Mary is 62 years old. She is brought to hospital after she collapsed suddenly at home. Her neighbour found her unconscious, and called the ambulance. When they arrived she was deeply unconscious and at risk of choking on her own secretions. They put a breathing tube in her airway, and transported her urgently to hospital.
When Mary arrives she is found to have suffered a massive stroke. A brain scan shows very severe bleeding inside her brain. In fact the picture on the scan and her clinical state is described by the x-ray specialist as ‘devastating’. She is not clinically brain dead, but there is no hope. The emergency department doctors have contacted the neurosurgical team, but they have decided not to proceed with surgery as her chance of recovery is so poor.
In Mary’s situation, the usual course of events is to contact family members urgently, to explain to them that there is nothing more that can be done, and to remove her breathing tube in the emergency department. She would be likely to die within minutes or hours. She would not be admitted to the intensive care unit – if called, the ICU team would be likely to say that she is not a “candidate” for intensive care. However, new guidance from the National Institute of Clinical Effectiveness, released late last year, and endorsed in a new British Medical Association working paper, has proposed a radical change to this usual course of events.
Instead of the above course of events, Mary would be admitted to intensive care. Extra tubes would be inserted into Mary’s blood vessels, breathingmachines started, and blood pressure medicines provided – until there had been a chance to talk to Mary’s family about the possibility of organ donation. The idea is that this may provide enough time to find out whether Mary would have liked to donate her organs. This may take some hours, or perhaps even a little longer. If Mary’s family take a while to agree to organ donation, she may have become brain dead in the meantime. Alternatively, intensive care can be withdrawn in controlled circumstances, allowing her organs to be retrieved after her heart has stopped beating. It it turns out that the family decline donation, life support will be stopped in intensive care.
This proposal is a version of a practise called “elective ventilation“. This euphemism refers to the idea of ‘electing’ to provide intensive care for a patient who is not thought to be able to benefit from it – in order that they might donate their organs. In the late 80s and early 1990s, this approach was used by doctors in Exeter to increase the number of organs available for donation. At the time, the main focus was on patients becoming ‘brain dead’. The practise largely, if not entirely disappeared in the UK because of advice that it was illegal to provide treatment that was not in patients’ best interests.
But elective ventilation has been resuscitated. The critical shortfall in organs has led NICE and now the BMA to seriously countenance a major change in the approach to provision of intensive care for seriously brain injured, critically ill patients.
Is this the right approach?
Is it ethical to prolong the death of patients until their (and their family’s) wishes about organ donation are known?
Is it legal?*
Let us know your thoughts
In the coming months, the Journal of Medical Ethics is going to have a mini-symposium on the rejuvenation of Elective Ventilation. Papers on any aspect of the ethics of Elective Ventilation are welcome. In the meantime comments here are welcome. What are the key objections to Elective Ventilation, and do they stand up?
*Edit 17/2/2012
John Coggon has drawn my attention to his paper in the BMJ from 2008
In it he and colleagues address the central legal concern that led to Elective Ventilation losing favour
Coggon argues that
The law is clear: treating a patient in accordance with his or her best interests means more than doing what is medically indicated. It requires us to explore the patient’s values and to choose the course of action that accords best with them. Where a patient would wish to donate, measures such as those described here are not unlawful if they are necessary for organ donation to proceed. They serve, rather than deny, the best interests of a patient.
Edit 19/2/2012
The BMJ have just published an editorial on this issue authored by a group of intensive care consultants (and myself). It concludes
Although changes in practice may increase the number of organs that become available for transplantation, this benefit must be weighed against real potential harms, particularly for those people who would not wish their life to be prolonged purely for the purposes of organ donation and for those not wishing to donate their organs (and their families). There is a need for public debate about the proposed changes and for more detailed and specific information to be provided to prospective donors before these guidelines can be supported.
Although I am much more positively inclined towards elective ventilation than some of my colleagues, this concluding sentiment expresses an important note. Before Elective Ventilation is embraced, it is important that there is public debate, and organ donors know what this is about. As I have argued elsewhere – this is not something that the public should fear. But one significant argument against EV is that it would lead to a backlash against donation and actually reduce organ donation rates. Hence the importance of openness, publicity, and debate.
Edit 25/2/12
The BMJ featured this blog, and elective ventilation in their podcast this week
Arguably, we do lots of things that are not for the best interest of patients. We let visitors into hospitals, which introduce patients to germs and viruses that they may be carrying. This just adds another to the list, and ultimate, it is in the best interest of the patient, simply not this patient. It serves other patients who are awaiting for organ transplants.
Hi Wayne,
thanks for kicking off the comments. So one concern that might be expressed about EV is that it involves instituting (or continuing) treatments that are not in the patient's best interests. From the doctors' point of view, this seems to involve something more than simply the arrangement of hospital visiting hours and policy
There are two levels to this concern: EV might not be actively *in* the patient's interests – because the patient will not be benefited by the treatment (but as you point out it may benefit others). Can we do things (especially medical things) to patients for the benefit of others but not themselves?
Or some might argue that that EV is *against* or potentially against the patient's interests. Two questions here then – could EV be harmful to the patient? If it could, is it permissible to harm this patient (or risk harm to the patient), in order to benefit others?
Thank you for your interesting post, Dominic.
In order to retrict the length of my reply, I'll take your first three paragraphs as given. That is, Mary is already dead, or at least her death is inevitable whatever the treatment that might be given.
This signifies to me that nothing is either in, nor against her best interests : Mary is dead.
However, most of us would be shocked to see her dead body thrown into a crude wooden box and left in a corner; or to see a doctor beating a tam-tam rhythm on her stomach… My intuition is that this is because even a dead person is worthy of a certain dignity – and that this belief is not at all restricted to religious believers. This sense of dignity has nothing to do with the individual's best interests : it is more to do with a universal sense of respect for persons, and how we should treat the end of life.
Returning now to elective ventilation. It is one thing for a relative or partner who accompanies Mary to hospital to be told of Mary's death and then be asked about prolonging Mary's metabolism for possible use of organs : It is another to come to the hospital several hours later and be confronted by Mary in intensive care, purely because her organs might be useful to someone else.
And this is not just because the hospital generates an important conflict in the relative who sees someone in intensive care (implication: «she is still alive, there is hope») but is told that she is dead or that nothing can be done.
It is also because asking at the time offers the opportunity to make an altruistic gift; but asking afterwards is an instrumentalisation of her body.
(To those who want to make the gift themselves, nothing stops them from carrying a donor card.)
Hi Anthony,
we should be clear here – Mary is not dead at the time of Elective Ventilation. She is critically ill, and has such severe brain injury that further active treatment is judged not to be in her best interests. It is true that her death is inevitable within a short period of time.
But it doesn't follow that because of this nothing is either in, nor against her interests. It would certainly be in her interests to receive pain killers if she is, or could be in pain. It would be against her interests to cause her pain.
But I think that you point to two particularly interesting concerns about EV.
The first is that this 'instrumentalises' Mary – it treats her as a means rather than an end. So, the standard Kantian objection is that she is being used as a mere means.
What do others think, could Mary also being treated as an end-in-herself if she receives Elective Ventilation?
Your second point is about mixed messages, and the possibility that taking Mary to intensive care may make it harder for family members to accept the fact of her poor prognosis and imminent death. One possible concern is that if you admit Mary to intensive care, and then her family object to withdrawal of treatment, that she may end up stuck in the ICU for a long period of time – suffering treatment that is perceived to be futile and may be harmful, and racking up a considerable cost to the public health system.
But that raises another question. If the ICU doctors would be happy to refuse to admit Mary to the ICU on the grounds of futility/resources etc – why will they not withdraw treatment on the same grounds?
Hello Dominic
You are quite right that in Mary's case treating pain and avoiding inflicting it are in her best interests.
I was too quick in wanting to come to the two points you cite above.
However, there is a third point, which is my intuition that even where nothing can be said to be in or against a person's best interests (for example, they really are dead), there are things that we should not do.
Thanks Anthony,
so, you point to a the idea that treating Mary's dead (or dying) body in this way is undignified.
But the doctors are not proposing here to do anything unusual to Mary. They are not proposing to leave her in the corner, or use her body as a musical instrument. They are doing exactly what they would for most other patients – they are taking her to intensive care, stabilising, waiting for a period of time for more information before making a decision to stop treatment.
It is not clear why this is inconsistent with respecting Mary's dignity. Indeed, if donation is something that was potentially important to her, then what they are proposing to do is arguably *more* dignified than the alternative – allowing her to die and her organs go to waste, when they are no further use to her, and could have potentially saved the life of one or more other people.
John Coggon has drawn my attention to his paper in the BMJ from a couple of years ago that addresses the principle legal objection. I have added the link into the main post above.
NB Coggon argues there that "Elective Ventilation" isn't permissible because it leads to the risk of the patient surviving in a persistent vegetative state.
That was certainly one of the concerns about the previous form of Elective Ventilation that involved waiting for patients to become brain dead. But is this concern reasonable for the *new* form of elective ventilation? How likely is it that a period of continued respiratory support for a few hours would lead to a patient surviving in a vegetative state who would otherwise have died?
I have added in a link to an editorial just published in the BMJ – see footnote above.
Although I am much more positively inclined towards elective ventilation than some of my colleagues, the concluding sentiment in this editorial expresses an important note. Before Elective Ventilation is embraced, it is important that there is public debate, and organ donors know what this is about. As I have argued elsewhere – this is not something that the public should fear. But one significant argument against EV is that it would lead to a backlash against donation and actually reduce organ donation rates. Hence the importance of openness, publicity, and debate.
The BMJ have featured this blog, and the question of elective ventilation in their podcast this week
http://www.bmj.com/podcast/2012/02/24/elective-ventilation-and-future-medical-professionalism
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