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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. Li

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 3y 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 3y 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 3y 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.
  - datadrivenangel 3y ago
    That's what makes it such a fascinating ethical issue! 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.
dbt00 3y ago
I might agree with the decision to keep the one person alive, but right now we have limited numbers of machines and medical professionals to run them. 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?
- margalabargala 3y ago
  Like most things, it's not that simple. 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?
renewiltord 3y ago
Just so it's clear: Your preferred strategy is that once anyone is placed on ECMO, they should not be removed except through their consent under any circumstances. Is that true?
- margalabargala 3y ago
  No, that's not it. 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.
  - renewiltord 3y ago
    Understood. So in time, provided that such people exist in sufficient quantity and we don't avoid placing them on the machine, then we should expect that all ECMO machines will eventually be occupied. What happens to the next guy?
    - paulcole 3y ago
      > What happens to the next guy? This one’s real simple! They die.
      - renewiltord 3y ago
        Just a trolley problem in the end, eh?
        paulcole 3y ago
        Yeah I mean it’s pretty obvious. 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.
gscott 3y ago
> because he wouldn't just hurry up and die 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.
iancmceachern 3y ago
The largest part of the ethical dilemma here was caused by a simple, solvable problem. 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.
- inglor_cz 3y ago
  Those machines need highly qualified personnel in order to save patients. 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.
  - iancmceachern 3y ago
    100% 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.
- Zenzero 3y ago
  This is almost becoming too much to respond to everyone in this thread saying this. 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?
  - iancmceachern 3y ago
    I know, I design these things. 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.
flakeoil 3y ago
But who is going to pay for it? There are more and more amazing machines, treatments and medicines available every year and soon it will be impossible for society to pay for it. And the longer our lifetimes extend thanks to one treatment, the more treatments we can use in a lifetime, and the cost increases even more. 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.
- margalabargala 3y ago
  The same person paying for it now? In the case study above, they weren't suggesting taking the teenager off the machine due to non-payment.
  - flakeoil 3y ago
    Well my point is that healthcare is getting more and more expensive. At some point we will come to a limit where the money is not there or that the individual himself has to directly pay for it and take that decision. Will the kids work their asses off for the rest of their lives to give their dad another year? Or are we prepared to pay double the tax rate we pay today to cover all the new opportunities in healthcare? If more and more people live to 100 and beyond, then we will need more and more healthcare over a lifetime. Who will pay for that?

wizzwizz4 3y 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 3y 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 3y 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.
- datadrivenangel 3y ago
  That's what makes it such a fascinating ethical issue! 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.

dbt00 3y ago

I might agree with the decision to keep the one person alive, but right now we have limited numbers of machines and medical professionals to run them. 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?

margalabargala 3y ago
Like most things, it's not that simple. 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?

renewiltord 3y ago

Just so it's clear: Your preferred strategy is that once anyone is placed on ECMO, they should not be removed except through their consent under any circumstances. Is that true?

margalabargala 3y ago
No, that's not it. 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.
- renewiltord 3y ago
  Understood. So in time, provided that such people exist in sufficient quantity and we don't avoid placing them on the machine, then we should expect that all ECMO machines will eventually be occupied. What happens to the next guy?
  - paulcole 3y ago
    > What happens to the next guy? This one’s real simple! They die.
    - renewiltord 3y ago
      Just a trolley problem in the end, eh?
      - paulcole 3y ago
        Yeah I mean it’s pretty obvious. 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.

gscott 3y ago

> because he wouldn't just hurry up and die 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.

iancmceachern 3y ago

The largest part of the ethical dilemma here was caused by a simple, solvable problem. 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.

inglor_cz 3y ago
Those machines need highly qualified personnel in order to save patients. 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.
- iancmceachern 3y ago
  100% 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.
Zenzero 3y ago
This is almost becoming too much to respond to everyone in this thread saying this. 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?
- iancmceachern 3y ago
  I know, I design these things. 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.

flakeoil 3y ago

But who is going to pay for it? There are more and more amazing machines, treatments and medicines available every year and soon it will be impossible for society to pay for it. And the longer our lifetimes extend thanks to one treatment, the more treatments we can use in a lifetime, and the cost increases even more. 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.

margalabargala 3y ago
The same person paying for it now? In the case study above, they weren't suggesting taking the teenager off the machine due to non-payment.
- flakeoil 3y ago
  Well my point is that healthcare is getting more and more expensive. At some point we will come to a limit where the money is not there or that the individual himself has to directly pay for it and take that decision. Will the kids work their asses off for the rest of their lives to give their dad another year? Or are we prepared to pay double the tax rate we pay today to cover all the new opportunities in healthcare? If more and more people live to 100 and beyond, then we will need more and more healthcare over a lifetime. Who will pay for that?