virtue and caring are essential. These help the physician to discern the patient's interests and to be motivated to serve those interests. They help the physician discern how the normative principle is to be honored in this concrete case, but they cannot replace principles. Principle-based, person-based, and case-based ethics are all necessary. Principles are blunt instruments without details; details are blind guides without principles.

Nonabandonment is a long-standing ethical obligation inherent in the nature of the physician-patient relationship, but it is not synonymous with all the dimensions of personalized, ethically responsive, situation-oriented care, as Quill and Cassel suggest. Nor is it an ethical concept fundamental enough to carry the heavy moral weight assigned to it. Such expansive refurbishment of nonabandonment dilutes its pristine meaning, confuses the moral and legal dimensions of care, and fails both in ameliorating the supposed rigidity of principles and in assuring attention to the uniqueness of each patient's illness. Nonabandonment deserves restatement, but not such extensive refurbishment.