The Karamazov complex: Dostoevsky and DNR orders

Families making difficult end-of-life decisions in the intensive care unit often do not exercise their autonomy in accord with the individualistic philosophic and legal models that currently prevail. Instead, they try to avoid responsibility and deny complicity, even for decisions that they ultimately approve. This paper examines two novels and a recent case from a neonatal intensive care unit that reveal how people actually make tragic decisions for family members. Dostoevsky's The Brothers Karamazov and Kenzaburo Oe's A Personal Matter explore the patterns of communication by which people in such situations test complicity and share or submerge accountability. The psychological similarities between the novelists' portrayals and the actual processes that families undergo in the ICU have practical clinical implications for the ways physicians approach discussions about do not resuscitate (DNR) orders with patients' family members.