Special of the week; Issue 14-71 "The Ethics of Death"

NDE are the national educational radio network presents special of the Week this week from Yale University New Haven Connecticut from its series called Yale reports. The old saying goes that there are only two certain things. Death and taxes. Although the ethics of taxes may not be open to much discussion the ethics of death is becoming an increasingly important topic with medicine's ability to prolong life artificially with a newly developing art of organ transplantation and with our generally increasing lifespan. The definitions of life and death are more difficult today on you know reports. The Reverend Paul Ramsay Harrington spear Paine professor of religion at Princeton and former visiting professor of genetic ethics at Georgetown University Medical School debates the question of life and death with Dr. Franklin Epstein professor of medicine at Yale Medical School. The Reverend Ian Sagan's lecturer in church history at Yale moderates. Mr. Sagan's the ethical considerations that the physician should take into account when caring for the dying patients.

My view is that the one mission of medicine is the conquest of disease. And that has relentlessly to be pursued. But it does seem to me that there are limits to medicine and effort to cure or to say the life of a patient. Especially on the conditions of modern medicine. All of our very elaborate medical technology interventions are so massive the prolongation of life. Our prolongation apparent life can be so extensive that it seems to me that in our present day if we are not going to be forced as a society to embrace a medical practice I would regard as immoral. Namely euthanasia or the direct killing of terminal patients death selection because the need for hospital

beds resources. So for that we must invoke I more ancient category of medical ethics that has been developed in our western society long before modern technical medicine namely the category of allowing to die. To me there is a moral and quite a definite distinction between directly. Killing a terminal patient and the medical man. And I know edging that his efforts to cure this patient in this condition now have failed and simply standing back and allowing the patient to die. So that seems to me a most urgent business to try to explore those conditions under which it would be a responsible thing for

a patient no longer to want to oppose death. And for the medical profession no longer to to oppose that. Thank God for the practicing physician what to the difficulties in finding as guidelines as a doctor who. Takes care of many patients who we can't cure. I find it very difficult to agree. That there is ever a situation where the doctor should permit the patient to die through a process of judicious neglect. It's difficult for me to appreciate the distinction between pushing a man overboard and watching him drift away in the ICC when someone else has pushed him overboard refraining from throwing him the life preserver. But giving him a smile and wave while accompanying with him in his

death. And I would make a few points from the standpoint of a doctor who is interested in the practical consequences of this kind of decision. Because I think that the points I'm going to mention are not sufficiently appreciated by moralists family who were not doctors. The first is that the doctor is not omniscient. The myth of the doctor's omniscience is perpetuated perhaps mostly by the medical profession because humility is not a major characteristic perhaps of doctors but doctors very often simply don't know. And when they don't know they know in terms of statistics. But it's very hard to really know about individual patients. It may be possible for a doctor for example to say that the chances are nine out of 10 that our

treatment will not help. But for the tenth man it's not a 90 percent chance of failure it's a hundred percent chance of success. And it's almost never possible to know except in retrospect whether one is dealing with nine men or with the tenth man. So that's the first point. The second point that I want to make very strongly is that the doctor is not it is not an impartial observer the doctor is an interested party. It's very hard to take care of a patient who's dying it's a frustrating business. It's difficult to walk in and give support and condolence and hope every day. And no one can appreciate this better than the doctor who comes in in the morning nerving himself to face the ordeal of seeing a man who's not getting better and being told that by the nurse on duty that sorry doctor Mr. Smith died last night. Such as such a sense of

relief that envelops the doctor and the patient's relatives. That it's very hard sometimes to believe that the patient can't experience it the same sense of really. So that's the second point that I would make that the doctor is an interested party and the decision should not be left to him. The line should be drawn so clearly that he should not have to make the decision. The third point I would make is that simply as a practical matter. There are evil practical consequences for the patient and the patient's family of withdrawing hope and announcing the decision of course. It can never be kept secret. It's always apparent to the nurses the family sometimes to the patient that hope is being withdrawn. And I have

seen very bad consequences of that. For one thing the patient doesn't die on time. Everyone stands around nervously looking at their watches. The children have to go back to school. Other appointments must be met. And in the mean time one is counted on the death and death doesn't appear and that's a terrible thing to impose on a family it's embarrassing and it causes all kinds of guilt. I would like to respond that I don't think that what seems to you to be a distinction without much of a difference is correctly illustrated by your example of saying that there is no moral difference and I agree there is no moral between pushing a man overboard and benignly neglecting to save him. He's drifting away through the icy waters. But in that case you have a retrievable life presumably and that it was strange and

to commit the deed or to omit the deed of mercy are certainly both severely morally culpable. But what the actual case is we're talking about is whether or not there are any moral limits to the extension of care. To judge the bookcases in our hospitals. To preserving a lie in the devastated human existence. Now in any case your illustration of the difference between acknowledging that death has won all that one can no longer hold it back and save a significant human existence is not illustrated by the case of the man overboard. The consequences for the profession as a whole you say rightly that the question of what would come to be the practice in our society would come to be the

practice in medicine is for me a very urgent problem as it is for you along with acts of mercy toward an individual person which I do think include caring comforting him making a presence with him but now acknowledging that one can no longer cure him. Isn't it the case that what are called palliative operations in cancer surgery. I used to be considered indicated a number of years ago more than they are now or are now taken often as not indicated. And I don't mis understand what that means. It seems to me that the cancer surgeons at an earlier period where using what they call palliative operations costly you know assaulted the surgery you see. For which they expected no very great results and that now more and more they are judging this not to be vindicated. If that is a true state of affairs if the medical profession can get

together as it must either on whole criteria and you criteria to define what are those criteria by which we state that a man has done. Is it not possible for there to be some common agreement about those criteria. Our test for a state of affairs in which. They would declare given kinds of terminal illnesses but palliative treatments are no longer indicated. Frank the notion of evil life to what extent is that a medical and to what extent a moral problem if you don't practice. Well I think that you put your finger on the key word here in Paul's argument. I think that it would be easy for me to agree with you that useless treatments should not be employed.

If we only knew that they were useless. No Doctor transplants a heart for a man who's dying of septicemia. No one amputates a limb. The problem is that there's a brain tumor. The treatments where there are sort of sauteed of nature or drastic surgery or medical treatments are usually undertaken because there is some hope of either cure or a prolongation of life or relief of pain. And the problem is that we don't know. We really do not know. In most cases in practically all cases whether the issue really is irretrievable. If the issue was stated in terms of or not not only of recovery to fold one's full powers but of the

prolongation of life. And if one says that the prolongation of life is not the main thing then it must be life of a certain quality that it must be life where a man can let's say Appreciate the Sunday Times or recognize his wife or know the difference between warm and cold or know anything at all. Then we put ourselves in the position of deciding whether there is a life that is not worth living. And that's a decision which I feel cannot be made on an art Hoke basis and the implications for the medical profession making such a distinction are so disturbing to me that I would prefer almost any definition of death. But let that draws a line because once we then say that

there is a man a human life and I feel that it's not worth his living then we take ourselves out of the position of being civilized men and put ourselves back in the position of the Eskimos of the old lady can't you anymore she's put out on the ice that's all right for Eskimos but it's not alright for free men living in a civilized society. In other words you would prefer a simple definition of death correct. Whatever it was I mean it's not. Yes I would say whatever it was I. Course I wouldn't include your god. But I don't but in any case a reasonable definition of death is a far more extensive one. Yes and we know her. That's right because one that would be easy to the medical profession would know that up to that point that it was a whole duty you know was to try to present that right. Let me say that I have a kind of not altogether logical but

emotional feeling about this. The medical profession really is the only profession that is completely entrusted by society with that duty to preserve life and to preserve the life of one's client. You know not to necessary the job of the doctor is not to necessarily to avoid the suffering of the mother or to relieve the guilt of the children. There is a contract between the patient and his doctor to preserve the patient's life as long as the patient wills it. Now should the patient wish to commit suicide. It seems to me this is not up to the doctor nor up to society decide whether the man the quadruple amputee should live. It may be up to the quadruple amputee. And I have trouble ethical trouble which perhaps Paul can help me with and then deciding to what extent society should countenance suicide. I feel for that from the narrow viewpoint of the doctor. The situation is not easy. A patient can always discharge a doctor.

A patient it's not difficult for a patient to commit suicide if a patient can't do anything but not move. You know I simply think he can always stop eating. It's not a particularly painful form of death. But the doctor doesn't have to be involved in that. He can understand he can be the patient's friend. But if the doctor is discharged from the case you no longer has a physician's responsibility to keep that old man with a bony face from the head of the bed. The quotation that I like you know for in this which expresses For me the ideal of the Doctor is the one by Cyrano de Bergerac in the play. And when he sees death at the end of the bed he has a lucid nation and he says. You say being Khalaf by nonparty Juma bodies your

mob boss is your MO bar doesn't. I know that at the end you will drag me down but I don't care. I fight and I fight and I fight and I fight. Despite your escape hatch in terms of a new definition of death. So that the prolongation of life be the sole duty of the profession up to that point. You do seem and I admire this very much to envision the prolonging the indefinite us all present a new medical resources to provide prolong life under conditions that would I think been regarded by traditional ethic as conditions that invoke the category of allowing to die. Does strike me that what you are saying is that while the man may have a way out of committing suicide that I would regard that as on his part an offense so far less than as I would regard it to be an

offense to commit euthanasia plan. You see that his position would be that he might wish he had wound up in the small town clinic. You know where not all of these resources were available to be expended with out qualifications. You say are without relativity too. To his condition now I feel the force of what you say about the fact the doctor doesn't know. But surely it is the case that treatment itself being diagnosed. Not just of a disease abstractly but of this man's response. In the treatment of the use of respirators and you know the treatment that is extended to vegetable case. One at some point unless one is going to make a real absolute which I hear you doing of

prolonging life that there would come a point at which it would be a kind of fanaticism to hope that a new cure might come over the horizon. Or the man might become responsive after for weeks and months he has not been responding to any known treat himself. Meantime all of these are live. It is being expanded. You know and some of these are the kinds of things which I call a kind of humanistic definition not of what life one should destroy but those conditions under which one should acknowledge that one can no longer see this devastating existence and should stand aside and allow it to talk. Well when you talk about resources there you hit on a very vulnerable part of my argument. It's clearly wrong in a

kind of general sense that as a children's scholarship money the bank account should be dribbled away while an unconscious man is kept alive with a respirator in a hospital. But this is not a difficult problem to solve and looked at from the standpoint of society this is only our own society in modern civilized countries has this problem. If we had a proper general national health insurance as we should have why this would not be an individual burden. It would be a kind of burden that we now think nothing of carrying when a defective child is born. We take care of thousands of paralytic polio patients so. Children from birth to grave are taken care of in state institutions at great cost. The reason we do it is that it's a small price to pay for

preserving our sense of the uniqueness of human life. That's why we do it. And you would would you say that about the following case. I read in the newspaper some years ago of a patrol. A deep head injury. Who because his wife had the patrolman's benefits and they kept coming in as long as he was quote unquote. I was actually maintained for 12 years before he finally succeeded and in the presently accepted definitions of this surely you may wish to embrace it in your new definition of death now. But this was surely a case in which something more than just a little less effort to prolong life until it succeeds in flagging out against all. You say to me it is a very very questionable extension of medical care.

Well I would say this about that case and that's that's a good case to bring up because it raises the extreme of my position right now that no good was served. It turned out by allowing the man no good to the man was served perhaps nor to his wife perhaps by allowing the man to live. But no harm was done and a greater harm would have been done. We would have done violence to our ideas of what an individual life means if we allowed the man to die now this is a well recognized principle the Supreme Court. Will throw out of court the case of a conviction of rapist a murderer. If the evidence used to convict him was obtained unlawfully. So as to encroach on the man's civil rights and the idea behind this of course is that it's not the individual man's civil rights that are encroached on it's the rights of all of us. And I think that it's an easy analogy to make that if the rights of the basket case if the rights

of the man with a cerebrum shot away are allowed to be dwindling then the rights of all of us are threatened. And I think that the history of the doctors of infamy. Is is a case illustration of that kind of point. Would you care to make any comment upon what actually is the practice of your profession. This regard would be a member of the public be wrong in supposing that doctors do take responsibility for as we say pulling up the plug for interrupting for intervening on their interventions for stopping treatments. What started so that your position really would be if this is a finding of fact that you might make observation on your position really would be that you are upholding a practice that you regard as often volatile.

Well I think it's infrequently violated but it is sometimes violated and it's sometimes violated in such a way that the family the doctor. I can't say the patient because I I don't believe the patient cares much after he's dead. But I think that it in such a way that the family benefits. I think it's sometimes violated in a way that's bad for the patient and for the family. And I can remember a case cases for example which this is one. When a woman was dying of Urania she had had a carcinoma of the cervix the uterus. It was assumed it was generally assumed that the cancer was infiltrating the orders that she had widespread cancer and that nothing could be done the best thing was to allow her to die peacefully. With morphine and judicious neglect and it turned out that the it was not cancer it was a simple scar which could have been relieved by an operation. Another case

of tumor of the spine paralyzing a man and interfering with the function of his kidneys. Abandoned to morphine by the neurosurgeon turned out to be a tumour which could be treated with X-ray because it was a lymphoma then lived several years more. My point is not of course mistakes happen on the other side. But the point about all this is that a mistake made in treatment in the hope that one will prolong a life which doesn't turn out that way. That's not such a terrible error. You merely tried and it cost money yes but in a proper society the money would be borne by some general insurance borne by society as a small cost looked at overall. But if the mistake is on the other side and one doesn't try and one could've succeeded why that's a big mistake that's a life. And if one believes as I do that once that life is lost it'll never come again. Why that's that is an irretrievable loss. One mistake doesn't balance

another and such an equation. What sort of moral guidance do you think the medical profession ought to have in choosing that line defining when a man is dead. I don't think anybody the medical profession can make that definition. The definition of death is a medical matter. The judge declares that a man has done. It is the medical responsibility. The law endorses his doing so. Maybe certain legal statements of this society puts back of the medical profession. But discussions of the criteria for stating that a man has done. The doctors are well aware that death is a continuum and all of that but deliberately choose to put my language in the past and that is to state that a man has done is to state that our greed process greed test you know how I have all been verra. Now these could not possibly be produced by a moralist or a theologian

part of the reason why I would like a clear line drawn to define death. Is that is very hard for me to decide if one does not have that line. What length of life is worth fighting for. You know in a sense we're all dying. We have within us the seeds of our death from the time we're born. From the standpoint I suppose of the creator if I can use that expression we live for but a moment. The. Who is to say that five years of life is worth it. Twenty years I suppose we would all agree one year there might be some descents a month certainly many would give a million dollars for a month or more. But it is a week more worth it is a day what about an hour when one is faced with the practical decision on the ward of a hospital and a sick patient. The enormity of such a decision makes the physician like

myself want to have a simple rule. Preserve life as long as you can. Let someone else that old guy at the head of the bedside when its going to go. And you know the fact is that we're not so successful. We don't have to worry that the world will be populated with corpses that the people are going to die they're going to die we do a very little bit. But what we do may be important not only so much for the patient but for our whole concept of humanity that it has to be preserved. The ethics of life and death. The Rev. Paul Ramsay Harrington spear Paine professor of religion at Princeton and author of the patient as a person and fabricated man published by Yale University Press. Talking with Dr. Franklin Epstein professor of medicine at Yale Medical School. The Reverend Ian seconds lecturer in church history at Yale moderated groups for these programs are available for 25 cents each in a coin or two dollars and fifty cents for a 26 week subscription right to Yale reports

1773 Yale station New Haven Connecticut 0 6 5 2 0. This program originates in Yale's audio visual center and a Rs special of the week. Thanks Yale University for the recording of this Yale report. This is NPR the national educational radio network.