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"Vex not
his ghost. Oh, let him pass! He hates him, that
would upon the rack of this tough world stretch him out
longer."
The Tragedy of King Lear, Act V, Scene III
From time immemorial it has been taken for granted that a
doctor's primary occupation is to treat his patient -
"to cure sometimes, to relieve often, to comfort
always". Till a few decades ago, there was no real conflict of interests
- a doctor did his best to preserve life, the sanctity of his patient's
life being considered paramount. The increasing availability
of sophisticated medical technology, life support systems and
critical care units changed
the entire picture. Today the question is, how long to
continue treatment and the purpose
of such treatment. It is possible, to keep a person biologically alive - heart,
lungs, kidney and other organs functioning - but in coma,
"living" in a critical care unit setting.
The "quality of
life" of the patient being treated, is the
critical issue. Langfitt in a thought provoking article "Critical
care, when is enough enough?"
discusses the several issues involved. What is
"quality of life"? Who decides this and whose life is it any
way?
Social Utility is a recent concept
- the concept that a person can be biologically alive but
socially dead. The same respirator that helps a patient with
Gillian Barre syndrome to recover
completely senselessly prolongs the life of a young individual,
in irreversible coma. The mature physician
should realize, that healing the sick, at some point fails.
Life can be revered not
only in its preservation, but also in the manner in which we allow
a given life to reach its end.
Death with dignity is as important as life with dignity.
To keep a person biologically alive in a
critical care setting would mean an expenditure of Rs 5000 to 7500 a day in India. Can we afford this, when there
are thousands dying of
malnutrition and diarrhea every day. Even in the USA where 12% of
the gross national product is pumped into the health
industry cost containment is the talk of the day. At
the same time is it not morally repugnant
to deny useful treatment purely on economic grounds.
Today, with the legal
recognition of brain death it is necessary for the critical care
specialist to view his/her brain dead patient also as a potential
organ donor. To whom does the doctor
owe a greater responsibility - to his brain dead
unsalvageable patient or to a kidney failure patient desperately
waiting for a functioning kidney. Would providing eyesight to two blind
people, by switching of the respirator,
be termed a conflict of interests? Again from the
patient's point of view what can be a nobler way to die than to save five
dying persons? As one mother of a head trauma victim, who consented for
multiple organ donation put it
"My son never died. He is traveling
in different people".
Several ethical issues have to be
considered in the diagnosis of brain
death especially when organ transplantation is the
primary aim.
They include the following:
Waiving of intensive care bills
normally payable, when the relatives agree for
organ donation. Sometimes this bill
is settled by the recipient. Is this not a form of compensation ?
Providing free medical care to the relatives of the brain
dead individual. Is this not a form of inducement ?
The death certifying team
should be different from the transplant
team.
Terms like "heart beating
cadaver" have come to stay. Unfortunately, in India
there are hardly any formal courses in medical
ethics either at the undergraduate or
postgraduate level. Hospital ethical
committees are few and far between. Serious discussions
on the definitions of death, o~ the personal, moral,
legal and economic issues involved
in death related decisions are totally absent in
the training of a doctor. How does
the physician of today, dealing
with critically ill patients, face these complex
challenges.
Managing a critically ill patient is not a
purely technical affair. It
is much more than correcting the serum sodium
or monitoring arterial blood gas levels. The attitude
to death, both of the physician and the patient
(or his near and dear) play a vital part. What happens after
death - the fear of the unknown -
is a very real fear. A student once asked a
Zen master as to what happens after death. The master replied
"I do not know". "But
you are a Zen master" said the student. "Not
a dead one" replied the master.
Seldom does one accept death with equanimity. The fear
of leaving behind loved ones and to cope with loneliness
is a very real fear. "I have not lived enough" applies to the centurion
as well as the teenager.
When is enough enough? When does the
physician treating a critically ill patient say "This far and
no farther". Unfortunately, not withstanding all
the rhetoric, there are no unambiguous rules. Medicine is
never black or white. It is always various shades of gray. Neither
patients nor the organs in their bodies
read the latest journals, monographs or the Supreme Court
judgments. The science of medicine can never do away
with the art of medicine. It is this very element of uncertainty whether it be in life or
death, which makes managing a critically ill patient a
challenging affair.
The fundamental ethical
guidelines in the management of a patient
probably revolve around the following:
Beneficence - to do good by
restoring health and relieving suffering.
"Primum non nocere"
- to do no harm or non-malificence,
a concept which the doctor treating the critically ill
patient has to always remember. Administration of morphine may
relieve pain. It may also cause respiratory depression. The dividing line is often a very thin one.
Justice - when medical
resources are limited, treatment should be
administered to the patient who is most likely to benefit.
However the primary obligation is to the patient
at hand.
To follow the directions of a
"living will" if one exists - that is a
written document or a reliable testimony, that the patient
had prior to his illness, expressed a desire for a par-ticular mode of treatment in a particular condition.
Autonomy - a legally competent
informed adult, has the right to refuse or accept medical
treatment, including life support measures. The right to self
determination does not however include the right to
commit suicide with or without physician assistance.
Easier said than done. In a situation
where the brain is primarily involved,
either in head injury or other neurological problems,
due to organic brain damage, the patient may not be able to take
part in the decision making process. Who then is empowered to take the
role of a surrogate decision maker? Even if the attending doctor
gives the full information to the patient's relatives, is it
reasonable to expect them to take a calm, unruffled
calculated decision after weighing the pros and cons, all in a
critical care setting. Any decision making process involving life and
death, is influenced by the cultural and socio economic milieu.
By the same token is it fair to ask the
attending doctor to play God. Combining the role of a "devils advocate" and "amicus
curae" he has to justify the
blind faith reposed in him by the patient's grief stricken
relatives. Quality of life may mean
different things to different people at different times. In a
developing country, where there is seldom a third party payor, the socio economic burden for caring for
a chronically comatose patient, is so enormous that it reflects on
the health and wealth of the family.
As in any discussion
on ethical issues, this article asks more questions
rather than providing answers. It is
essential that medical ethics be introduced in the curriculum so
that the delivery of critical care will truly be need based.
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