It must be recognized that this situation when the patient is in full possession of his mental faculties is not comparable to turning off the respirator of an unconscious patient with irretrievable brain damage. The patient who has the possibility of rejecting hemodialysis must weigh not only the financial and emotional cost to his family but also the cost to the society to which he belongs. Medical resources in this field are limited: utilization by one deprives another.
The unconscious patient with overwhelming brain damage can be maintained only by extraordinary means. When it becomes evident that the brain is dead, there is an obligation to discontinue extraordinary supports. But one must remember that the termination of extraordinary care even for just reasons, with death to ensue, can have a shocking effect on observers.
The family of the patient very often want to terminate their agonizing death watch; they urge a discontinuance of extraordinary measures.
Some of those who have an interest in organ transplantation press for a new appraisal of what constitutes death so the organ sought may be taken while circulation continues.
The hospital and society in general have a vested interest in terminating this appallingly costly and useless procedure in hopeless cases. Occupancy of such a bed jeopardizes the salvageable.
The presence of vested interests, however correct, raises the possibility of selfish rationalization and is a warning of the need for caution. Then too, a new definition of death, when there are those who have a vested interest in it, could lead to public questioning and doubt and an unfortunate blurring of the line between this and euthanasia.
It would be a grave mistake to underrate the attitude of the public as to the inviolability of the body. Doubtless in many cases this is based upon religious beliefs concerning the resurrection of the body. The Roman Catholics and strict Orthodox Jews oppose cremation; but this feeling about the body is prevalent in some atheistic countries too.
Perhaps the theologian, with his distinction between ordinary and extraordinary means of sustaining human life, will also say with Arthur Hugh Clough:
"Thou shalt not kill;
but need's not strive
Officiously to keep alive."
These situations and these possibilities pose a serious problem for hospitals. Inevitably, with more and more bold and venturesome and commendable attempts to rescue the dying, more and more individuals will accumulate in the hospitals of the land, individuals who can be maintained "alive" by extraordinary means, individuals in whom there is no hope of recovery of consciousness, let alone recovery to a functioning, pleasurable existence.
It seems clear that the time has come to re-examine this situation.