"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?

* When, if ever, and under what circumstances is it right to use for transplantation the tissues and organs of a hopelessly unconscious patient?

* Can society afford to discard the tissues and organs of the hopelessly unconscious patient when they could be used to restore the otherwise hopelessly ill but salvageable individual?

The ever-broadening experimentation in the transplantation of tissues and organs has already led to the use of organs of hopelessly unconscious patients while their hearts were still beating. The ethics of this have been questioned. There is, therefore, some urgency to face up to the problems mentioned.

I mentioned Judge Cooley's memorable phrase (1888) that there is "the right to be let alone." Implicit in this is the right to live and the right to die. There is also the opposite right, to communicate. The individual's right to be let alone conflicts with the advancement of that part of society which is based upon scientific research. The development of science requires reasonable freedom for the investigator; at the same time a healthy society imposes restraints on him for the sake of the individual. Thus tension exists between society and scientific man. "This tension between society and science extends to all disciplines in the social, physical and life sciences. It affects the practitioner as well as the research investigator." There is also the "...conflict of science and scientific research with the right ... of private personality."

These thoughts and others to come are relevant to this presentation because of the pressures to use the hope-lessly unconscious patient's tissues and organs in an attempt to help the otherwise hopelessly ill but still salvageable patient in certain experimental procedures.

The moment of death can have legal importance, but the criteria by which death is established must depend upon medical evidence. Granted that there may be a time when it is good, i.e., appropriate, to die -- but when is that moment? What are its criteria?

Starzl (1966, p. 98) has spoken of "the declining curve of life," implying that as the end approaches there is less and less life in the individual, that there is present quantitative factor, a sort of death by inches. To a certain point this is supportable in that all organ and never centers do not become irreversibly damaged simultaneously: consciousness as a brain function is often irretrievably destroyed months to years before the respiratory and vasomotor centers fail. At the same time one can share Schreiner's (1966, p. 100) disconent and insist that "a coordinating vital principle exists which is either there or not there." This vital principle comes into being when the sperm fertilizes the ovum and persists until life no longer is present. The moment of death can only be approximated.

From ancient times down to the recent past it was perfectly clear that when the respiration and heart stopped, the brain would die in a few minutes; so the obvious criterion of a heart in standstill as synonymous with death was accurate enough. This is no longer the case when modern resuscitative and supportive measures are involved. These improved activities can now restore "life" as judged by the ancient standards of persistent respiration and continuing heart beat. This can be the case even when there is not the remotest possibility of an individual recovering consciousness following massive brain damage. In other situations "life" can be maintained only by means of artificial respiration and electrical stimulation of the heart beat, or in temporarily by-passing the heart, or, in conjunction with these things, reducing with cold the body's oxygen requirement.

Or, to phrase it differently, death occurs at several levels. . . .

It is interesting that we have to ask the series of questions: When is death, what is death, what is life? It is self-evident that there is no simple answer to what life is. Quoting Dr. Zhivago as saying that we live solely in others, one can submit that life is the ability to communicate with others. . . .

Some have spoken of taking organs from a dying person. "I would like to make it clear [says Alexandre] that, in my opinion, there has never been and never will be any question of science and scientific research with who has "no reasonable chance of getting better or resuming consciousness." The question is of taking organs from a dead person, and the point is that I do not accept the cessation of heart beats as the indication of death." (Certainly such individuals have lost their ability to communicate. The question is, have they also lost their right to be let alone.) Their legal position depends entirely on what is determined to be the legal definition of death. . . .

It seems clear that any "updating" of the moment of death, in view of the differences among the experts who have given much thought to the matter, would be a legal impossibility at this time, however theologically and scientifically sound it might be. This is not to argue against "updating"; it is to suggest the propriety of caution. These are encouraging signs. Consider the following celebrated case.

In this case (E.D.R.S. and G.L.B.T, 1963) an inquest was held in Newcastle on a man who on being struck fell backwards onto his head. Respiration failed 14 hours after hospital admission and he was placed on a respirator. A day later, with his wife's consent, a kidney was removed for transplantation. Following the nephrectomy the respirator was turned off. There was no spontaneous respiration. A medical witness declared the man had virtually died at the time he was put on the respirator, although it was legally correct to say death occurred following the interruption of artificial respiration. The surgeon, described as an assailant, was charged by a jury with manslaughter. He was then committed for trial by the coroner. The coroner had consented to the nephrectomy in accordance with the Human Tissue Act, 1961, section 1(5) and the jury found that this had not contributed to death. In the discussion following, it was proposed that the moment of death be defined as the moment when spontaneous heart beat cannot be restored. Others (Louisell, 1966) raise the question of whether the moment of death might not best be defined as "the moment at which ireversible destruction of brain matter, with no possibility of regaining consciousness, is conclusively determined." . . .

. . . Vested interests impinge on most moral choices. This stuation is not difficult. It will be best to consider whence these pressures come. Their presence calls for caution.

First from the patient's point of view: If conscious, he is not obliged to avail himself of extraordinary means of survival. A good case in point is the use of intermittent hemodialysis for the man with kidney failure. At a recent symposium, "Ethics in Medical Progress" (edited by Wolstenholme and O'Connor, 1966) considerable discussion was devoted to the question of whether it is suicide for a man who has the opportunity to avail himself of intermittent hemodialysis to reject it. The answer is surely no: It is still experimental; the subject has the right to withdraw. It is an extraordinary process for maintaining life; therefore not obligatory. (Plus XII, 1957)

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.