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Unite3Doctor’sDilemma:TreatorLetDie?AbigailTrafford1.Medicaladvancesinwonderdrugs,daringsurgicalprocedures,radiationtherapies,andintensive-careunitshavebroughtnewlifetothousandsofpeople.Yettomanyofthem,modernmedicinehasbecomeadouble-edgedsword.2.Doctor’spowertotreatwithanarrayofspace-agetechniqueshasoutstrippedthebody’scapacitytoheal.Moremedicalproblemscanbetreated,butformanypatients,thereislittlehopeofrecovery.Eventhefundamentaldistinctionbetweenlifeanddeathhasbeenblurred.3.ManyAmericansarecaughtinmedicallimbo,aswastheSouthKoreanboxerDukKooKim,whowaskeptalivebyartificialmeansafterhehadbeenknockedunconsciousinafightandhisbrainceasedtofunction.Withthepermissionofhisfamily,doctorsinLasVegasdisconnectedthelife-supportmachinesanddeathquicklyfollowed.4.Inthewakeoftechnology’sadvancesinmedicine,aheateddebateistakingplaceinhospitalsandnursinghomesacrossthecountry---overwhethersurvivalorqualityoflifeistheparamountgoalofmedicine.5.“Itgetsdowntowhatmedicineisallabout,”saysDanielCallahan,directoroftheInstituteofSociety,Ethics,andtheLifeSciencesinHastings-on-Hudson,NewYork.“Isitreallytosavealife?Oristhelargergoalthewelfareofthepatient?”6.Doctors,patients,relatives,andoftenthecourtsarebeingforcedtomakehardchoicesinmedicine.Mostoftenitisatthetwoextremesoflifethatthesedifficultyethicalquestionsarise---atthebeginningfortheverysicknewbornandattheendforthedyingpatient.7.Thedilemmaposedbymodernmedicaltechnologyhascreatedthegrowingnewdisciplineorbioethics.Manyofthecountry’s127medicalschoolsnowoffercoursesinmedicalethics,afieldvirtuallyignoredonlyadecadeago.Manyhospitalshavechaplains,philosophers,psychiatrists,andsocialworkersonthestafftohelppatientsmakecrucialdecisions,andoneintwentyinstitutionshasaspecialethicscommitteetoresolvedifficultcases.DeathandDying8.Ofallthepatientsinintensive-careunitswhoareatriskofdying,some20percentpresentdifficultethicalchoices---whethertokeeptryingtosavethelifeortopullbackandletthepatientdie.Inmanyunits,decisionsregardinglife-sustainingcarearemadeaboutthreetimesaweek.9.Eventhedefinitionofdeathhasbeenchanged.Nowthattheheart-lungmachinecantakeoverthefunctionsofbreathingandpumpingblood,deathnolongeralwayscomeswiththepatient’s“lastgasp”orwhentheheartstopsbeating.Thirty-onestatesandtheDistrictofColumbiahavepassedbrain-deathstatutesthatidentifydeathaswhenthewholebrainceasestofunction.10.Morethanadozenstatesrecognize“livingwills”inwhichthepatientsleaveinstructionstodoctorsnottoprolonglifebyfeedingthemintravenouslyorbyothermethodsiftheirillnessbecomeshopeless.AsurveyofCaliforniadoctorsshowedthat20to30percentwerefollowinginstructionsofsuchwills.Meanwhile,thehospicemovement,whichitsemphasisonprovidingcomfort---notcure---tothedyingpatient,hasgainedmomentuminmanyareas.11.Despiteprogressinsociety’sunderstandingofdeathanddying,theoryissuesremain.Example:Awoman,87,afflictedbythenervous-systemdisorderofParkinson’sdisease,hasamassivestrokeandisfoundunconsciousbyherfamily.Theirchoicesaretoputherinanursinghomeuntilshediesortosendhertoamedicalcenterfordiagnosisandpossibletreatment.ThefamilyoptsforateachinghospitalinNewYorkcity.Testsshowthewoman’sstrokeresultedfromabloodclotthatiscurablewithsurgery.Aftertheoperation,shesaystoherfamily:“Whydidyoubringmebacktothisagony?”Herhealthcontinuestoworsen,andtwoyearslatershedies.12.Ontheotherhand,doctorssayprognosisisoftenuncertainandthatpatients,justbecausetheyareoldanddisabled,shouldnotbedeniedlife-savingtherapy.Ethicistsalsofearthatundertheguiseofmedicaldecisionnottotreatcertainpatients,deathmaybecometooeasy,pushingthecountrytowardtheacceptanceofeuthanasia.13.Forsomepeople,theagonyofwatchinghigh-technologydyingistoogreat.Earlierthisyear,WoodrowWilsonCollums,aretireddairymanfromPoteet,Texas,wasputonprobationforthemercykillingofhisolderbrotherJim,wholayhopelessinhisbedatanursinghome,avictimofseveresenilityresultingfromAlzheimer’sdisease.Afterthekilling,thevictim’swidowsaid:“IthinkGod,Jim’soutofhismisery.Ihatetothinkithadtobedonethewayitwasdone,butIunderstandit.”CrisisinNewbornCare14.Attheotherendofthelifespan,technologyhassorevolutionizednewborncarethatitisnolongerclearwhenhumanlifeisviableoutsidethewomb.Newborncarehasgothugeprogress,soitisabsolutelyclearthathumanbeingcansurviveindependentlyoutsidethewomb.Twenty-fiveyearsago,infantsweightinglessthanthreeandone-halfpoundsrarelysurvived.Thecurrentsurvivalrateis70percent,anddoctorsare“salvaging”somebabiesthatweighonlyoneandone-halfpounds.Tremendousprogresshasbeenmadeintreatingbirthdeformitiessuchasspinabifida.Justtenyearsago,only5percentofinfantswithtranspositionofthegreatarteries---thecongenitalheartdefectmostcommonlyfoundinnewborns---survived.Today,50percentlive.15.Yet,formanyinfantswhoowetheirlivestonewmedicaladvances,survivalhascomeataprice.Asignificantnumberemergewithpermanentphysicalandmentalhandicaps.16.“Thequestionoftreatmentandnontreatmentofseriouslyillnewbornsisnotasingleone,”saysThomasMurrayoftheHastingsCenter.“ButIfeelstronglythatretardationorthefactthatsomeoneisgoingtobelessthanperfectisnotgoodgroundsforallowinganinf