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Rapid Responses: Rapid Responses published:
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Temporal Perspectives on Ethics
- Simon J Clark (22 February 2005)
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Withdrawing and withholding may be different
- shimon Glick (28 February 2005)
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Timed out
- Joanne M Shaw (8 March 2005)
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Acts, Intentions and Timers on Ventilators
- Andrew N Papanikitas (9 March 2005)
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Simon J Clark, Consultant in Neonatal Medicine Jessop Wing, Sheffield S10 2SF
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Dear Editors, In ethics time is generally considered in a pragmatic way, which while reasonable, may be inaccurate. If the ethics are valid, they should remain so regardless of the time scale. As a human my understanding is limited and my scientific understanding of time may well be. However, time may be non-existent and is merely an illusion created by the progression of changes within the universe. Alternatively, time is distortable as part of quantum theory. In either case there is actually no difference between the suggested continuous and discrete treatments. On a quantum scale all procedures are discrete, for example a 0.1 second pause between end expiration and new inspiration is a massive quantum time period. However, on a geological time scale one week is a miniscule period of time. Therefore, disconnecting the ventilator at the end of its cycle is no different from disconnecting the dialysis catheter. In both cases death is not instantaneous. On a quantum scale an enormous period of time will pass before death ensues from withholding further ventilation. On a geological time scale death from withdrawing dialysis will appear to be instantaneous. Both deaths, from differing temporal perspectives, appear to be due to actions rather than inactions, but are actually due to interrupting a cycle of treatments, ie withholding the next cycle. I believe that this logical application of time would negate the use of timers on a ventilator. Yours sincerely, Simon Clark Competing interests: None declared |
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shimon Glick, professor emeritus ben gurion university faculty of health sciences, pob 653 beer sheva, israel
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The differentiation between withdrawing and withholding which Western lawyers and bioethicists have tried valiantly to obliterate is not a peculiarity of Jewish religious law. There exists a strong psychologic factor which affects those (physicians and/or nurses) who have to make the decision and carry it out. A study of neonatologists in 10 European countries(1) showed that about two thirds of them did not agree with the equation of the two processes. A more recent study of European physicians reported that they were more willing not to start treatment than to withdraw it after it had been started(2). The process of terminating life by an overt act is much easier for an ethicist or lawyer who does not personally have to throw the switch 1.Rebagliato M et al Neonatal end-of -life decision making:physicians' attitudes and relationship with self-reported practices in 10 European countries.JAMA2000;284:2451-2459 2.Bosshard G Archives of Internal Medicine 2005;165:401-407 Competing interests: None declared |
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Joanne M Shaw, Director, Medicines Partnership Medicines Partnership, 1 Lambeth High Street, London SE1 7JN
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Sir, Timers may sound like an elegant solution to an issue of religious law, but the idea of adding an auto-cutoff function to machines essential to the preservation of life seems to fly in the face of current efforts to design-in safety. How can we be sufficiently confident about the operation of the complex human and technical processes within a modern hospital to be sure that no ventilator fitted with a timer would ever be set to stop when it wasn't supposed to? Surely all the evidence points to the inevitability of it happening somewhere, at some time, with catastrophic results. Did the committee consider the time-honoured solution of the Shabbas Goy, in this case a non-Jewish healthcare worker not governed by the precepts of Jewish law and therefore by definition not contravening it? Competing interests: None declared |
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Andrew N Papanikitas, SHO in Paediatrics Eastbourne DGH, BN21 2UD
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Dear Sir Supposing I rigged up a euthansia device on a timer so that the patient/relatives had to press a button by a certain time to avoid a lethal injection. If the button is not pressed and the patient dies, would I not have a) intended the outcome, b) arranged the means of the outcome? Would there be an appreciable difference, ethically, with this and my personally administering the injection? The intention and outcome exist irresprective of the time delay, and it could be argued that deliberately setting up the timer is a more complicated way of pressing the button. The initial lethal intervention is a clear 'act'. Whether or not one believes in a distinction between acts and deliberate ommissions, if one classifies switching off a ventilator as an act, then, by the same token, must one not classify setting up the timer as an act? As far as religious conscience is concerned, there is very little difference between this approach, and persuading someone with different beliefs to perform the proscribed activity, the setting up of the machine still represents an act with the intention to withdraw ventilatory support, as does the delegation of the task to a 'gentile'. If we are being brutally honest. Competing interests: None declared |
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