LIFE SUPPORT SYSTEMS AND THE DILEMMAS OF MODERN MEDICINE
Posted By mike on July 18, 2010
A TV documentary earlier this week revealed the extraordinary story of a man involved in a motorbike accident whose life support system was about to be switched off – until he blinked. What does his story tell us?
The case of Richard Rudd, movingly and sensitively told on Tuesday’s television documentary Between Life And Death, illustrates the dilemmas to which modern medicine often gives rise.
Mr Rudd, 43, was injured in a motor accident. He was paralysed and thought to be severely brain damaged.
However, taken to the neuro-intensive care unit at Addenbrooke’s Hospital in Cambridge, he was kept alive by the miracle of modern technology, without which he would undoubtedly have died.
His close relatives and doctors thought that the life he now had was not worth living. They prepared to turn off the machines keeping him alive. They thought this is what he would have wanted. It is also what most of us probably would have thought too.
At the last hour it was noticed he was able to move his eyes and that by doing so he could communicate a little. And what he communicated to everyone’s surprise was that he wanted to continue to live, even the life that he was now living. In other words his relatives and the doctors, with the best intentions in the world, had been mistaken.
This should not have surprised us. If people, particularly when they are young and active, are asked what would make their lives not worth living, a good proportion reply it would not be worth living if they were paralysed from the neck down.
It is not just laymen who think this. Health economists think so too. A widely used measure of the relative value of medical treatments is the Quality Adjusted Life Year (QALY). Thus if treatment A brings about twice as many QALYs as treatment B it is thought to provide twice the value for money.
Health policies are often decided on the basis of QALYs. Interestingly and alarmingly the QALY assumes that the life of a quadriplegic (someone paralysed from the neck down) not only has no value for the person who lives it but has a negative value for him: that is to say such a person would rather be dead and in fact would be better off if he were dead.
Whatever they thought before they were paralysed, however, most quadriplegics think their lives are worth living.
With a few exceptions,such as the young rugby player who was accompanied by his parents to Switzerland to be able to be given assistance in suicide, they don’t want to die. The fact that before they were paralysed most quadriplegics thought (as most people, including health economists think) that life as a quadriplegic would not be worth living but change their minds once they are quadriplegic, has very important implications for the idea of living wills.
In fact it invalidates the very idea. It is impossible to decide in advance what would be intolerable for you until you experience it. I remember as a very young man having the now ridiculous thought that I would rather die than go bald. I had other, equally ridiculous thoughts and now that I am bald (or should I flatter myself and say balding?) I find that life is not one whit the worse for it.
The adaptability of human beings is remarkable. Very early in my career I worked on a ward in which the patients had a severe arterial disease brought on by smoking. Most had had their legs amputated and some an arm, or even two.
To my intense irritation, for it offended my sense of rationality, they continued to smoke even though they were fully aware of the dire consequences to them if they did so. And far from being wretched and miserable they were cheerful.
How could this be when I would have hated to be in their situation and done everything possible to ensure that the condition progressed no further? It is not only difficult to guess what another man would want in any given situation, it is difficult for us to guess what we ourselves would want.
When you add to this that prognosis in medicine is not an exact science, that mistakes and surprises occur even in the practices of the best doctors, too great a readiness to dispose of lives thought to be valueless or of negative value is clearly dangerous.
This is especially so when financial stringency means that we are perpetually on the lookout for ways of saving money. I can already imagine the argument: why spend money on treating 100 people with condition A, when only one of them will recover to have a life worth living, instead of spending it on treating 100 people with disease B, 50 of whom will recover?
One of my memories of the hospital in which I worked was of a manager – a nice man, thank goodness but not to be guaranteed – prowling the wards to find patients who might be discharged so that others could be admitted. Only a few years ago this would have been unthinkable.
Of course there are people who want to die as well as those who want to live. What of them? Every adult who is of sound mind has the right to refuse treatment even if it is life-saving. If Mr Rudd had (as the doctors expected) signalled that he did not want any further treatment the doctors, once they were persuaded that this was not a momentary whim on his part, would have had to stop treatment and he would have died.
There are a few people who want to die who, while pretty helpless, will not die the moment treatment is stopped.
What of them? Ought they not be helped to die, whether by assisted suicide or euthanasia? It is within the capacity of every conscious human being to kill himself. All he has to do is to stop drinking. Provided he does not have fluids forced upon him some other way he will die very shortly. But the death is not a comfortable one, though a degree of comfort can be brought to it.
One of the problems with assisted suicide and euthanasia is what the Americans call mission creep. We live in non-discriminatory times: why should only certain categories of patients have the benefit of what Keats called “easeful death”? Indeed, when euthanasia was legalised in Holland it was not long before a psychiatrist killed a patient with supposedly intractable depression.
Why should only the terminally ill and the quadriplegic have the right to assisted suicide or euthanasia? Do other people not suffer equally, at least in their own estimation? An old saying goes that hard cases make bad law and it is also true that there are pitiful cases in which a quick death would seem a merciful release.
Unfortunately it is well within the capacity of carers to make suffering unbearable and therefore death seem the preferable, quick and merciful option. And if people have a right to death on demand then someone has a duty to provide it, otherwise the right is worthless, a dead letter.
Who is this person who has such a duty? Will we strike off doctors for refusing to kill their patients? This is something that the indomitable Mr Rudd would not approve of and I think he deserves to be heard.
Via: www.express.co.uk. Thursday July 15, 2010. By Theodore Dalrymple.