"Vex  not his ghost. Oh, let him pass! He hates him,  that  would upon the rack of this tough world stretch him out longer."

The Tragedy of King Lear, Act V, Scene III

From time immemorial it has been taken for granted that a doctor's primary occupation is to treat his patient -  "to cure sometimes, to relieve often, to comfort always". Till a few decades ago, there was no real conflict of interests - a doctor did his best to preserve life, the sanctity of his patient's life being considered paramount.  The increasing availability   of sophisticated medical technology, life support systems and critical care  units  changed  the  entire  picture. Today the question is, how long to continue treatment and the  purpose  of such  treatment.  It is possible, to keep a  person biologically alive  - heart, lungs, kidney and other organs functioning -  but in  coma, "living" in a critical care unit setting.

 The  "quality of  life"  of the patient being treated, is the  critical  issue. Langfitt  in a thought provoking article "Critical care, when  is enough enough?" discusses the several issues involved. What  is "quality of life"? Who decides this and whose life is it any way?

Social  Utility is a recent concept - the  concept that  a person can be biologically alive but socially  dead. The same respirator that helps a patient with Gillian Barre  syndrome to  recover completely senselessly prolongs the life of a  young individual,  in irreversible coma. The mature  physician  should realize, that healing the sick, at some point fails. 

Life can  be revered  not only in its preservation, but also in the manner  in which we allow a given life to reach its end. 

Death with dignity is as important as life with dignity.

To keep a person biologically alive in a  critical care setting would mean an expenditure of Rs 5000 to 7500 a day in India. Can we  afford  this,  when  there  are  thousands   dying  of malnutrition and diarrhea every day. Even in the USA where 12% of the gross national product is pumped into the health  industry cost  containment is the talk of the day. At the same time is  it not morally repugnant to deny useful treatment purely on economic grounds.

Today,  with the legal recognition of brain  death it is necessary for the critical care specialist to view  his/her brain dead patient also as a potential organ donor. To whom does the  doctor  owe a greater responsibility - to  his  brain  dead unsalvageable patient or to a kidney failure patient  desperately waiting for a functioning kidney. Would providing eyesight to two blind  people,  by  switching  of the  respirator,  be  termed  a conflict  of interests? Again from the patient's point of view what can be a nobler way to die than to save five dying persons? As one mother of a head trauma victim, who consented for multiple organ  donation  put it "My son never died. He is  traveling  in different people".

Several  ethical issues have to be  considered  in the diagnosis  of   brain death especially  when organ transplantation is the primary aim. 

They include the following:

Waiving  of  intensive care bills normally payable,  when  the relatives  agree  for organ donation. Sometimes this  bill  is settled by the recipient. Is this not a form of compensation ?

Providing free medical care to the relatives of the brain dead individual. Is this not a form of inducement ?

The  death  certifying  team  should  be  different  from  the transplant team.

Terms  like "heart beating cadaver" have  come  to stay. Unfortunately, in India there are hardly any formal courses in medical  ethics either at the undergraduate  or  postgraduate level.  Hospital  ethical  committees are few  and  far between. Serious discussions on the definitions of death, o~ the personal, moral,  legal  and  economic issues  involved  in death  related decisions  are  totally absent in the training of a  doctor.  How does  the  physician  of  today,  dealing  with critically   ill patients, face these complex challenges.

Managing a critically ill patient is not a  purely technical  affair.  It  is much more than correcting  the  serum sodium  or monitoring arterial blood gas levels. The attitude  to death,  both  of the physician and the patient (or his  near  and dear) play a vital part. What happens after death - the fear  of the  unknown  - is a very real fear. A student once asked  a Zen master  as to what happens after death. The master replied "I  do not  know". "But you are a Zen master" said the student. "Not  a dead one" replied the master.

Seldom does one accept death with equanimity.  The fear of leaving behind loved ones and to cope with loneliness  is a very  real  fear. "I have not lived  enough"  applies  to the centurion as well as the teenager.

When  is  enough enough? When does  the  physician treating a critically ill patient say "This far and no  farther". Unfortunately,  not withstanding all the rhetoric, there  are  no unambiguous rules. Medicine is never black or white. It is always various shades of gray. Neither patients nor the organs in  their bodies read the latest journals, monographs or the Supreme  Court judgments.  The science of medicine can never do away  with  the art of medicine. It is this very element of uncertainty  whether it  be  in life or death, which makes managing a  critically  ill patient a challenging affair.

The   fundamental   ethical  guidelines   in   the management of a patient probably revolve around the following:

Beneficence  -  to do good by restoring health  and  relieving suffering.

"Primum  non  nocere" - to do no harm  or  non-malificence,  a concept  which the doctor treating the critically ill  patient has to always remember. Administration of morphine may relieve pain.  It may also cause respiratory depression. The  dividing line is often a very thin one.

Justice  -  when  medical resources  are  limited,  treatment should  be administered to the patient who is most  likely  to benefit.  However the primary obligation is to the patient  at hand.

To  follow the directions of a "living will" if one  exists  - that  is a written document or a reliable testimony, that  the patient  had  prior to his illness, expressed a desire  for a par-ticular mode of treatment in a particular condition.

Autonomy  - a legally competent informed adult, has the  right to refuse or accept medical treatment, including life  support measures.  The  right to self determination does  not  however include the right to commit suicide with or without  physician assistance.

Easier  said than done. In a situation  where  the brain  is  primarily  involved, either in head  injury  or  other neurological problems, due to organic brain damage, the  patient may not be able to take part in the decision making process. Who then is empowered to take the role of a surrogate decision maker? Even  if the attending doctor gives the full information to  the patient's  relatives, is it reasonable to expect them to  take  a calm,  unruffled calculated decision after weighing the pros  and cons, all in a critical care setting. Any decision making process involving life and death, is influenced by the cultural and socio economic milieu.

By the same token is it fair to ask the  attending doctor to play God. Combining the role of a "devils advocate" and "amicus  curae" he has to justify the blind faith reposed in  him by  the patient's grief stricken relatives. Quality of  life  may mean different things to different people at different times.  In a developing country, where there is seldom a third party payor, the  socio economic burden for caring for a chronically  comatose patient, is so enormous that it reflects on the health and wealth of the family.

As  in  any  discussion on  ethical  issues,  this article asks more questions rather than providing answers. It  is essential that medical ethics be introduced in the curriculum  so that the delivery of critical care will truly be need based.