27/7/97
Mortal
dilemmas
Physicians used to work under the banner ג€Save the patient at all costs.ג€ Now
it's more like ג€Save
the patient? At what
cost?ג€
As fast as medical science advances, its parallel Pandora's box advances even
faster. Once, a dying
person died and that
was that. With the advent
of techno-wizardry,
a dying person didn't
die until every magical
gizmo had its turn delaying
the inevitable interminably.
Which brings us to today's
philosophy on dying:
you call that living?
Welcome to the dicey field of medical ethics. ג€It used to be a paternalistic
relationship -- that is, physician to patient. Now it's autonomous,
but it went too far,ג€ says Prof. Avraham Steinberg, a medical ethicist
who teaches the subject.
Steinberg, on staff
at Jerusalem's Shaare
Zedek Hospital, sits
on a national ethics
committee that makes
agonizing decisions
on -- in the extreme
-- who shall live and
who shall die.
He believes the Patient's Rights Law, which is based on a US model, is a mistake.
ג€The law isn't wide-ranging
enough. We're left with
ethics but not law.
It leaves too much decision-making
to people; it's too
risky. But on the other
hand, in medicine it
is important to have
a degree of flexibility.ג€
Not surprisingly, even in the matter of dealing with dilemmas, there are dilemmas.
Steinberg found it difficult
to speak uninterrupted
about the subject because
his phone kept ringing.
ג€Another agonizing decision,ג€
he explained after the
umpteenth call. ג€A baby,
born perfectly healthy.
The mother nursed for
the first time, then
put him in the crib,
waiting for someone
to return him to the
nursery. When a nurse
finally came, the baby
was completely blue.
He was unconscious for
about seven minutes.
Now, a week later, he
doesn't react, doesn't
breathe on his own;
he has good heart function
and good blood pressure,
so according to the
standard criteria, this
baby is alive but non-functioning.
ג€The dilemma is, how certain are we that this baby is doomed to a vegetative
state? Or will it recover
to some extent but still
be very disabled? Or,
who knows, maybe it'll
recover fully. Should
we continue treating
this baby and possibly
leave the parents to
care for a baby with
no function? Or should
we stop treatment and
let it die?
ג€The question is, who's to judge? The parents? The doctor? Society? The courts?
The ethics committee?ג€
The decision here will have to be paternalistic because the only one who can't
decide is the baby itself.
ג€It's a question of value of life versus quality of life. Once you start saying
that certain types of
life have no value,
you are venturing on
to a slippery slope.
What quality of life
is not worth living?
Where do you draw the
line? Is it fair for
the child to die because
the parents cannot bear
the burden?ג€
The nature of this field is that for every thousand questions asked, there may
-- or may not -- be
one answer. ג€This brings
us to the slippery slope:
tomorrow comes a similar
baby who's not completely
vegetative: he has a
bit of an IQ, he screams
a little, there is some
eye contact. Will you
preserve this one? If
you go to extremes,
it's much easier. Either
you say, 'I don't care
what kind of life, I
give everyone the best
treatment possible and
that's it.' Or you say,
'Any quality of life
I don't like, I don't
preserve.' ג€
There are three end-of-life decisions a physician can take. ג€One: you have no
right to judge any type
of life, your obligation
is to treat everyone,
to do the best you can
and never mind the consequences.
Very few people hold
this view. One person
who did was Yeshayahu
Leibowitz. He taught
that you have no right
to judge life because
then you'll be Nazis
because what did the
Nazis do? They said
this life is worth living,
and this one isn't.
ג€Two: the other end of the scale is what's happening in Holland, where physicians
kill patients by means
of active euthanasia.
They believe in preserving
quality of life.
ג€Option three: passive euthanasia, which is somewhere in between. It is what
most people believe.
You take into account
quality of life, but
you never kill a patient.
This is, of course,
where you find the toughest
dilemmas.ג€
Not all medical-ethics quandaries are so pointedly life-and-death. There is
the unending debate
of resource allocation
-- that is, with funding
as limited as it is,
what should be acquired
or developed, at the
expense of what else?
In Israel, the confluence of so many religious and ethnic ethics sometimes provides
the committee with unusual
challenges. It recently
grappled with an interesting
case involving Arabs'
attitudes toward women.
ג€There is a new law
that states kidney donors
do not have to be blood
relatives -- but a committee
has to agree. This presents
another dilemma: people
need organs, of which
there's a shortage.
But on the other hand,
some people might be
willing to donate them
for the wrong reasons.
ג€A village mukhtar needed a kidney. His blood relatives could not be donors
for medical reasons.
Someone who works for
him, expressing appreciation
to his 'master,' said
he was willing to donate
a kidney but when he
was tested, he was found
to be inappropriate.
So the worker asked
his siblings to be donors.
ג€His sister -- who is divorced with two children -- turned out to be suitable,
so the family decided
she should be the donor.
The committee had to
assume she was coerced
into consenting. The
surgery would have left
her with a large visible
scar on her abdomen
and, combined with her
status of divorcee with
two children, she would
never be able to remarry
within the Arab community.
ג€The
committee felt it would
be unfair to her and
decided that we should
turn down her offer
-- though if one of
her brothers had offered,
we would have agreed.
In this case, we put
social considerations
ahead of medical.ג€
It isn't easy playing God.
