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Tuesday, August 3, 2010

Life Support, or a Replacement Part?

When transhumanists equate wearing eyeglasses with replacing healthy flesh and bone with cybernetics, one must not downplay the power of analogy in bioethical reasoning. The simple response to the transhumanst is that eyeglasses do not alter the body at all nor do they become part of the person nor do they consider otherwise healthy eyes as disposable. (We'll not explore all of the ways the analogy limps in this post.)

Analogy is the very heart of the reasoning used by the Mayo Clinic in deciding that physicians can ethically withdraw a left ventricular assist device (LVAD) at a patient's request.  The device keeps the heart going in the cases of heart failure, where left ventricular hypertrophy has diminished the heart's ability to pump blood.  It is often used by patients awaiting a heart transplant.

According to a WSJ article on the topic, some clinicians feel uncomfortable with withdrawing LVAD because the device seems more like a replacement device than life support -- more like an artificial heart that lets a patient engage life than a ventilator that simply forestalls death when there is no life-saving treatment to be had.  Withdrawing LVAD would thus appear to be more like assisted suicide an euthanasia, rather than discontinuing a useless treatment.

The Mayo Clinic saw things in the exact opposite way. Withdrawing LVAD imposes no new pathology, but simply lets underlying pathology run its course. They consider it a treatment that any patient has a right to refuse and they recommend that clinicians respect their patients' wishes.

Yet that is also the weakness of the analogy.  The right to refuse treatment, like every other right, carries with it some responsibility.  No right is absolute -- people do not have the right to say whatever they want, whenever they want.  They have a responsibility to speak truthfully and not to slander, to keep the peace and not to incite a riot, and to keep silent and not to breach a confidence.

Patients can refuse treatments, but they have a responsibility -- to themselves, their loved ones, society and, yes, God -- also to maintain and restore their health.  Allowing existing pathology to run its course can be a form of murder, euthanasia, or assisted suicide -- not saving a savable life is the same as taking it. Circumstances will determine whether withdrawing LVAD means discontinuing a useless treatment that has no benefit, or causing an unethical hastening of death.

The discomfort of advanced heart failure and a life maintained by a mechanical device can make things seem pretty dismal to the patient. The patient needs advice, not obedience.  Above all, bioethics cannot make physicians into obsequious technicians that abdicate all ethical responsibility to others and remain authentic.

Sometimes a physician has to say, "No, it would be wrong." The Mayo Clinic seems to have taken that responsibility away from them.

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