"Thou shalt not kill, but needst not strive Officiously to keep alive."

The individual's right to be let alone conflictswith the advancement of Society...

(Following are excerpts from a lecture delivered this month in New York by Dr. Henry K. Beecher, Dorr Professor of Research in Anaesthesia. The speech gains added significance in the light of the heart and other organ transplants performed since it was written.)

Not long ago, in company with several others, I made a project site visit to a great Southern university. During the course of that visit we were told about a man on their wards who had been hopelessly unconscious for more than a year. He got pneumonia. The question was, should he be treated? He was. And the reasons he was treated do not reflect any very great credit on his institution. He was treated, as the medical personnel pointed out, "because the nurses made us do it." This was neither a humanitarian nor a medical decision: it was simply an emotional decision. Please do not think that I decry the compassion of those nurses. It stems from their very best qualities. But we had better take a look at the consequences of this decision.

It costs about $30,000 per year, probably more, to maintain such an individual. It is not, I insist, crass to speak of money in such a situation: Money is human life in a hospital. If we had more money we cohld save more lives. Remember, this man was hopelessly unconscious. Are we obliged to treat such an individual when he can be kept "alive" only by extraordinary means? Pope Pius XII answered that question plainly, clearly: "No, you are not," he said. A little later we can consider the Church's attitude to these and related matters.

In the meantime let us return to considering the further consequences of treating this hopelessly unconscious man's pneumonia: If the average hospital stay is two weeks, then by occupying a bed for a year, such a patient has kept 26 others out of the hospital, others who are salvageable, as this man is not. With the present critical shortage of hospital beds, the admission of patients, even those with cancer, may be delayed for some weeks, possibly long enough for the disease to progress from the curable to the incurable state. Thus we may sacrifice those who can be saved to those who cannot. Can anyone believe in the situation I have described, that first things were truly put first?

As medicine's power for prevention, for healing grows, as progress made in conceptual and technical matters grows, it is evident that moral and ethical problems increase in kinds and in complexity. I think it may be profitable to take a look at the underlying situation. And to do this will require an examination of some underlying propositions.

In the first place, it is startling to observe how a single procedure can turn a controversy that might have been limited to a laboratory into everybody's business; for example, the injection of live cancer cells into unknowing, unconsenting subjects. Suddenly almost everyone begins to watch the medical scientist: his privacy and the privacy of his laboratory are abruptly invaded. The invasion of privacy works in two directions; it can involve the investigator no less than the subject.

The word privacy did not appear in legal literature until 1890, when Warren and Brandeis discussed it. There is nothing said about privacy in the United States Constitution.

The invasion of privacy takes many forms....

A serious invasion of privacy is the use of subjects in experimentation without their knowledge or specific consent....

The scientist recognizes the need for straightening out his own house and he has attempted to do so through the establishment of guiding codes. In most cases these are quite unrealistic and quite unsatisfactory. Their problems and shortcomings are great.

These remarks will be limited to the single situation of the unconscious and irretrievably injured man who is kept "alive" only by extraordinary means. Four very different kinds of questions arise from this situation:

* Under what circumstances, if ever, shall extraordinary means of support be terminated, with death to follow?

* From the earliest times the moment of death has been recognized as the time the heart beat ceased. Is there adequate evidence now that the "moment of death" should be advanced to coincide with brain death while the heart continues to beat?