Dead when the doctor says you are: Ethicists wrestle with the changing nature – and timing – of death
[The Star] Dead is dead, except when it’s not.
“Death used to be a little more self-evident,” says Kerry Bowman, a medical ethicist specializing in end of life issues at the University of Toronto’s Joint Centre for Bioethics.
“Today, you’re dead when the doctor says you are.”
Deciding when somebody is dead or about to die is quickly emerging as one of the top ethical issues in medicine today as technology makes it increasingly possible to keep people alive who would otherwise have died not so long ago.
“The technology has far outstripped the ethics,” says Tim Falconer, author of That Good Night: Ethicists, Euthanasia and End-of-Life Care. “Feeding tubes and ventilators weren’t designed to keep people alive for 15 years, but that’s what they’re being used for.”
As well, says Bowman, with organ transplants more common, deciding the precise moment of death has become vital, since under the “dead donor rule” organs can only be harvested once the donor has died. And the sooner after death that happens, the healthier the organs will be.
Such issues become matters of public debate when cases arise like that of Terri Schiavo in the United States or Italy’s Eluana Englaro, in which families fight publicly with medical officials over whether to maintain life support. A generation ago, the case of Karen Ann Quinlan of New Jersey captured headlines when her parents fought to let her die in her persistent vegetative state. They won the right to remove her respirator in 1976, but she lived in a coma, breathing on her own, until 1985.
And just last week in Toronto, the debate began again with the case of 2-month-old Kaylee Vitelli at the Hospital for Sick Children, whose parents were told she could not live without a respirator and wanted to donate her heart to another baby at the hospital.
But when the respirator was removed to make way for the transplant, Kaylee kept breathing – forcing all those involved to question their assumptions about her seeming impending death. Yesterday she was continuing to breathe with oxygen assistance.
“This little girl just wasn’t ready to die,” says Moira McQueen, director of the Canadian Catholic Bioethics Institute. McQueen worries about a blurring of the line between dying and dead, saying we sometimes treat people as already dead once they are deemed terminal – a notion Kaylee challenged with her survival.
Organ donations most often take place after brain death, a concept articulated 40 years ago at Harvard University and meaning the irreversible end of all brain activity.
In a brain dead patient, the brain no longer tells the body to keep living, so machines do that, instead.
Brain dead soon came to replace the historic understanding of death – the heart stopping. After all, a stopped heart no longer seemed relevant when machines could keep a heart beating indefinitely.
However, the increased popularity of donation after cardiac death, or the harvesting of organs from patients whose hearts have been allowed to stop beating, has once again got the medical community looking at how to define death according to the functions of the heart.
Like Kaylee, such donors are often on life support because of an illness or disability that requires them to be permanently hooked up to machines. Removing those machines means death by cardiac arrest.
While doctors have long harvested organs such as kidneys and livers from such patients, taking a heart is relatively new. That’s because cardiac death requires the person to be dead for several minutes before the heart can be taken out. In that time, the heart is damaged.
How long to wait is a matter of heated debate. One recent study recommends taking out the heart 75 seconds after it stops. The standard in most jurisdictions, including Canada, is five minutes. Catholic hospitals, McQueen says, are increasingly moving to 10 minutes “to be doubly sure” the patient is dead.
But in series of articles last summer, the prestigious New England Journal of Medicine questioned whether heart transplants after cardiac death are inherently unethical, since the criteria for taking the heart out of the donor is that the patient’s death be irreversible.
The problem, the Journal said, is that the donated heart is soon restarted in another body – which means it could probably have been restarted in its original body, as well, raising the question of whether the donor was, in fact, irreversibly dead.
“If a heart is restarted, the person from whom it was taken cannot have been dead according to cardiac criteria,” wrote Robert Veatch, professor of medical ethics at the Kennedy Institute of Ethics at Georgetown University.
In such a case, Veatch writes, death was caused by the donation of the heart, not its stopping.
Such quandaries make donation after cardiac death very problematic for many people.
In recent months, even the long-held acceptance of brain death has been called into question, particularly in the Catholic Church.
Last summer, a front page column in the Vatican newspaper L’Osservatore Romano questioned whether brain death violates traditional Catholic teaching by equating human life with brain activity only. It pointed to the case of a brain dead pregnant woman who was able to give birth to her child.
McQueen says the column did not shake Vatican support for the brain death definition, adding she draws a distinction between “being alive” and “being kept alive” by machines.
When cases like that of Kaylee come along and capture the public’s imagination, Falconer says, it unleashes a debate about death and dying. “This is a discussion we need to have.”
“Dead” should be when the family decides that they don’t want care to be given anymore. Until then, doctors should do everything possible to keep the person alive’.
Very well said, by one commentator at site; but still! This is controversial when we litigate it with controversy in terms of ethics.
This is because no body has right to decide the last breath of any individual may it be a legitimate relation.
Should I take this decision as prerogative that we all have rights to award death for being under belief of legitimacy hence relation or in terms of consent?
What if some one with millions in pocket living alone succumbs his fate on ventilator and the one as closed relation, say a son with a penny decides his last breath as his prerogative for being his father.
I think we must redesign this system of consent under the terms of such scenes of impending death.
This decision of removal at least must have a rational way as ethical law where decision must go through the hands of multiple as experts and as well as relatives and government functionaries.
This would definitely rule out this element of say as ethical or non ethical.
This is a very tragic event to declare ‘dead’ before a person is really ‘dead’.
Actually this is an event where no demarcation between life and death exist.
And this is all because of this advancement.
Infact there is no demarcation at all, between life and death but contrary; it seems it’s the process of blending of life with fate as death.
Without prejudice, as opinion; it is here where religious theme glare as right and righteous.
I am unable to understand advancement as modalities in medical science.
In my opinion advancement as sophisticated artificial means; has denoted this issue as ethics, to the major extent of share.
Observe the phenomena of putting some one on ventilator and similar phenomenon of removing from ventilator.
What if; ventilators were not there to provide an alternative or assistance to ventilation?
Under such unavailable mode as artificial assistance; demarcation between life and death would have been a premised and defined event.
But this advancement as technology though at one end minimized the hectic engagement of clinician to follow patient for recovery but at other end provided him an opportunity to gain little time in the name of treatment or procure business and as well to prepare relatives towards an event as impending death or whatever as outcome.
Putting a patient on ventilator seems and presents more as irrational treatment; which seemingly supports the theme and requirement of business of hospital than in the context of patient welfare.
This contempt as my opinion can only be perceived logical, if at all some one as clinician rationally and ethically contrives and contravene it with the concept of justification.
Here my point is; what frame of time is expectedly or presumably; a presumptive reflection as possible recovery, hence to get a prognostic progress as life from this mode of technique.
In my opinion it has undefined minutes as hours hence weeks or months or years.
Exceptions may be if there is a genuine requirement based on post surgical or acute cases of trauma and etc; which definitely have limitation as time and selection as requirement hence as understanding in terms of standardized law as belief.
A clinician by his skill and experience shall and must judge his patient condition prior to the demand and advice as, artificial assistance.
But if at all he could not manage to define the fate of individual and tenure of his treatment in tame of time under ventilator; my feel as logic should drag him towards the plateau of malpractice as assumption.
Since, there seems no justification of putting patient and his family over the cross of burden as charges or bills where outcome have already defined and presumed notions in terms of interest only.
Why shouldn’t I say here that clinician knows his exact methodology of subjecting of his patient to this treatment?
It is here where ethics demand ethical way hence to preserve confidence among people around as relatives and surround as ethicist.
We can not just argue treatment as logical for being an only option or optional or a chance or a desire of attendant.
This is a matter of emotions since life and death and similar facts as fate have troublesome impacts on relatives as relation.
In my opinion it is this ‘optional or chance legacy’ that is the main hurdle or conflicting point which drags this treatment within the concept of ethics.
It is because of this very same legacy that demands justification of removal from the mode.
In my opinion, what have been started as option or clinical mode should have a reasonable justification in case of non recovery in terms of removal.
This phase as span on ventilator is a terrible period where people around burden their thought in variant theme hence from death to recovery or as many ideas as can be perceived for their patient.
It is here where ethicist say that “Today, you are dead when the doctor says you are.”
I think we need to sort this issue in terms of laid criteria as limitation and selective textual prohibition as protocol.
In my opinion this point of putting some one on ventilator for any cause as intent and diagnosis; should have a protocol in which any breach may become or be dragged in to an audit.
Prerequisite for putting on Ventilators should be legislated under medical text as compulsive defined protocol.
Similarly removal from ventilator must be govern under the head of set of rules as barred days; as decided in terms of text by medical authorities as protocol.
Where as! Issue of organ donation; should be restricted similarly by protocol, again under medical authority as text by unanimous decision; for only those who are and were never wean or wined through ventilator but rather natural death.
In my opinion this controversy as ethics in contest of “you are dead man; when doctor says, you are dead” would continue unheard within the deep helpless murmuring of patient, their attendant and humanity because; this difference of decision making as per skill and knowledge between these two parties as clinician and patient; would continue to peer as oppressor and suppressor.
This prerogative of being a clinician will always keep the last breath under their own domain as interest; therefore would and shall always be a reaction as controversial by ethicist or populace.
Regards