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"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.

by skerit 2y ago

"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.

margalabargala 2y ago
Fully agree. They have this case study later in the article: > 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.
- wizzwizz4 2y ago
  The most ethical position is utilitarianism, up until the point where people who aren't weak or sick or poor or otherwise downtrodden have to sacrifice a single grain of rice, after which it's deontological ethics and how dare you infringe upon property rights. (And I'm not just criticising other people, here.) 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 https://www.principiadiscordia.com/book/45.php contains about as much actionable advice as this here complaint of mine.
- datadrivenangel 2y ago
  How much work should we expect a person to do to keep another person alive? 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.
  - margalabargala 2y ago
    We as a society make a significant distinction between declining to provide something in the first place, and choosing choosing to take back something someone already possesses. To wit: > 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.
sithadmin 2y ago
>able to walk and read the newspaper. 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.
- morningsam 2y ago
  The article made it sound like it's commonplace. Thank you for this perspective.
darth_avocado 2y ago
> The only ethical problem I see is other people deciding what life is worth living. 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.
- xboxnolifes 2y ago
  Even more complicated is debating if it's ethical to take someone off the machine if it leads to savings more people. I know triage and giving up on treatment has precedent, but I'm not too familiar with forced removal of on-going treatment, knowing it will kill someone.
  - tnias23 2y ago
    I wouldn’t be surprised if combat medics are trained in triage ethics adjacent to this. Dumb example: you only have one tourniquet, and it’s on someone who will probably die, and suddenly you have another person who will only die if they don’t get that tourniquet.
    - darkerside 2y ago
      Great example. I'm curious if anyone has experience with this or similar.
    - xboxnolifes 2y ago
      There's difference in removing a tourniquet from someone who will likely die even with the tourniquet verses taking someone off a machine who won't die while on it, but is permanently reliant on it.

by skerit 2y ago

margalabargala 2y ago

Fully agree. They have this case study later in the article: > 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.

wizzwizz4 2y ago
The most ethical position is utilitarianism, up until the point where people who aren't weak or sick or poor or otherwise downtrodden have to sacrifice a single grain of rice, after which it's deontological ethics and how dare you infringe upon property rights. (And I'm not just criticising other people, here.) 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 https://www.principiadiscordia.com/book/45.php contains about as much actionable advice as this here complaint of mine.
datadrivenangel 2y ago
How much work should we expect a person to do to keep another person alive? 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.
- margalabargala 2y ago
  We as a society make a significant distinction between declining to provide something in the first place, and choosing choosing to take back something someone already possesses. To wit: > 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.

sithadmin 2y ago

>able to walk and read the newspaper. 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.

morningsam 2y ago
The article made it sound like it's commonplace. Thank you for this perspective.

darth_avocado 2y ago

> The only ethical problem I see is other people deciding what life is worth living. 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.

xboxnolifes 2y ago
Even more complicated is debating if it's ethical to take someone off the machine if it leads to savings more people. I know triage and giving up on treatment has precedent, but I'm not too familiar with forced removal of on-going treatment, knowing it will kill someone.
- tnias23 2y ago
  I wouldn’t be surprised if combat medics are trained in triage ethics adjacent to this. Dumb example: you only have one tourniquet, and it’s on someone who will probably die, and suddenly you have another person who will only die if they don’t get that tourniquet.
  - darkerside 2y ago
    Great example. I'm curious if anyone has experience with this or similar.
  - xboxnolifes 2y ago
    There's difference in removing a tourniquet from someone who will likely die even with the tourniquet verses taking someone off a machine who won't die while on it, but is permanently reliant on it.