Journal ArticleThe most painful of all medical care decisions concerns life-preserving measures which, because of limited resources, require certain individuals to be excluded in favor of others. How does one weigh the relative rights of individuals to such care? Whenever possible, decisions to withhold lifesaving therapy should be made in advance. but in the absence of a clear expression that lifesaving care should be withheld, the person in charge must assume that care was intended

Battin, Margaret P.

McIntyre, Kevin M.

English

The University of Utah: J. Willard Marriott Digital Library

Case Stud ies: Two Cardiac A rre sts , One M edical TeamA uthor(s): K evin  M. M cIn tyre , R o b ert C. B e n fari, M. P abst B a ttinSource: The H astings C en ter R eport, Vol. 12, No. 2 (A pr., 1982), pp. 24-25Published by : The Hastings CenterS table URL: http://www.jstor.org/stablc/3561803A ccessed: 0 4 /0 3 /2 0 1 1  12:31Your use o f the JSTOR archive indicates your acceptance o f JSTOR's Terms and Conditions of Use, available at http://www.jstor.org/page/info/about/poIicics/tcniis.jsp. JSTOR's Terms and Conditions o f Use provides, in part, that unless you have obtained prior permission, you may not download an entire issue o f a journal or multiple copies o f articles, and you may use content in the JSTOR archive only for your personal, non-commercial use.Please contact the publisher regarding any further use of this work. Publisher contact information may be obtained at http://www.jstor.org/action/showPubIishcr?pubIishcrCodc=hastings.Each copy of any part o f a JSTOR transmission must contain the same copyright notice that appears on the screen or printed page o f such transmission.JSTOR is a not-for-profit service that helps scholars, researchers, and students discover, use, and build upon a wide range of content in a trusted digital archive. We use information technology and tools to increase productivity and facilitate new forms of scholarship. For more information about JSTOR, please contact support@jstor.org.The Hastings Center is collaborating with JSTOR to digitize, preserve and extend access to The Hastings Center Report.http://www.jstor.orgCASeSIUDItS____________________________Two Cardiac Arrests, One Medical TeamGeorge Burnham and Donald Mattison were patients in adjoining rooms in the rehabilitation division of a state medical center. George was a thirty-three-year- old, severely retarded man who had lived in state institutions since the age of three. His family had had no contact with him for over twenty years. George had been trained to feed himself and to keep himself reasonably clean, but at the age of twenty-five he had suffered a cardiac arrest that left him with some paralysis. After rehabilitation he only occasionally lacked bowel control. A second recent cardiac arrest left him semi-paralyzed and totally incontinent. The chances of his regaining even his former level of continence, the stafT felt, were hopeless.Donald Mattison, a forty-eight-year- old businessman, active in communityCOMMENTARYby KEVIN M. McBSTYRE and ROBERT C. BENFARIT.A. he most painful of all medical care decisions concerns life-preserving meas­ures which, because of limited resources, require certain individuals to be excluded in favor of others. How does one weigh the relative rights of individuals to such care? Whenever possible, decisions to withhold lifesaving therapy should be made in ad­vance. But in the absence of a clear ex­pression that lifesaving care should be withheld, the person in charge must as­sume that care was intended. Should in­competency, the patient’s family status, capacity to contribute to society, and re­lated considerations be woven into the de­cision-making process? Let us considerK e v in  M . M c In t y r e , M .D . ,  J .D ., is in the department o f medicine at the Peter Bent Brigham Hospital, VA Medical Cen­ter, West Roxhury, and at Harvard Medi­cal School. R o b e r t  C. B e n f a r i  is in the department o f behavioral science at the Harvard School o f Public Health.and church affairs, married, and the fa­ther of four, had suffered a minor stroke, which left him slightly para­lyzed. In his six weeks on the rehabilita­tion ward he had regained almost total use of his arm and leg. His prognosis for full recovery seemed excellent.The hospital has at least one cardiac- arrest team on duty twenty-four hours a day, and one crash cart in every patient area at all times. The possibility of si­multaneous cardiac arrests seemed re­mote. If it were to happen, there would not be time to transfer an additional crash cart from another patient area, since the rehabilitation ward is served by an extremely slow elevator.But in this case the improbable hap­pened. George had a cardiac arrest at 3:00 one morning. Within four minutes the cardiac team had arrived in hiseach case on its own merits, then look at the priorities so as to answer the troubling question: “Who shall we permit to die?”George has just suffered his third cardiac arrest. Since there was sufficient clinical information from two prior arrests to antic­ipate that cardiac arrest might occur again, in the absence of directions not to resusci­tate we must assume that care should be initiated, as it was. George’s severe retar­dation does not per se justify withholding resuscitative efforts, nor does his addi­tional brain damage and total incontinence. The courts have indicated (in the Dinner- stein and Spring cases) that cardiopul­monary resuscitation (CPR) as well as other forms of lifesaving and life-prolong­ing therapy can be withheld in appropriate circumstances. But an appraisal by either care-provider or family of the “quality of life" of the life-long incompetent as a basis for withholding such therapy has been spe­cifically rejected (in the Saikewicz and the Storar and Eichner cases).Recently, the highest court in the State of New York ruled without equivocation that there exists in some circumstances a positive obligation to provide lifesaving treatment to the terminally ill life-long in­competent based on the common law re­quirement that a guardian act only in theroom and was ready to begin work. At that very moment Donald also had a cardiac arrest. Knowing of the simulta­neous cardiac arrests, every team mem­ber hesitated. Two also knew both patients’ histories; the others, including the team leader, did not. After a mo­ment, the team leader said, “ First come, first served. Let’s go to work.” With no further hesitation, the team began to re­suscitate George.Without the emergency aid, Donald died. George was resuscitated, but suf­fered yet another cardiac arrest at 8:20 the next morning. This time another team was unable to revive him, and he too died. Did the team leader make the right decision in resuscitating George instead of Donald? Is “first come, first served” the proper principle to apply in such cases?best interest of the ward. While some may disagree, that decision supports the con­clusion that there existed an obligation to treat George unless a court had already determined that withholding CPR was in George’s best interests.As for Donald, there are no indications that he had refused or would refuse re­suscitation. He had a good prognosis for full recovery. He was young, married with four children, and employed.Assuming that George would have re­ceived the full attention of the CPR team had Donald not arrested, how is one to proceed fairly? With a single crash cart and one cardiac arrest team, if we attempt to initiate CPR for both men, it is likely both will die. Donald’s prognosis is better than George’s. In addition, Donald’s wife and children are emotionally and econom­ically dependent on him so that there are broader societal costs were he to die. On balance, the choice clearly favors full commitment of CPR to Donald. Should we then abandon poor George? Or is it possible to allocate care in such a way that he may survive without seriously compromising Donald’s chances?One approach would be to initiate basic life support (artificial ventilation and ex­ternal chest compression) immediately for24 The Hastings Center Report, April 1982Donald, using a single member of the team, and, as quickly as possible, attempt to defibrillate George. If initial attempts at defibrillation were unsuccessful, or if the attempt took more than thirty to sixty seconds, we would abandon efforts with George and concentrate totally on Don­ald. If George were in asystolic cardiac arrest (no electrical activity, as opposed to chaotic electrical activity in ventricular fibrillation) we would terminate efforts on his behalf because the likelihood of suc­cessful resuscitation would be very small and the time required would very likely preclude Donald’s resuscitation.This approach is based on the following considerations: (1) both George and Don­ald have a right to lifesaving treatment; (2) George’s immediate prognosis is poorer than Donald's; (3) the societal costs of Donald's death would be substan­tially greater than those of George’s; (4) George’s best chance of returning to his previous state is immediate defibrillation.Even the brief delay to defibrillate George may decrease the likelihood of successfully resuscitating Donald. But if Donald could be effectively ventilated (providing adequate air exchange in and out of the lungs of a patient whose breath­ing has ceased) and receive effective ex­ternal chest compression (for the purpose of circulating blood in a patient whose heart has stopped beating) for a period not to exceed thirty to sixty seconds before all energies were directed toward him, the delay should not entail great additional risk. The small increase in risk to Donald must be balanced against the alternative, which would be to withhold all chances of survival from George. Would that consci­entious decision making were as simple as . . first-come, first-served!”COMMENTARYby M. PABST BATTENTA  o consider what would have been the right course of action for the crash-cart team leader, let us look at two aspects of the case: first, the distributive principles to which one might appeal in order to honor fundamental moral commitments, and sec-M . P a b s t  B a t t in  is associate pro­fessor o f philosophy. University o f Utah.ond, the procedural strategies one might use to put them into practice.Of the many possible principles, at least three are plausible in this case:Better prognosis. "When both cannot live, treat the one with the better prog­nosis.” This principle, similar to that used in military triage, would clearly have pre­ferred Donald. It reflects a moral commit­ment to maximizing the preservation of life. It should be applied only where the disparity between prognoses of competi­tors for treatment is relatively great: it will decide between two individuals when only one is likely to survive if treated, but it will not decide cases where the disparity is un­certain or small (for instance, which pa­tient will receive a kidney, if one's recovery would probably take five weeks and the other's six). This principle can be applied without reference to George’s re­tardation: if the medical history of arrests had been reversed, he would have been preferred.Social worth. ‘‘When both cannot live, prefer the one who has greater value for other persons.” This principle, although often attacked as inviting racism, sexism, and bias against the elderly, retarded, and mentally ill. may also be understood with­out bias: it prefers the person whose con­tinuing life is of greater importance to others. This need not automatically mean Donald. Though George was seriously re­tarded, he might have contributed signifi­cantly to the life of the patients and staff of the ward; conversely, though Donald had prominent public status, he might have been a vicious abuser of relationships with his wife, children, and associates. How­ever, we have no evidence for any such claims, and it is highly likely that Donald had greater value for other persons. Like “better prognosis," this principle is also to be applied only where the disparity be­tween competitors is great; it will not de­cide, for instance, between saving the parent of two children and the parent of three. Correctly applied, it reflects a funda­mental moral commitment to protecting important human relationships.First come, first served. “When both cannot live, treat the one who is presented for treatment first." This principle, which the leader of the team chose to follow, is blind to the particular characteristics of competing individuals; since George’s ar­rest occurred first he is to be saved, but it could have happened the other way around. Insofar as the principle is neutralto persons, it is similar to random selec­tion, and seems to reflect a moral commit­ment to the equality of all.We might praise the team leader’s choice as reflecting a primary commit­ment to the equality of persons. But is this what the team leader’s choice really shows? Note that both the other princi­ples— "better prognosis” and “social worth"—would have required the team leader to make a comparative judgment about the conditions and circumstances of Donald and George. But the person-neu­tral “first come, first served” principle re­quires no background information about the competitors, presupposes no disparity except time of presentation for treatment, and will decide every hard-choice case except genuinely simultaneous ones. Did the team leader's choice (and do “ first come” institutional policies) actually re­flect a commitment to human equality, or the fact that this distributive principle is easier to apply? The fact that every mem­ber of the team "hesitated” before treat­ing George suggests that other bases for decision were evident to all; is it sheer convenience that gives priority to this one?Because non-neutral principles require judgments about conditions and circum­stances, they are subject to bias when the disparities between competitors are small. Between Donald and George, however, the disparities in prognosis and social worth were very great; hence, bias would have been much less likely to arise.To say that medicine might well pay greater attention to non-neutral distribu­tive principles is not to deny that there will be disagreements over these princi­ples, or occasions when relevant informa­tion is not available, or cases in which there are multiple disparities, some of which favor one competitor and some the other. But these are the hard cases. The case of Donald and George is not a hard case: both non-neutral principles could have been applied and would have favored Donald over George. Only a two- minute disparity in time of presentation favored George; a genuinely neutral prin­ciple would have permitted treatment of either one. In hard cases, retreat to neutral distributive principles cannot be avoided, but in this case the team retreated too soon. The society that resorts to easy strategies even before the choices become hard may fail to honor the fundamental moral commitments it makes.The Hastings Center25

Two cardiac arrests, one medical team

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Two cardiac arrests, one medical team

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