9 - Digitized Collections

The Daily Collegian
Tuesday, March 25, 1986
Medical ethics:
Probing whether to 'pull the plug or sustain life with technological advances
By CHRISTINE KILGORE
Collegian Science Writer
"Ten years ago, my brother was hit by a
car and went into a coma for about a month.
Then he recovered (but that was) after the
doctors said he had no brain waves. At that
time, there was never any question (about
removing him from the respirator). But, £/
there had been, my parents never would have
given up."
his life-and-death situation, faced by a
University student and her family,
T exemplifies one of the most debatable
bioethical issues in today's society: who
should be maintained by medical technology?
In an age of rapidly-growing medical technology,
bioethical questions concerning pulling
the plug on comatose patients like the
young man described above, and an array of
other dilemmas face doctors and society.
The sky-rocketing costs of medical care,
the allocation of resources, the role of state
and federal governments, and the question of
who should make life and death decisions, are
some of the issues that have quickly come to
the forefront.
Sheldon R. Gelman, professor of social
work and director of the Social Work Program
at the University, said many students
will confront bioethical issues sometimes in
their lives.
"Young people — and college students —
tend to think they're immortal and invincible,"
said Gelman. "But what happens if
they're involved in an accident? Do they want
to be hooked to machines? Do they want to be
subject to new technology? Those kinds of
things have to be thought about beforehand."
Gelman pointed to the landmark case of
Karen Ann Quinlan, who in 1975 lasped into a
coma at the age of 21 after taking a combination
of tranquilizers and alcohol. After laying
comatose in a New Jersey hospital for ten
years, she died last year, ending the case that
sparked interest in bioethical decision-making.
"That's probably the first case that got as
widespread publicity, because it involved an
attempt by her parents to make a decision to
forego the use of the respirator to prolong the
life of their daughter," Gelman said. "The
unusual thing about Karen Ann Quinlan was
that once the respirator was removed under
court order, she continued to live, and live,
and live."
"There were many others like her who
remained in a vegetative state with no real
likelihood of ever coming back to possess
those human qualities other people possess,"
he said.
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Dilemmas with technology
Gelman said the Quinlan case, and the
whole argument of bioethics, is related, in
part, to "the expanded technology and the
ability to prolong or maintain life almost
indefinately."
'(The Karen Ann Quinlan case is) probably the first case that
got as widespread publicity, because it involved an attempt
by her parents to make a decision to forego the use of the
respirator to prolong the life of their daughter. The unusual
thing about Karen Ann Quinlan was that once the respirator
was removed under court order, she continued to live, and
live, and live.'
Sheldon R. Gelman, professor of social work and director of the
University's Social Work Program
Leonard J. Waks, University professor of
science, technology and society, agreed that
advancing technology is driving many of
today's bioethical dilemmas.
"It's a slow and changing evolution.
Through all technology, there are unanticipated
risks," Waks said. "Technology is
going to, over time, have effects we can't
assess."
Robert A. Walker, professor of science,
technonogy and society-health education,
said the United States is presently in a stage
of "half-way technology," where health-care
is constantly being improved for the next
generation.
"We're in an adolescent period," Walker
said.
"Clearly, it is the role of the human being to
take the risks associated with technological
development," he said.
Technology advances cause skyrocketing
health care costs. This raises the question of
who will receive expensive medical care,
Gelman said.
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"Someone eventually has to pay for (technology's)
application," he said.
Such long-term implications of medical
technology are now being addressed with the
artificial heart, as some critics claim the
risks and costs are too high. Others say the
heart is worth it.
Danner Clouser, humanities professor at
the University's Hershey Medical Center,
said the main bioethical dilemma surrounding
the artificial heart involves the cost and
consequently, the allocation of resources.
These resources, he explained, are limited
public funds.
"The question is, who should get (the
artificial heart)? Of course, this dilemma is
true of any new technology," Clouser said.
Using the artificial heart "is just so incredibly
expensive," he said. "I've been told that
for the first artificial heart transplant, we
could have given free pap tests to all the
women in the country. This would have saved
many lives."
However, Gelman said artificial organs is
just one of the issues linked to economics.
"With limited funds, should we prolong the
lives of severly handicapped children or an
elderly person with minimal brain function,
or should we reallocate these resources?"
Gelman said.
Waks said to find an answer, people must
look at each situation and ask whether there
is any value in prolonging life.
"We have to look at the quality of life,"
Waks said. "If a person is paralyzed and
isolated and can't go on living the life they
carved out for themselves, there's a serious
question."
"I don't have shallow views on life ... and
I'm all for health care of the elderly," Waks
explained. "I'm not talking about interventions
that are useful — many are. What I'm
not for is the death-extending process."
One should ask whether respirators and
other "life-sustaining" medical treatments
are prolonging life or extending death, he
said.
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The struggle for solutions
Waks is one of many professors, physicians,
clergy members, and families who are
struggling for answers.
According to a March 17 New York Times
report, the American Medical Association
recently ruled it is ethically appropriate for
doctors to withhold "all means of life prolonging
medical treatment" from patients in
irreversible comas but not necessarily terminally
ill.
This policy, it was reported, will be of
greatest concern to the estimated 10,000 people
who are in irreversible comas in institutions
throughout the country today.
Gelman said the policy "may give courts
some direction in terms of what the current
medical thinking is," when they deal with
life-and-death cases.
"The courts don't have any medical expertise,"
Gelman said, adding that they look for
opinions among physicians.
Gelman said although the United States has
begun addressing bioethical issues, the costs
and allocating resources is not "something
we've formally dealt with in this country."
"England, for example, has a policy that no
one who develops kidney disese and is above
the age of 55 can be provided access to kidney
dialysis," he said. "People over 55 who can
secure the costs themselves may certainly
receive dialysis. We're talking about public
funds, however."
"It may seem like a coarse approach (to
the federal government's) role, something
we're not ready to deal with yet in this
country," he said,
"Bioethical dilemmas that have been faced
for years were always handled by small
numbers of people without much public scru-
'(The study of ethics) can't be reduced to a formula. In the
medical community, doctors have to penetrate to the heart
of the lives before them. An ethics problem can't become
like a physics problem.'
—Leonard J. Waks, University professor of science, technology and
society
tiny as to either the process or the outcome,"
Gelman said.
"Today people are thinking about these
things," he added.
He pointed to the well publicized cases of
Elizabeth Bouvia, the quadriplegic who
asked for medical assistance in starving
herself to death; Baby Fae, an infant who
received a baboon s heart, and Baby Doe, a
severely handicapped Indiana infant who
was denied medical treatment by the parents
and state courts.
Just as the medical community is recognizing
and dealing with biomedical ethics, the
general public is becoming more aware of the
bioethical dilemmas faced today, Gelman
said.
"Most people would prefer not to be aware,
however. It's very difficult for any individual
to make a decision that involves whether or
not somebody lives or dies," he said.
But Gelman explained there are no simple
answers.
Each day physicians, families and courts
learn what may be the best ethical choice for
one patient may be the worst for another.
This is why bioethical decisions must be
made on a case-by;case basis, remembering
that life is a basic human right, he said.
Gelman said exactly who makes life and
death decisions is a leading issue. Some
physicians are becoming more reluctant to
make decisions that were traditionally theirs.
"Some welcome the input of others, including
the family," he said.
Ethics committees form
Gelman said one result of the Baby Doe
case was a recommendation that hospitals
develop intricate review, or ethics, committees
to provide counsel and advice.
"The notion of ethics committees has
grown rather dramatically in the last three or
four years," Gelman said. "They deliberate
very difficult, tragic choice decisions."
Gelman is one of about a dozen members of
a recently established ethics committee at
Centre Community Hospital, which includes
health care professionals, social workers,
and clergy members.
"The group should serve as an adviser and
consultant in difficult situations in which a
physician or other health care provider really
is torn between the directions they can go —
between treating and not treating, between
resuscitating and not resuscitating," Gelman
said
Jack Branigan, executive director of
Centre Community Hospital, emphasizes that
the committee is "strictly an advisory
board."
Brannigan said the non-medical perspective
of the committee is extremely important.
"The committee is a recognition on the part
of our medical community that there is a
need to consider ethical issues associated
with life and death," he said.
A similar ethics committee has been established
at Hershey in response to new regulations
following the Baby Doe case.
Clouser said this group — the Infant Care
Review Committee — meets to review cases
when physicians are considering whether to
withdraw life support.
In response to the growing importance of
bioethical decision-making, many medical
schools are beginning to offer and even require
courses in medical ethics, Gelman said.
"Eventually, that kind of course will be an
integral part of the medical education curriculum.
There are courses now in ethics for
nurses, engineers, and business people," he
said. "What it does is inform people that the
decisions that people in various professions
make have implications for the broader society."
Waks said, however, that the study of
ethics, "can't be reduced to a formula."
"In the medical community, doctors have
to penetrate to the heart of the lives before
them," he said. "An ethics problem can't
become like a physics problem."
"Ethics — if it's of any life — comes from
compassion, not from logic," Waks said.
"And this compassion comes from experience."
"What might be more valuable (than an
ethics course) would be to confine doctors to
a hospital room," Waks said. "It would be
like a criminology student going to jail for a
day."
Coleen Rickabaugh (freshmen-pre-medical)
is pleased that an ethics course may be a
required part of her future medical curriculum.
"You can form opinions on your own, but
you should be presented with options," she
said.
Gelman said, "Those who have made (life
and death) decisions have made them after
what they believe to be very careful consideration."
Gelman reiterated that no matter what an
individual decides, it has to be made on a
case-by-case basis, with no set rules or regulations
to follow.
"They've got to be careful that they're not
absolutely sure that they did the right thing,
because the minute you're absolutely sure
about anything, it makes it very easy the next
time to reach the decision," he explained. "If
it comes easy, you can lose sight of the
individual case you're dealing with and start
to fit people into categories — there always
has to be a question."
"You should always take the process very
seriously, without any quick or snap judgements."