Timers on ventilators
BMJ 2005; 330 doi: https://doi.org/10.1136/bmj.330.7488.415 (Published 17 February 2005) Cite this as: BMJ 2005;330:415
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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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
Acts, Intentions and Timers on Ventilators
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
Competing interests: No competing interests