"A patient whose heart has stopped could potentially live on the machine for months, awake, able to walk and read the newspaper. But he might never leave the I.C.U."
The only ethical problem I see is other people deciding what life is worth living.
The only ethical problem I see is other people deciding what life is worth living.
> Around a decade ago, a teenager who couldn’t be saved was admitted to a New England hospital. Like Shania Arms, he had cystic fibrosis. A previous lung transplant was failing, and his only hope was another transplant. He was put on ecmo while he waited. Two months later, doctors discovered that he had developed an incurable cancer. Now there was no way for him to leave the I.C.U. His lungs were beyond recovery, and the cancer made him ineligible for transplant. He was caught on a bridge to nowhere.
> Some members of the medical team thought that ecmo should be stopped. Transplant was no longer possible, and ecmo machines were scarce. As long as the patient was on the machine, it couldn’t be used to save someone else. It’s also expensive; according to a 2023 study, the median hospitalization charge for covid patients on ecmo was around eight hundred and seventy thousand dollars, and prolonged cases can exceed several million. These resources might be needed to help other patients, and the boy couldn’t live in the I.C.U. indefinitely.
> But others on the team disagreed. “He was texting with his friends,” Robert Truog, a pediatrician and bioethicist who was involved with and wrote about the case in The Lancet, said. He was spending time with family, and doing homework online. Because he could be awake on ecmo, he could still engage in activities that were meaningful. Situations like this represent a “profound ethical dilemma,” Raghu Seethala, an intensivist and ecmo specialist at Brigham and Women’s Hospital, told me. “The technology is ahead of the ethics,” another expert said.
The technology isn't "ahead of the ethics" as the one quote indicates. This is a simple case of some people apparently advocating for killing a living, conscious, interacting-with-the-world teenager because he wouldn't just hurry up and die, and they want to use his resources for something else.
I bet those same people would learn that over 80% of people aged 70-75 reside in a home they own, and immediately come up with a modest proposal for how to solve the housing crisis.
It's a hard problem. We have different intuitions for large groups (do whatever saves the most people) and individual cases (how dare you even consider killing someone for spare parts!); and somehow, improving society somewhat – say, funnelling some of that yacht money towards lifesaving treatment – never factors in to these life or death decisions. So what can you do, with limited resources?
It's a coordination problem, more than anything. https://www.principiadiscordia.com/book/45.php contains about as much actionable advice as this here complaint of mine.
At a certain point, our obligations to another person have to end. At what point do we fault someone for not putting in work to delay someone else's death?
Obviously, withholding immaterial support is ethically deplorable. If it costs $1 of medicine to cure a child's life threatening illness and give them a high probability of living a typical human lifespan, you'd be a monster to not help.
But what if it costs $100,000 and has a low chance of healing them?
Or $10,000,000, with no probability of them ever leaving the hospital room, and their use of the room and machines will mean 10 additional deaths that could have been prevented?
I think we should be biased towards life over money because it's more humane and we'll probably learn useful things along the way that improve care in the future, but even with that overweighting, at some point it looks like a bad trade-off.
> At what point do we fault someone for not putting in work to delay someone else's death?
That isn't what is happening. I'm faulting someone for putting in work, to expedite someone else's death.
Sure, there's all sorts of math you can do to justify things either way. You can say "oh but it'll cost ten gajillion dollars and the equipment could have saved an entire ethnic group from extinction", as though you have as much certainty about hopeful future hypothetical benefits as you do about the person dying. On the other side you can say "oh for someone age 16 a week is the same proportion of their life so far as 3.5 weeks for someone aged 55, so if we can keep the 16 year old alive for another week that's better than keeping a 55 year old alive for 3 weeks".
It really all comes down to the difference between action and inaction, between causing harm and declining to prevent harm. Is someone who pushes someone in front of a bus no worse than someone who sees a bus coming at someone and doing nothing to warn them? That's a hard sell.
Action/Inaction is an important distinction for ethical frameworks and our intuition, but this situation is so difficult to reason about because it forces us to ask when triage/lifeboat ethics apply. Even more tricky because the obvious solution to triage/lifeboat/trolley ethical problems (avoid getting into them) doesn't make sense here because the technology can save so many people!
How many lives can we ethically save in exchange for putting doctors and biophysicists into trolley problems? Entropy is why we can't have nice things.
>> At what point do we fault someone for not putting in work to delay someone else's death?
> That isn't what is happening. I'm faulting someone for putting in work, to expedite someone else's death.
My understanding is someone on ECMO needs continuous monitoring and infusions of things. You could put in work to proactively remove them from ECMO, hastening their death. Or you could stop putting in the work to continue the treatment and let what happens happens. Are those equivalent?
Maybe the machine needs maitenance to continue functioning and you don't do it.
Maybe you designed the machine so that it must be disconnected every 30 days, so that the default is death after a month and the doctors have to actively choose to replace the machine every 30 days if death is to be avoided.
Imagine taking someone off ECMO to save others but they all die too. A bird in the hand is worth two in the bush.
How many people would have to die because this one person is monopolizing the one (if any small N, even of one) ECMO machine before it’s unethical to keep them on it waiting to die of cancer?
Frequently these machines are used for things like surgeries, which frequently may not need to be done right this day while still being important. Keeping this one person on it may simply have decreased the number of such surgeries that could be performed per day, mildly increasing patient wait time.
How much of an increase in surgical throughput is worth killing someone for?
In the situation where they are on ECMO, and their removal from ECMO would result in their certain death (as opposed to, say, their recovery, or their transfer to a different life sustaining technology) then they should not be removed except with their consent.
That's an important piece of nuance.
This one’s real simple! They die.
If the resources that keep people alive are all taken and you’re not willing to take that resource from somebody using one, then the next person who needs one is going to be left out.
So either we get OK with pulling the plug, build more of the machines, come up with a new idea, or be OK with people who need these things dying.
The scenario you describe happens if sufficiently many such people exist, and if they are all placed in machines, and the rate of new machine construction plus the rate at which the current patients die of other causes is higher than the rate at which such people are being born.
I don't think that's a plausible scenario.
That is how I read it. One day he is texting and enjoying his friends (virtually) the next day it is just to expensive so they let him die. His friends wonder what happened.
Have enough machines. Make it so they're like ventilators.
Nothing in this story would rise to the level of "ethical dilema" if they had enough machines.
Unlike machines, people cannot be manufactured in large enough numbers, and there is an upper limit on people capable, skilled and willing to work in a high-stress environment like the ICU.
We can work to make the machines easier and more effective to use, etc. Hopefully these will improve the day-to-day lives and throughput these caregivers are able to provide.
The problem is not the machine. It is the human labor involved in maintaining operation of that machine. Vents are also labor intensive. You can't just intubate a patient and push the on button.
The problem is quite literally that it takes time and effort from a limited group of people. Do you allow new admits to die because your staff is consumed with maintaining people indefinitely on ECMO?
What I'm saying is that in the 70s, when dialysis started, with those reusable parallel plate dialyzers, that assisting someone with dialysis was a full time job for a person.
Now, because of advancements in dialysis machines, a single person can care for a whole clinic.
We can do the same thing for ECMO.
It's for sure going to become a dilemma going forward (and already is today). Saying that costs will simply go down with volume will likely not be true. At least that is not what the trajectory for the last 50 years has been.
People would hesitate to pay these large sums themselves, if at all they could, and people don't like higher taxes.
In the case study above, they weren't suggesting taking the teenager off the machine due to non-payment.
Reading the newspaper is a 'maybe' here, but the notion of patients just generally walking around while on ECMO treatment as we know it today is absurd. Letting a patient be ambulatory during ECMO treatment is still in the realm of very, very, very small-n clinical trials, and the risk of near-immediate death from things like a cannula dislodging are very high. Even if it was safe, you're looking at a massive cart of equipment and 1-2 dedicated personnel to walk around with the patient while tweaking its settings.
In general, nobody being treated by ECMO is 'reading the newspaper', if they're cogent and conscious at all. It has absolutely brutal effects on the body, and people are kept sedated while receieving the treatment for good reason.
It’s more complicated than that. If there’s only 10 ECMO machines available in a hospital, someone has to decide who gets those machines. Like the entire field of medicine, triage is necessary and sometimes ethics dictate someone should not go on that machine based on their chances of survival.