Pulling the plug: who decides?
By J.D. Wallace, MD Ever since the electronic era provided with an increasingly complex variety of machines used to artificially prolong human life, physicians have been faced with a serious problem which has moral, ethical and legal overtones when to pull the plug and shut off the machine. As indicated by debates at CMA General Council these past 2 years, an equally vexing problem is whether in the first place the machine should be plugged in. Despite some ar¬ guments to the contrary by nonmedical authorities, it is the physician in charge of the case who, with appropriate con¬ sultant advice, must eventually make this onerous decision. The buck, as a historical figure might have observed, stops there. These problems were highlighted in the news media again recently because of a sad incident in the United States concerning a young woman who, though over the legal age of consent, was in a long and deep coma. The medical experts agreed she would not recover from the coma and were main¬ taining her life through the use of a respirator and other electronic equip¬ ment. The girl's parents, who knew the case was hopeless, first requested and then demanded that the use of the lifesustaining apparatus be discontinued to let their daughter die with dignity. The doctors refused on the grounds that the electroencephalogram indicated there was still some minor reflex activity in the brain. The requirements of the legal definition of death death of the had not been met. As this is brain written, the parents are seeking a court injunction on the matter. If they suc¬ ceed, the question of who pulls the plug will become urgent. Who decides the doctors (under duress), the judge, the parents, a hospital official? It is a very real problem for all concerned. The CMA Code of Ethics indicates that when death is inevitable, the us
.
.
.
major sociological and medico-legal problem coincides with the beginning of the era of successful organ trans¬ plants. Artificial life support equipment can no longer be denied as unnatural or impracticable. Positive human decisions based on scientific judgement hopefully mellowed by such humanistic attributes as compassion and mercy will ensure re¬ referred to above. sponsible use of such equipment. Most Close relatives should always be kept such decisions are based on a patientin close consultation with the physician doctor-family relationship and receive no publicity. On the other hand, can during illness, but should they have you imagine the public agonizing that or the right either directly through the courts to order an ethical physi¬ would have gone on had one of the moon space shots missed cian, against his professional judge¬ man on theinto earth's atmosphere and ment, to pull out the plug if he feels its re-entry off on an uncharted eternal skipped there is even a slight chance for re¬ into nowhere? How easy would covery? His responsibility to sustain (if voyage it have been for the experts at Houston not artificially prolong) life is strong. He knows it is not only morally and control to say "Well, so long fellows" and pull the plug on the life support ethically but legally wrong to partici¬ systems in the flight module? The basic shortin act which pate any artificially human decision has the same profes¬ ens life. It is indeed a dilemma. sional and emotional impact in each I still vividly recall one of the last case. major poliomyelitis epidemics in the However, such decisions must be early fifties, when life support was pro¬ made, and they must be made by in¬ vided to polio victims with respiratory dividuals who through their training muscle paralysis by the "iron lung". and experience have the ability to as¬ To ensure constant intensive care, a sess all factors. Expert committees can considerable number of these large ma¬ come up with guidelines on use that can chines were centralized in one room in be enshrined in hospital bylaws and reg¬ which members of the medical and ulations. But in the end, the final deci¬ nursing staff served long hours on a sion that terminates the treatment must voluntary basis. I recall a fellow physi¬ be made by an individual physician on cian, stricken by the dread disease and the basis of meaningful consultation aware of what lay in store for him, with colleagues and the patient's fam¬ who, as the machine breathed in and ily. Such decisions are emotionally out for him, labouriously whispered, stressful and cannot be taken lightly, "Please pull out the plug." It was emo- but they must be made. Only if this tionally difficult not to comply with responsibility is respected can we avoid his request. Fortunately, before too a legalistic jungle in which members long, nature overcame that primitive of the public carry "Do not resuscitate" machine and he got his wish. cards and court injunctions replace While the ability to extend life competent medical judgement in the at through artificial means has been with use of life support technology
physician should not use heroic to artificially extend life but should allow the patient to die naturally and with dignity. No health profes¬ sional would argue with that and as a general principle it has been supported as well by the clergy and by the public. The problems arise in the interpretation of an ethical principle when it is ap¬ plied to a specific case, like the one ethical
measures
.
us
for many years, its emergence
as a
least that's the way I
see
it... ¦
CMA JOURNAL/JANUARY 10, 1976/VOL. 114 57
By J.D. Wallace, MD Ever since the electronic era provided with an increasingly complex variety of machines used to artificially prolong human life, physicians have been faced with a serious problem which has moral, ethical and legal overtones when to pull the plug and shut off the machine. As indicated by debates at CMA General Council these past 2 years, an equally vexing problem is whether in the first place the machine should be plugged in. Despite some ar¬ guments to the contrary by nonmedical authorities, it is the physician in charge of the case who, with appropriate con¬ sultant advice, must eventually make this onerous decision. The buck, as a historical figure might have observed, stops there. These problems were highlighted in the news media again recently because of a sad incident in the United States concerning a young woman who, though over the legal age of consent, was in a long and deep coma. The medical experts agreed she would not recover from the coma and were main¬ taining her life through the use of a respirator and other electronic equip¬ ment. The girl's parents, who knew the case was hopeless, first requested and then demanded that the use of the lifesustaining apparatus be discontinued to let their daughter die with dignity. The doctors refused on the grounds that the electroencephalogram indicated there was still some minor reflex activity in the brain. The requirements of the legal definition of death death of the had not been met. As this is brain written, the parents are seeking a court injunction on the matter. If they suc¬ ceed, the question of who pulls the plug will become urgent. Who decides the doctors (under duress), the judge, the parents, a hospital official? It is a very real problem for all concerned. The CMA Code of Ethics indicates that when death is inevitable, the us
.
.
.
major sociological and medico-legal problem coincides with the beginning of the era of successful organ trans¬ plants. Artificial life support equipment can no longer be denied as unnatural or impracticable. Positive human decisions based on scientific judgement hopefully mellowed by such humanistic attributes as compassion and mercy will ensure re¬ referred to above. sponsible use of such equipment. Most Close relatives should always be kept such decisions are based on a patientin close consultation with the physician doctor-family relationship and receive no publicity. On the other hand, can during illness, but should they have you imagine the public agonizing that or the right either directly through the courts to order an ethical physi¬ would have gone on had one of the moon space shots missed cian, against his professional judge¬ man on theinto earth's atmosphere and ment, to pull out the plug if he feels its re-entry off on an uncharted eternal skipped there is even a slight chance for re¬ into nowhere? How easy would covery? His responsibility to sustain (if voyage it have been for the experts at Houston not artificially prolong) life is strong. He knows it is not only morally and control to say "Well, so long fellows" and pull the plug on the life support ethically but legally wrong to partici¬ systems in the flight module? The basic shortin act which pate any artificially human decision has the same profes¬ ens life. It is indeed a dilemma. sional and emotional impact in each I still vividly recall one of the last case. major poliomyelitis epidemics in the However, such decisions must be early fifties, when life support was pro¬ made, and they must be made by in¬ vided to polio victims with respiratory dividuals who through their training muscle paralysis by the "iron lung". and experience have the ability to as¬ To ensure constant intensive care, a sess all factors. Expert committees can considerable number of these large ma¬ come up with guidelines on use that can chines were centralized in one room in be enshrined in hospital bylaws and reg¬ which members of the medical and ulations. But in the end, the final deci¬ nursing staff served long hours on a sion that terminates the treatment must voluntary basis. I recall a fellow physi¬ be made by an individual physician on cian, stricken by the dread disease and the basis of meaningful consultation aware of what lay in store for him, with colleagues and the patient's fam¬ who, as the machine breathed in and ily. Such decisions are emotionally out for him, labouriously whispered, stressful and cannot be taken lightly, "Please pull out the plug." It was emo- but they must be made. Only if this tionally difficult not to comply with responsibility is respected can we avoid his request. Fortunately, before too a legalistic jungle in which members long, nature overcame that primitive of the public carry "Do not resuscitate" machine and he got his wish. cards and court injunctions replace While the ability to extend life competent medical judgement in the at through artificial means has been with use of life support technology
physician should not use heroic to artificially extend life but should allow the patient to die naturally and with dignity. No health profes¬ sional would argue with that and as a general principle it has been supported as well by the clergy and by the public. The problems arise in the interpretation of an ethical principle when it is ap¬ plied to a specific case, like the one ethical
measures
.
us
for many years, its emergence
as a
least that's the way I
see
it... ¦
CMA JOURNAL/JANUARY 10, 1976/VOL. 114 57
