Timers on ventilators
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《英国医生杂志》
1 Social and Behavioral Research Branch, National Human Genome Research Institute, Bethesda, MD, USA
Correspondence to: Department of Clinical Bioethics, Warren G Magnuson Clinical Center, National Institutes of Health, 9000 Rockville Pike, Bethesda, MD 20892-1156, USA vravitsky@mail.nih.gov
Jewish religious law considers human intervention to end the life of dying patients unethical. Timers on ventilators are proposed as a solution to prevent unnecessary suffering
Introduction
Within Halakhic literature, withholding treatment at the end of life, generally perceived as a permitted noninterference in the natural process of dying, is traditionally distinguished from interventions involving direct contact with the body or immediate environment of the dying person—for example, the withdrawal of treatment that has already started.5 This distinction stems at least in part from the religious approach that humans should not have an active role in the dying process, which should remain in the hands of God. Jewish religious law does not approach the issue from a consequentialist perspective, where the moral value inheres only in the end result. Rather, the procedure leading to the outcome has independent moral value.
Under Halakhic law dying patients cannot be disconnected from a ventilator
Credit: HANK MORGAN/SPL
The Halakhic literature reasons using a metaphor of the dying person as a "flickering candle," and the idea that one should not be "placing one's finger on the candle." In his book Alternatives in Jewish Bioethics, Noam Zohar notes that "this clearly excludes an understanding of the forbidden hastening of death in consequentialist terms: the deed's wrongness is not determined by its result—namely, the fact that the patient is dead at a certain earlier moment—but rather by its symbolic characterisation as extinguishing the candle."6 This means that withdrawal of treatment is perceived as forbidden even if the death of the patient at that point in time is an ethically appropriate outcome.
In this cultural context withholding is acceptable but withdrawing is not.7 Consequently, an individual's request to withdraw life sustaining treatment, such as mechanical ventilation, is perceived by many as conflicting with this traditional approach. Patients may request not to be connected to a ventilator, but they cannot ask to be disconnected once treatment has been initiated. This approach delineates limits imposed even on the autonomy of competent adult patients. Israel thus faces the challenge of respecting personal autonomy and the right of individuals to choose how and when to end their lives, while taking into consideration traditional values that sometimes demand limits on these choices.
Regulating end of life treatment
The committee thus sought a solution that would resolve the tension between the demands of individual autonomy and those of Israeli communitarian values that echo the Halakhic approach. Instead of attempting to "educate" the medical community and the public to disregard the distinction between withholding and withdrawing treatment, committee members opted to devise a technical solution. Since the main practical issue is that of withdrawing mechanical ventilation, they came up with the idea of transforming the continuous into discrete by installing timers on ventilators, with the assumption that "not renewing treatment that has been interrupted can be defined as withholding treatment."10
A second committee was established with the goal of developing delayed response timers. These will allow a ventilator to be set for a limited time (such as a week), at the end of which it will be turned off without human intervention. This would allow time for appropriate discussion among patients, family members, and healthcare providers. The discussion may result in a decision to extend the operation of the ventilator for a time determined by medical need or by the wishes of the patient or the family, or in a decision to let it turn off at the set time, providing the patient is under appropriate sedation. Such timers are being developed, but before they are put into clinical use their safety will have to be tested in an ethically approved clinical trial.
Timers have been in use for decades as a technical solution to reconcile centuries of Halakhic law with the use of modern technologies. For example, according to orthodox Halakha, turning electric devices on and off is forbidden during the Jewish Sabbath. Orthodox Jews use timers to regulate operation of electric devices in advance, thus preventing the need for active intervention.
Bioethical analysis
British Medical Association. Withholding and withdrawing life prolonging medical treatment: guidance for decision making. 2nd ed. London: BMJ Books, 2001: 12-14.
President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. Deciding to forgo life-sustaining treatment—a report on the ethical, medical, and legal issues in treatment decisions. Washington, DC: US Government Printing Office, 1983: 73-5.
Glick SM. Unlimited human autonomy—a cultural bias? N Engl J Med 1997;336: 954-6.
Gross LM. Autonomy and paternalism in communitarian society: patient rights in Israel. Hastings Cent Rep 1999;29: 13-20.
Steinberg A. Encyclopedia of Jewish medical ethics. Volume III. Jerusalem: Fedheim Publishing, 2003: 1046-88.
Zohar NJ. Alternatives in Jewish bioethics. New York: State University of New York Press, 1997: 43.
Israeli Medical Association. Position paper: the dying patient . Jerusalem: IMA, 1997.
Barilan YM. Is the clock ticking for terminally ill patients in Israel? Preliminary comment on a proposal for a bill of rights for the terminally ill. J Med Ethics 2004;30: 353-7.
Public Committee on the Dying Patient. Proposed law: the dying patient . Jerusalem: Ministry of Health, 2002: Section 12.
Halperin M. Clinical experiment in secured systems that transform ventilation into discrete medical treatment—ethical introduction. Report submitted to the Israeli Ministry of Health by the chief officer of medical ethics . Jerusalem: Ministry of Health, 2002: Section A.3
Barilan YM. Revisiting the problem of Jewish bioethics: the case of terminal care. Kennedy Inst Ethics J 2003;13: 141-68.(Vardit Ravitsky, bioethics fellow1)
Correspondence to: Department of Clinical Bioethics, Warren G Magnuson Clinical Center, National Institutes of Health, 9000 Rockville Pike, Bethesda, MD 20892-1156, USA vravitsky@mail.nih.gov
Jewish religious law considers human intervention to end the life of dying patients unethical. Timers on ventilators are proposed as a solution to prevent unnecessary suffering
Introduction
Within Halakhic literature, withholding treatment at the end of life, generally perceived as a permitted noninterference in the natural process of dying, is traditionally distinguished from interventions involving direct contact with the body or immediate environment of the dying person—for example, the withdrawal of treatment that has already started.5 This distinction stems at least in part from the religious approach that humans should not have an active role in the dying process, which should remain in the hands of God. Jewish religious law does not approach the issue from a consequentialist perspective, where the moral value inheres only in the end result. Rather, the procedure leading to the outcome has independent moral value.
Under Halakhic law dying patients cannot be disconnected from a ventilator
Credit: HANK MORGAN/SPL
The Halakhic literature reasons using a metaphor of the dying person as a "flickering candle," and the idea that one should not be "placing one's finger on the candle." In his book Alternatives in Jewish Bioethics, Noam Zohar notes that "this clearly excludes an understanding of the forbidden hastening of death in consequentialist terms: the deed's wrongness is not determined by its result—namely, the fact that the patient is dead at a certain earlier moment—but rather by its symbolic characterisation as extinguishing the candle."6 This means that withdrawal of treatment is perceived as forbidden even if the death of the patient at that point in time is an ethically appropriate outcome.
In this cultural context withholding is acceptable but withdrawing is not.7 Consequently, an individual's request to withdraw life sustaining treatment, such as mechanical ventilation, is perceived by many as conflicting with this traditional approach. Patients may request not to be connected to a ventilator, but they cannot ask to be disconnected once treatment has been initiated. This approach delineates limits imposed even on the autonomy of competent adult patients. Israel thus faces the challenge of respecting personal autonomy and the right of individuals to choose how and when to end their lives, while taking into consideration traditional values that sometimes demand limits on these choices.
Regulating end of life treatment
The committee thus sought a solution that would resolve the tension between the demands of individual autonomy and those of Israeli communitarian values that echo the Halakhic approach. Instead of attempting to "educate" the medical community and the public to disregard the distinction between withholding and withdrawing treatment, committee members opted to devise a technical solution. Since the main practical issue is that of withdrawing mechanical ventilation, they came up with the idea of transforming the continuous into discrete by installing timers on ventilators, with the assumption that "not renewing treatment that has been interrupted can be defined as withholding treatment."10
A second committee was established with the goal of developing delayed response timers. These will allow a ventilator to be set for a limited time (such as a week), at the end of which it will be turned off without human intervention. This would allow time for appropriate discussion among patients, family members, and healthcare providers. The discussion may result in a decision to extend the operation of the ventilator for a time determined by medical need or by the wishes of the patient or the family, or in a decision to let it turn off at the set time, providing the patient is under appropriate sedation. Such timers are being developed, but before they are put into clinical use their safety will have to be tested in an ethically approved clinical trial.
Timers have been in use for decades as a technical solution to reconcile centuries of Halakhic law with the use of modern technologies. For example, according to orthodox Halakha, turning electric devices on and off is forbidden during the Jewish Sabbath. Orthodox Jews use timers to regulate operation of electric devices in advance, thus preventing the need for active intervention.
Bioethical analysis
British Medical Association. Withholding and withdrawing life prolonging medical treatment: guidance for decision making. 2nd ed. London: BMJ Books, 2001: 12-14.
President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. Deciding to forgo life-sustaining treatment—a report on the ethical, medical, and legal issues in treatment decisions. Washington, DC: US Government Printing Office, 1983: 73-5.
Glick SM. Unlimited human autonomy—a cultural bias? N Engl J Med 1997;336: 954-6.
Gross LM. Autonomy and paternalism in communitarian society: patient rights in Israel. Hastings Cent Rep 1999;29: 13-20.
Steinberg A. Encyclopedia of Jewish medical ethics. Volume III. Jerusalem: Fedheim Publishing, 2003: 1046-88.
Zohar NJ. Alternatives in Jewish bioethics. New York: State University of New York Press, 1997: 43.
Israeli Medical Association. Position paper: the dying patient . Jerusalem: IMA, 1997.
Barilan YM. Is the clock ticking for terminally ill patients in Israel? Preliminary comment on a proposal for a bill of rights for the terminally ill. J Med Ethics 2004;30: 353-7.
Public Committee on the Dying Patient. Proposed law: the dying patient . Jerusalem: Ministry of Health, 2002: Section 12.
Halperin M. Clinical experiment in secured systems that transform ventilation into discrete medical treatment—ethical introduction. Report submitted to the Israeli Ministry of Health by the chief officer of medical ethics . Jerusalem: Ministry of Health, 2002: Section A.3
Barilan YM. Revisiting the problem of Jewish bioethics: the case of terminal care. Kennedy Inst Ethics J 2003;13: 141-68.(Vardit Ravitsky, bioethics fellow1)