Variations on an End-of-Life Theme


Really fascinating comments by Mike Darwin about what amounts to variations on end-of-life themes.

I think it’s a reality that the human body is programmed to deteriorate in time, probably led by brain function, anatomically and physiologically. It’s been said that this deterioration is universal and expected and so it’s incumbent on us to do what we can in the limited time we have. I have patients in their 60s that suffer dementia outside of the usual etiology of diabetes, hypertension and multiple stroke.  I routinely see 50 year old guys that look and act like they’re 80. I have had guys stroke big time in their 30s. Some have multi-organ disease, some don’t.  I knew guys that were old men in high school.

But the variation in brain function as the body deteriorates is very remarkable. My mother is 93 years and her body has just about hit the terminal skids. She’s deaf as a post, now wheelchair bound from generalized osteoarthritis. She weighs about 70 pounds now.  But she instantly recognizes me, asks about my family, knows all their names, remembers fine points of the past and I bring her big print books and crossword puzzles that she devours using a big magnifying glass.  My father died at age 90, the day before he had a mild stroke he was wandering around town in a sport jacket shopping for books to read. He was not hypertensive and never took a single medicine in his entire life. He died of anesthesia complications after an emergency operation for strangulated hernia (I suspect).  My paternal grandmother was dating much younger men in her late 60’s, advising them she was 50 and getting away with it. My German professor in college was 93.

Mike and I differ in that I look at life span very fatalistically. I’m acutely aware that I have been graciously given a finite amount of time on this earth and there will be limits to want to get done. And there is little in anything I can do about that. As I age, I find that I can do less and less of what I was able to do when I was 20 or even 40.  It just is what it is, and the benchmark is how much you can do in the time allotted.

Most of my friends who work with the brain are “scientists” who ponder about how the brain “works”. They poke and prod and measure things trying to find out what it means when an impulse moves from one place to another through various neurotransmitters.  Personally, I don’t think any of this matters because it won’t lead to an understanding of what and why we are.  Where the rubber meets the road is what makes us cognitive humans, not collections of neuron circuits. I think the ultimate explanation, if there is one, lies in the realm of philosophy. I try to understand it using a common sense filter.

I suspect there are aspects of the brain that are very computer-like.  Hawking said there is no after-life because when the computer is shut off, it’s function totally vanishes in a volatile fashion. But I’m not so sure.  The human soul is what differs us from dogs and cats, and does not necessarily depend on computer function to exist.  Whether the seat of the soul will be the ghost in the computer is a much more interesting and elusive concept.  It could be argued that person-hood probably has some storage area. Maybe not, but let’s argue that it is unlikely to exist in the ethereal mist. Everything that makes David Crippen or Mike Darwin a “person” is possibly contained in the transfer-RNA of those parts of his brain reserved for memory and storage of experience.  The technology for unlocking this resource and transferring the information to a super-computer does not currently exist but it will in the future, as the development curve for computer power is almost vertical. It’s only a matter of time. As far as that goes, it’s only a matter of time before computers become “self aware” as in the “Terminator” sense, but I digress.

If this information can be uploaded, there is no technical reason why it cannot be downloaded back into another storage area (super-computer?) or (why not?) another brain wiped clean of information. There are people that think this is possible, or will be in the future.  But, does that make David Crippen the same guy that now tutors doctors, drives exotic sports cars, ogles gorgeous blondes, plays in a rock band and tours the world on two wheels?  Technically, it’s possible but I suspect not. The information held in the portion of the brain that serves as the repository of the person of David Crippen is not all there is. I suspect the person-hood of David Crippen is more than the sum of his parts. It is the interaction of the sum of the parts that would not necessarily occur outside the delicate balance in its original setting, even though all the parts were present. Like cutting up a camel and then putting him back together. All the parts would fit but they would not necessarily work the way they did before.

Mike wants a chance to come back and live another lifetime, maybe an infinite number of lifetimes. The potential to do that is unlikely but possible. I’m not sure at all that I would want to do that as the same person that I am now. I have managed to pack a lot into my life and plan to pack in a lot more before age incapacitates me. But I think I will be happy with what I can do in a “lifetime”, for a lot of reasons.

I think if my brain were reconstituted from it’s current iteration by transferring all my t-RNA (constituting my memories) into a super-computer and then downloading it into a wiped clean brain, there is no guarantee that I would emerge as me.  My memories are not necessarily my soul, and there is no guarantee that my soul can be localized, accessed and reproduced. I am a creature of my present, an integral part of my present. There is no guarantee that I would not find a future to be like an LSD experience, an untenable psychosis in which I would not be able to participate. It has been my experience that many people I have known welcome death at an advanced age. They did what they did and the time came.

On the basis of my family history, I suspect I will live to my 90s.  I’ll probably dance on Darwin’s grave. If I do, I think I will accept the inevitable deterioration in my persona and do what I can with what I have to work with. It isn’t out of the question that someday I may reside in a personal care home for no other reason that I won’t be able to take care of myself. I’ll hang photos of glory days on the wall and hope my vision and hearing will allow a laptop that I can keep an eye on what’s happening in a world I can no longer participate in. I think I would be happy with that deal, all things considered. I don’t think I would be capable of starting over. I had my shot at it, I took it and when the time comes, it must be given up gracefully, ever thankful for the opportunity.

On the nature of death and personhood


Most of my friends who work with the brain are “scientists” who ponder about how the brain “works”. They poke and prod and measure things trying to find out what it means when an impulse moves from one place to another through various neurotransmitters. I don’t think any of this matters because it won’t lead to an understanding of what and why we are. I’m interested in where the rubber meets the road, especially what makes us people, not a collection of neuron circuits. Hammaroff is trying to explain philosophical concepts using physics. I didn’t think that was possible the first time I heard it, and I still don’t. I think the ultimate explanation, if there is one, lies in the realm of philosophy. But I’m not smart enough to understand much really involuted philosophy, and certainly not physics since I can’t add two and two three times and come up with the same number. I try to understand it using a common sense filter.

Having said that, I suspect there are aspects of the brain that are very computer-like, and those secrets will be unlocked in the future. Whether the seat of the soul will be the ghost in the computer is a much more interesting and elusive concept. Person-hood probably has some storage area. Maybe not, but let’s argue that it is unlikely to exist in the ethereal mist. Everything that makes a “person” is possibly contained in the transfer-RNA of those parts of his brain reserved for memory and storage of experience. The technology for unlocking this resource and transferring the information to a super-computer does not currently exist but it will in the future, as the development curve for computer power is almost vertical. It’s only a matter of time. As far as that goes, it’s only a matter of time before computers become “self aware” as in the “Terminator” sense, but I digress.

If this information can be uploaded, there is no technical reason why it cannot be downloaded back into a storage area (super-computer?) or (why not?) another brain wiped clean of information. There are people that think this is possible, or will be in the future. Cryonicists are involved in the practical aspects of this, and currently there are about 150 severed heads reposing in liquid nitrogen awaiting the day. (Am am not a Cryonicist myself but I understand the theory because I have friends that are passionately involved).

In so doing, all memory and experience would be restored in a different brain. Does that make the same individual that now tutors brainiac graduate students in physics? Technically, it’s probable but I suspect not. The information held in the portion of the brain that serves as the repository of the person is not all there is. I suspect the person-hood is more than the sum of his parts. It is the interaction of the sum of the parts that would not necessarily occur outside the delicate balance in it’s original setting, even though all the parts were present. Like cutting up a camel and then putting him back together. All the parts would fit but they would not necessarily function the way they did before.

We have very issues in deep in clinical medicine that blend into philosophy and even morality. The issue of organ donation for transplantation is quickly heading in this direction. For the moment I will simplify it for you. Traditionally organs are only donated after brain death, which is defined as clinical death by law and by current social agreement. Recently, another way of defining death has become popular, that of “cardiac death”, when the heart dies, the brain eventually dies, and so it’s death once removed. Again this is complicated, so trust me on this for a while.

The maxim is that when the heart dies, brain death is inevitable so the patient is “dead enough” to offer up organs for donation. But the key to brain death is “irreversibility”. By statute, the brain must be irreversibly dead become clinical death occurs. But with cardiac death, the brain may or may not be irreversibly dead. We don’t know because we don’t try to resuscitate the patient after cardiac death occurs. This brings up an interesting philosophical question involving cryonics.

Consider this interesting thought experiment.

The drill that occurs in the initiation of cryopreservation is interesting. The dying process is monitored and observed and then the patient is officially pronounced dead by a physician. At that point the patient is very legally dead. Once that pronouncement is made, the patient becomes a cadaver, and the rules for dealing with cadavers are quite different than with live humans. The concept of “consent” changes (a patient cannot consent to be dead at a finite point, but once dead, the family can order up just about anything). The consent for the cryopreservation kicks in (illegal before death). The cryopreservation team springs into action and “resuscitates” as much as they can to insure the best possible tissue condition for the procedure of preserving enough brain function to someday retrieve t-RNA and other goodies from the brain. This involves restoring blood flow to the brain ASAP. A mechanical CPR device is quickly brought to bear and “effective” CPR is initiated, creating forward flow of circulation. Inotropes and vasopressors are brought into play. The cadaver is intubated and placed on mechanical ventilation.

Now it gets interesting. In many instances, the cadaver “wakes up” following this treatment. Pupils respond again and spontaneous motion occurs. In many cases they use the potent sedative 5-hydroxy GABA (brought in from Mexico) to stop moving them around. Then the major artery and vein are cannulated and the preservation brew is circulated through the tissues to protect it from ice crystals during the freezing process with liquid nitrogen.

Was this patient really “dead”? Sure he was. He was officially pronounced dead by a licensed physician. A patient is dead when his doctor says he’s dead. The morgue and the Conqueror Worm await. Is the person Is morally, ethically spiritually, physically, positively, absolutely, undeniably, reliably and most sincerely dead? That’s a lot more arguable.

On death and cryonics


On death and cryonics

I was asked to be part of a panel for a meeting exploring the concept of death, it’s substance and timing for the 7th annual Alcor Life Extension Foundation. You can Google it. Alcor is an organization that pursues the goal of (essentially) preserving brain function for posterity, in the hopes that nanotechnology will be available at some time in the future to re-boot the brain, and participants (re)live again. The theory is interesting, and certainly not out of the question that it could work. Remember that what sits on my desk right now is more computing power that existed in the world in 1967. Fifty years on, it may be possible to do a lot of things that we don’t conceive of now. I am not a cryonicist, but I have close friends that are and I understand a lot of it. There are some pretty high powered PhD types, and a few MDs deeply involved. I have no doubt that Darwin will correct any of the above if I got any of it wrong.

At any rate, cryobiology is facing a big problem, that of the timing of death. In order to preserve the structures they are interested in, it’s necessary to first pronounce the patient dead. Obviously they cannot start any of their procedures if the patient is still alive. Once dead, the rules change regarding what can be done to a cadaver. Most of what happens thereafter comes under the Anatomical Gift Act. Normally, a physician pronounces the patient dead and immediately thereafter, the patient is (re)intubated and a mechanical CPR devise is attached to restore circulation while various intravenous preservatives are infused into the brain, preparing it for freezing.

Prior to the advent of high tech critical care, this was much simpler. A patient was dead when his pronouncing physician said he was dead. However, nowadays, it isn’t that simple. Patients sometimes show renewed “signs of life” following resurgence of ventilation and circulation. Pupils constrict and sometimes spontaneous motion is observed, sometimes requiring the use of potent sedative drugs intravenously to stop it. This then forces a very interesting and important question. Was the patient really dead when he was pronounced so? Or is it a resurrection.

Naturally, cryonicists are very concerned about this since the timing of what is sort of dead and stone dead directly impacts their entire function. The brain must have some semblance of continuing function in order to be resuscitated. For this reason they rely on Donation after Cardiac Death criteria, not brain death. There is frequently if not always some residual brain activity following cardiac standstill but the patient can be pronounced dead. They are counting on this flickering flame to be amenable to nurturing.

The other panelist and I spent a good bit of time explaining the realities of what constitutes death, following which we were opened up to questions from the audience. They (cryonicists) have some interesting ideas about all this, which I will outline below:

1. They are very much ethical utilitarians. If it is a good and just end, the route there matters little. Few of them seem to understand that the end is directly modified by how it’s achieved. They don’t understand why it’s a big deal to insure that the route taken is as pristine as the end they hope to achieve. It does not enter their logic how frighteningly dangerous utilitarianism can be.

2. They are deeply into “consent” as a trump card for all obstacles. If they are authoritative, autonomous individuals and they have a desire, that should trump all other issues. This is what they want for themselves, and that should be enough to cut through all the red tape. In fact, one fellow actually did get up and say: “This is what I want and that should be enough to cut through all the bullshit”.

3. At some point in my diatribe, I mentioned that there was nothing inherently evil about Donation after Cardiac Death. These patients were going to die anyway, and so it isn’t too big a stretch to use that fact to the advantage of others, BUT it IS a creative workaround of the rules which state that brain death is the only form of death defined by the Dead Donor regulations. And once a workaround starts, you can be sure there will be more and the foot gets deeper into the crack between the door and the jamb, and with the current high demand for organs, the bottom of the slippery slope might be selling organs on EBAY.

At this point no less than ten, or maybe more audience members yelled out: “What’s wrong with that?” I was stunned speechless, and that takes a lot for me. My jaw bounced off the floor with a loud clatter. I was totally at a loss for words. It took me a minute to reconstitute and utter something along the lines that any such transactions would always be at the expense of the poorest factions of society, most amenable to manipulation and abuse of others who would profit from them. And I thought that was unacceptable in a just society. Most didn’t seem to be impressed with that argument. The ultimate libertarians.

So, for my part, I left them with the following advice.

If they expect to evolve and assimilate into the mainstream of science, they need to start doing their research in mainstream labs and publishing in mainstream journals. They need to get over their current concept of consent as a trump card. One cannot consent to be dead at a specified time, and consent to be dead before that time is euthanasia, which is illegal and people go to jail for it. They need to start moving away from the concept that they are practicing medical interventions on cadavers. Technically, most if not all of their patients are still alive by brain death criteria, and DCD is this justification as is it still not universally accepted. They need to develop some kind of a mode of “intervening in a dying process” that will be found acceptable by ethicists and lawyers. Ultimately their ministrations will attract the attention of both if it hasn’t already.

On Organ Donorship and rules


A very healthy 40 year old college professor develops a headache and collapses at home. CAT reveals a large but localized intracranial bleed that turns out to be bleeding into a large Glioblastoma. The patient is intubated, unresponsive but postures to pain. No operative intervention. Neurosurgical opinion is patient will not get better but will not progress to brain death.

Family is VERY reasonable and accommodating. They say they understand the situation and accept it. The family VERY much wants to donate organs. The patient will not pass a brain death protocol. Nor is he a candidate for Non-Heart Beating Donation (Donation after Cardiac Death). His heart and lungs are strong and he ventilates normally on a T-Tube.

As it happens, there is a blood relative of the patient awaiting a kidney for chronic renal failure in another State. The family desires a Directed Living Related Kidney donor gift from the patient to the relative. So the plan was to take the patient to the OR, take the kidney as a normal donor might, close the operative wound normally, recover the patient normally from anesthesia, bring him back to the ICU and then withdraw care according to the wishes of the surrogate. But there’s a problem. The related recipient was tested in the usual fashion and doesn’t match. Something about having had children in the past and now is not a candidate for this kidney and is back on the list.

So……the family now desires a kidney to be taken from the patient in the same manner and given to anyone on the current list who will match. The wife says the patient would want to give his organs but the current rules of the game prohibit it, so what’s the problem with end-running the rules by simply making it a consent issue? He would want to give the kidney, the wife wants him to give the kidney and the relative can use the kidney. The “rules” only get in the way.

Is this ethically acceptable?

For the case I presented, I think there is a big difference in a terminally ill but not brain dead patient donating a Living Related Donor kidney and donating a kidney to the top of the anonymous list. It could (and has been) considered an intentional end-run of the “rules”. It is not done here at UPMC, BTW.

There are rules governing the donation of organs. The reason for those rules are to avoid the plot of the 70s movie Coma by Robin Cook and selling organs on EBAY. Anyone with an interest in how the rules go, look up the 1981 Uniform Determination of Death Act, Burke and Hare scandal, the “Dead Donor” rule. These rules say that brain death equals death and once death has occurred, organs, if they are viable because they have been supported, can be procured. If the brain is not dead, they can’t. I am hoping Leslie gives us her expertise on this matter but here are my thoughts, FWIW.

I can donate a kidney to anyone I want anytime I want but normally there has to be some reason I would want to do that. I can give it to my daughter if she needs one because it’s a good thing and the right thing to do. Maybe even my lifelong best friend if he matches. It passes the test of “reasonableness”. However, it isn’t as reasonable that I give a kidney to someone I don’t know and isn’t directly linked to me in some fashion. That would be a nice gesture if I really wanted to help my fellow man, but I wouldn’t do it and not many others would do it either. It doesn’t pass the test of reasonableness.

Dick mentions “bloody nearly dead”. That raises the subject of bending the rules. A patient that does NOT pass the criteria for brain death is excluded from donorship even if he or the family wants it. It is not a consent issue. It is a rules issue. Greater good. Avoiding potential damage to society by limiting the autonomy of a few. Them’s the rules. But, in order to create a bigger pool of organs, the rules have been bent just a little by Donation after Cardiac Death (DCD), formerly called Non Heart Beating Donation. In this scheme, cardiac death is substituted for brain death in patients that are “bloody nearly” brain dead. In DCD, the brain may very well continue to be alive when the patient is pronounced dead by cardiac criteria. The heart is irrelevant. It only informs as to the status of the brain, and the rules are clear. But in current dogma death is defined by the status of the brain. Donation after Cardiac Death is very, VERY controversial and a groundswell is building against it. But, for now, it’s legal and done in some hospitals. It is NOT out of the question that it may be stopped someday unless the rules change.

But that’s another argument. For the present argument, I personally (FWIW) think that a non-brain dead potential donor can (through pre-existing declaration of wishes or through surrogate) “decide” to donate an isolated kidney to a relative because it passes the test of reasonableness. If there is evidence he would do that anyway even if he was alive and healthy, it’s reasonable to assume he would do it if he had the opportunity but was incompetent to consent. So he might be taken to the operating room, the kidney removed as it would be in anyone else, the patient recovered in the Post Anesthesia Recovery Room and sent back to the ICU in the same condition he left, then life support withdrawn.

However, doing that exact scenario to give a kidney to an anonymous recipient on the transplant list is not quite the same thing. THAT scenario is EXACTLY as what might transpire had the patient been brain dead. It is not “reasonable” that the patient would, in life, give a kidney up to someone he doesn’t know so it isn’t reasonable in near-death. It VERY strongly smacks of end-running the rules just to get the organs, which is exactly why the rules were enacted.

SO, my advice is to adhere to the rules because the rules are beneficial and prevent abuse that would most certainly happen. If we want to increase the pool of organ donors, go to the public and make a case for expanding the pool by expanding the definition of eligibility. If a patient isn’t quite dead but “dead enough”, then they qualify. See if the public buys that. Until then, the rules should prevail to the letter.

On Terri Schiavo and the right to die


As of now (0600 hours in Pittsburgh) the court of appeals in Atlanta has upheld the ruling of the previous courts in the Schiavo case. There will be no more feeding tube. This is probably the last appeal. It is highly unlikely the Supreme Court will hear the case.

I have only a few brief comments before we shift this discussion to Med-Events where it belongs now.

In my opinion, this is a terribly scary potential precedent because it has been made an all-or-nothing issue. As it shakes out, if a person does NOT have a living will or some other instrument declaring their wishes, it is ASSUMED that they desire to be kept alive by any means possible. That’s ridiculous and a false premise. NO ONE would want to be in a nursing home with a feeding tube drooling and gawking at nothing in particular. This family has bought into the pie in the sky bye and bye long shot cure. They told the court they thought she has “Rehab: potential. She doesn’t. Bill Frist, in his clinical wisdom looked at the distillation of hours of video tape and made the statement that she seemed to be reacting to her environment. Her reaction to her environment is always the same. What Sanjay Gupta calls “unaware wakefulness”.

So in my mind, had this issue been resolved in favor of the parents and the feeding tube replaced, no one in this country would ever die without the full application of “everything”. I believe the husband is correct. That she at some point in their relationship made noises like she wouldn’t want to live in PVS should it ever occur because NO RATIONAL PERSON WOULD DESIRE IT. She doesn’t have a living will or other such document because she was a healthy person in her 20s and very few such young persons feel the need to draw up such a document. I believe a husband knows his wife’s wishes infinitely better than parents. He has the right and the authority to speak for her and that’s the end of it.

I think that the inverse of this issue should be considered. That a person who lands in PVS for more than a year should be considered to NOT desire that state and should be removed from all extraordinary care unless they provide a prospective document stating they WOULD want to be maintained in an indolent state with no home of ever coming back. I defy ANYONE in this group to tell me they would sign such a document.

Emotions have clouded the reality of this issue and it has become a fight to see who can win, not what’s in the best interest of all those involved in this disaster. Not one of the politicians that got together for this circus has the slightest interest in Terry Schiavo. They all knew this would never fly in the appeals but it gave them all an opportunity to show how “humanistic” they are for their constituents. Lots of crocodile tears and “vote for me in November- I’m for human rights”. Cheap points.

One more thing- on the way back from NC yesterday I was looking for a National Public Radio station and happened upon some National religious evangelist speaking on this issue. He introduced so and so who he described as a “bioethicist”. The “bioethicist” quickly launched into a personal opinion diatribe following the hard line of one side of this issue. I would have loved to have called in and asked after the qualifications of this “bioethicist” with lots of personal opinions and nothing else to offer. The whole point of bioethics is to look at the frameworks of these issues and how decisions are made, not to simply give a heavily biased opinion, couching it in terms of academia. In that regard we are lucky to have the real thing on CCM-L.

If there are any true villains here, they are the politicians that forced this issue into the Federal courts after due process was had at the State Level. They knew it wouldn’t fly there and they also knew it was an excellent opportunity to jump on the “humanistic” bandwagon risk free. It’as always politically correct to come out on the side of “human rights” even though that isn’t what this case is about. If there was a chance the court might have found for the parents, all of them would have hedged to see which side was the probably winner and then came out on that side.

They came out with some of the dumbest statements I ever heard. Not one of them had a clue what they were talking about including Bill Frisk. One bemoaned the terrible pain and agony of “starving to death”. It’s totally painless and discomfort free in this situation. Some female weighed in as a “mother” decrying that Terry “had done nothing to deserve starvation”, relegating this to a criminal case. The opportunistic bastards each and every one only did this to get some cheap points with the public. They’re responsible for this not to have ended like it should have, after due process.

Leslie Whetstine says that there is nothing new here. There are several states (Florida among them) that require “clear and convincing” evidence that any maneuver to an incompetent person is in their best interest. Remember the Cruzan case was in Missouri, a state also requiring CCE. Pennsylvania and most other states require only a “preponderance” of evidence, a much easier standard to achieve. So in Pensylvania, it is enough that a husband knows the wishes of his wife without having to prove a written declaration. In Florida and Missouri it is not enough.

The law in Florida is clear but there was dissension among the family and a lot of special interests involved, so it went through the court system and in the end the issue was resolved legally. The finding by the state high court that the husband was authoritative essentially threw out the premise that a written declaration was required, a ludicrous proposition anyway. Young people don’t make out living wills because they think they’re going to live forever. Old people don’t make out living wills because they’re afraid of death. It is a VERY fallacious argument that because these people choose not to declare in written form that they NECESSARILY wish to be artificially kept alive in a blank state as long as humanly possible. That’s simply ludicrous on the face of it.

The Clear and Convincing evidence rule instantly revokes the Principle of Unintended Consequences and needs to be abolished in my opinion. This case might be the first step.

As I remarked in earlier sagas, I heard a pulpit pounding tele-evangelist make this issue very clear from the religious right. He said that if we start going around deciding which incompetent persons should not be kept alive on the basis of what we “think” their mental status is, we’ll eventually let someone die who is capable of potential rehabilitation. Therefore, it is necessary to keep EVERYONE alive as long as possible to insure a very few don’t fall through the cracks. He made no distinction at all between PVS patients and ICU patients on vents and life support. Further- Terry or anyone else in similar circumstances may have a right to be sustained in a state of “unaware wakefulness” if she so desires, and there is no convincing evidence at all that she does, or that anyone else does either. But it is not clear at all whether the taxpayers have the same obligation to fund it.

There it is. That’s where this is going. Those who desire to keep Terry alive indefinitely do so because they belive that, even after fifteen years, she will someday wake up and be normal. Says so in the National Inquirer every issue. They advocate keeping all such persons alive on the vanishingly slim change one or two may unexpectedly get better. And they expect the taxpayers to fund it.

On Abortion and human rights


It is all well and good to mount moral outrage over the destruction of a little clump of cells nestled somewhere trying to grow. That’s just fine, all other factors equal. If it was just a little clump of cells somewhere trying to grow, it would not be the huge, monster issue that it is. But there is infinitely more to the story. What lawyers call mitigation and extenuation.

It isn’t an isolated issue and it cannot be treated as such any more than it can be said rigidly that it is ALWAYS mandatory to tell the truth or avoid killing in war. Truth telling has much more weight than lying, and other things being equal, it is always better to tell the truth, but not ALWAYS. I am reminded of the parable about the Roman guard coming to the door of the resident hiding innocent Christians in the basement, asked do you have any Christians in your basement (so we can kill them on the spot)? If strict truth telling is the maxim, then paradoxical harm can and does result. Accordingly, the preservation of life carries more weight than killing, but not ALWAYS. If the ALWAYS maxim is ALWAYS carried out, harm can and does occur. Had we taken the position that killing is ALWAYS wrong, then we would have sat on our thumbs and watched Hitler destroy the world. Sorry…..there is NEVER an excuse to kill another hominid so we’ll just shake our finger at them and tell them they aren’t being very sporting as the Storm Troopers advanced on us with bayonets.

It is VERY difficult for me to believe that anyone currently arguing this point is willing to tell me that it’s the right thing to allow the Roman to kill the Christians, or would have been the right thing to do to sit and watch Hitler take over the world without fighting, and necessarily killing, to preserve the world for humanity. So…..given that no one is willing to ague this, then it must be agreed that SOMETIMES lying and killing might be in the best interest of the greater good. Once we accept that, it then simply evolves to a matter of “which” lies might be appropriate and “who” is the right person to kill. If anyone does want to argue that we should all be killed in our beds to avoid having to take a life, then we no longer have a conversation here.

There are realities in life that extenuate the maxim that the preservation of life is foremost. One of those realities is that the carrier of that clump of growing cells is inexorably involved in the process, and that carrier is a “real” person with a real life, not a potential person with a potential life. And that real person has a fundamental driving force that is so powerful it has never been harnessed in the history of society. That fundamental force is the overwhelming, incapacitating compulsion for sexual intercourse. Like a fart, so powerful an elephant can’t hold it.

Females of childbearing and near-childbearing age indulge in various forms of sexual intercourse (with a huge supply of willing males) with a compulsion that is hard wired into the genome and impossible to assuage. It cannot be controlled or diverted or managed. It just happens, and it is such a powerfully consuming compulsion, the practical aspects of avoiding unwanted pregnancy are frequently left in the dust. the coming to of senses occurring after the red mist lifts. That’s just the way it is.

I remember when legal abortion was not available in the 60s, my father the surgeon told me that the staunchest opponents of abortion were as quick to sneak in the back door of an illegal abortion mill as anyone else when it affected their family. He predicted the legalization of abortion as early as the late 60s, if only to stop women from dying in septic shock with coat hangers sticking out of them. Current statistics, and although I cannot put my hand on them right this minute, that one out of three childbearing age females will have an abortion in their lifetimes are very convincing. Rapes, being carried away with the heat of the moment and well-intentioned birth control malfunctions and you have a very big pool of situations where the harm to the “real” person by a “potential” person is very real indeed. A situation where “real” lives are ruined in real time in a real society.

Your 17 year old daughter, just admitted to Harvard to start a career, caught in the heat of passion in the back seat of a car. Shaking your finger at her and telling her..sorry, the preservation of a rice sized bundle of cells comes before your life now. Sorry your life is ruined but there are no exceptions. Your Downs-syndrome daughter who didn’t understand the situation and will now be saddled with a baby she cannot fully comprehend. The ruptured condom, the failed BC pill or IUD……sorry no exceptions. The “welfare mother” with three kids she cannot support and will never be able to support, whose potential son awaits the age where he’ll be welcomed into the growth industry of Crips and Bloods and prison. The product of a rape from a sociopath’s genes mixing with your daughters.

These are mitigating and extenuating circumstances that MUST be considered in a just society. The ability to survive in a hostile environment is the ability to prioritize. And prioritization, by it’s nature, is sometimes neither fair nor equitable, but it must be accomplished in order to survive. Sometimes it’s a higher priority to prioritize the needs of one life over another. An active life as opposed to a virtual life. Maybe not totally moral, but necessary. Morality is sometimes an ideal that cannot be maintained. We should always try, but we cannot always succeed.

Accordingly, I am quite content to take the position that we should not lie and we should not kill. Most of the time. And I am very thankful that women have the right to choose.

I don’t bring this up to argue it. No one will change their mind on this issue because of anything I or anyone else thinks about it. I simply bring it up to tell you the logic of my opinion.

That’s the end of my participation in this thread.

Customer Satisfaction in medicine


A recent survey- about ONE THIRD of responders are willing to buy into “customer satisfaction” as an open ideal such that maintaining corpses in an acute care ICU is should be a family right and privilege and the corpse should stay right there till the family gives permission to remove it. Given the current “customer is always right” climate in medicine, I sort of expected this but I am still amazed by it. I think those electing to appease this mother are sincere in their idealism, but sincerely wrong, and this has the potential to do much more damage than good.

Medicine is different than fast food. It isn’t like Burger King trying to do ANYTHING they can to outfox McDonalds. They’re fighting over the same burger in a different wrapper. It doesn’t matter what one is willing to do to garner more customer satisfaction because it’s a zero sum game. But in medicine, allowing customers to rule has the potential for disaster. Medicine is one of the few, perhaps the only “business” where the customer is not always right. And the customer should not always have what they want. There are points in the delivery where the customer might very well use faulty, and especially media fueled logic to desire things that are paradoxically detrimental. At some point, those who know better must step in and divert that detriment, whether the prospective patient likes it or not.

So, in medicine we try to create customer satisfaction in the realm of public relations. We see that they get treated fairly, equitably, with kindness and compassion and that they get accurate information they can make decisions by. We do not, however, allow open ended customer satisfaction in the realm of clinical decision making. It is here that the notion that the customer is always right has over-extended.

When a corpse reposes in an ICU on a ventilator, a family has a right to accurate information, compassion and sympathy for their situation. They have a right of reasonable visitation with the decedent to say their goodbyes and acclimatize. After that, they do not have the right to maintain a corpse on “live” support interminably as a manipulation to express their anger at the socio-political ethos that brought them there.

This mother knew her son was going to be dead 48 hours before the fact. He was shot in the head and was completely unresponsive and was told in no uncertain terms that the chances of survival were nil, even before brain death. There was time to acclimatize. Once brain death occurred, and the death certificate was filled out, she then intentionally manipulated the situation, not for anyone’s benefit but only to assuage her anger. She was angry at having to live in a war zone. Angry that her son got mixed up with violent illegal activities. Angry that the cops and the community could or would not do anything about it. And that anger spilled over to the caregivers because we were all part of the same evil system as far as she was concerned.

So in her anger at the situation, she struck out to show them (us) all that she did too matter, and she did too have power, and she did too have the ability to make them all hop on demand, at least for a brief while. She struck out by insuring that her wishes were finally respected, if even for a brief period of time. She did so by making demands that showed them all. Not power to make things happen but power to keep things from happening. Same kind of power as far as she’s concerned. She did that by finding out what we all wanted, and making sure she got crosswise with it.

She had 48 hours from the time he was shot, then nine hours from the time the death certificate was filled out to be with the body of her son and do goodbyes. She spent 30 minutes of it at the bedside and all further negotiations took place by phone fro her phone. She made no attempt to come back in. She knew we wanted to move the body so she refused. It was her way of showing us who was in charge. Then she disappeared and refused to discuss it, saying only that she’s get around to it and she’s let up know when she got around to it. then stopped taking calls. She didn’t care that other sick patients were awaiting care in this acute care unit and that the corpse was literally blocking traffic. She cared only about getting quits with the powers that put her in the position she was in.

Is this the kind of customer satisfaction we should buy into because of the inalterable maxim “The customer is always right”?

The answer is no. This is no longer a matter of customer satisfaction, it is a matter now of simply doing the right thing come what may. This customer was never going to be satisfied no matter what was done. Her satisfaction derived specifically from getting as crosswise as possible with the “system” and getting away with it as a means of getting parity. The only means she had.

So she was gently told that she was not going to be allowed to maintain a dead body in an acute care area. it was not a decision she was authorized to make. Period. No further discussion. She then threatened to sue (an empty threat but a common one from people working the system), and then got in her car and drove here not to see her son, but to the Patient Relations office to complain that her demands were not being met and she was an unsatisfied customer. Mercifully, the Patient Relations office told her the same thing I did and also told her that they would be happy to have her lawyer (when she found one) contact the hospital lawyer.

Then then drove home and has not been heard from since. Presumably she feels she got quits with the system now and it’s back to business as usual.

D. Crippen, MD

On Diplomacy


By history, my father is a general surgeon in a small town in Georgia for his entire life. Currently retired at age 88 but still gets up every morning and goes to work somewhere, volunteering something. He has taken care of patients for 60 years.

From the time I started medical school till the present he has only given me two bits of advice on how to being a doctor. Just two. For what it’s worth, here are those sage bits of advice:

1) “You’ll probably like women but you’ll definitely hate doing pelvic exams. It loses the mystery at eye level under the hot lights”

2) “Don’t ever yell at the nurses. Everything immediately goes from bad to worse”.

I have found both of these tidbits to be true in spades. Of particular note is the admonition about yelling at nurses. In that regard, I have learned over the last 20 years that three laws hold irrevocably true:

1) The short term consequences of yelling at nurses are that you can be sure that anything going bad will instantly and irrevocably get worse. If they couldn’t or wouldn’t do what you wanted before you blew up, the real chances of it happening afterward simply evaporate. They either completely decompensate or run around at a quicker pace trying to look like they’re being more efficient with nothing effective being done. You can take this to the bank.

2) The longer term consequences of yelling at a nurse virtually guarantee that your name will sucked into the pipeline of “problems that need to be addressed” and you will then die the death of 1000 meetings, a painful and debilitating fate.

3) Surgeons who develop a reputation for yelling at people slowly lose repute among their colleagues. The old chestnut of “Lord, Master and Captain of the Ship” has pretty much been replaced by “Lord, Master and Team Player”. Like it or not, there is a lot more team effort involved in patient care than there was in the 50s, and not only are nurses part of that team, they don’t grow on trees anymore. Picture what your life would be like with out trained and experienced NICU nurses.

It has been my experience that these irrevocable laws simply make hassling nurses a lose-lose proposition, not matter how ego satisfying it might be at the time to establish who’s boss. I would suggest that the maximum efficiency possible occurs when you guide events with an even temper, simply emphasizing the importance by tone, and assuming everyone is doing the best they can under the circumstances. Perceived lapses are best handled after the fact.

My humble US$00.02 worth (probably over valued)

David Crippen, MD, FCCM