What if you were in a terrible car accident, and sustained life threatening injuries to your heart. In an effort to save you, doctors went to extreme measures, and implanted a left ventricular assist device, also referred to as an LVAD. What is an LVAD you ask? Well, it is a surgically implanted heart pump that is attached to one of the main pumping chambers of the heart and the aorta. The pump is attached to a tube that extends to the outside of your body, and attaches to a battery pack that you must carry around for the rest of your life. However, despite the fact that the LVAD has “saved” your life, what if you were paralyzed? What if you had burns over your body as a side effect of the accident? What if your body was altered in such a way that you no longer had the same quality of life as you did prior to the accident?
As bioethicist Katrina A. Bramstedt said, “Anytime you create new forms of life support, you create the possibility for new ethical dilemmas.” With the development of LVADs, a host of new ethical dilemmas have surfaced, especially for older patients who are actually affected negatively by the implantation of the LVAD. These cases typically deal with the debate about euthanasia. And in those cases, one can argue that the patient entered into the surgical procedure under fully informed consent (or at least as much consent as one can have in today’s society), and therefore they should not be granted the right to request that the pump be turned off by a physician because they were aware of the risks going into the procedure, and desired the continuation of their lives. But what about those that did not provide consent? Patients that were admitted as a result of emergencies, and then awoke to find their lives significantly altered, and saved only by the implantation of an LVAD.
Are these individuals allowed to then make the choice of whether they would like to end their lives? Perhaps this is simply a small detail in the greater argument of euthanasia, but then again maybe this difference is all that is needed to justify their request for their own death.
http://www.washingtonpost.com/wp-dyn/content/article/2008/04/23/AR2008042303534_pf.html
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2 comments:
This is a very interesting point that you surface--if left unconscious from an auto-vehicle accident, the patient did not give consent for the implantation of a life support device. This would mean that, technically, the patient would have the right to ask for the removal of the device and, hence, would have the right to ask for a form of euthanasia. However, I see two flaws in this argument.
The first has to do with the nature of emergencies and the meaning of the pledge that doctors take to do "anything and everything necessary." In emergency situations such as car accidents, or even when something goes wrong in the ER, doctors must do all that is necessary to save the life of the patient. Culturally, in American medicine, actually saving the life of the patient is of primary importance. In order to do this, there is not time/not a possibility of waiting until the anesthesia wears off to ask the patient to sign a consent form. The doctor is simply carrying out his or her duty by trying everything possible to save the patient's life. This need not always be considered a breach of "informed consent" but a drastic situation which called for quick measures in which a physician did his or her duty. There is no other option in this case except for the doctor to assume that the patient wants to live (since the doctor cannot physically ask the patient). What is the other option? Not doing anything for the patient and assuming that the patient wants to die?
Another issue is that not always is the procedure performed without any type of consent. Sometimes, the patients' family is brought in to the hospital after an accident and told that a surgical procedure will follow. If the patient's family allows for the procedure to proceed (essentially giving proxy consent), does this still mean that the patient did not give any type of "consent" and has the right to remove the device? Technically, "consent" was given, just by a different party.
Also, I found it interesting that Bramstedt spoke about these new cases of life support and that supposedly, "new dilemmas have surfaced, especially for older patients." Why only older patients? Wouldn't the quality of life of a young patient who was in the prime of his or her life be significantly impacted by the burden of being on life support for the rest of his or her life? Would this not be an equal or even greater burden than that carried by those who are older and have already lived a fulfilled life?
I definitely agree with you that a physician inserting an LVAD without obtaining “consent” first simply due to the face that the patient is unconscious and they are unable to contact the family, does not constitute a breach of informed consent. However, if that is not the problem, then we move towards the classic question of “how much care should be provided?” Especially in medical practice in America, physicians have been trained to try their hardest to save a patient’s life (whether it means two hours of attempted resuscitation or any other extreme form of aid), and have neglected the art of palliative care. So applied to the case of LVADs, should a physician insert an LVAD into the heart of a 95 year old man that was hit by a car? (Granted that the family of the patient cannot be reached).
As to the second issue that you raised, a family member can give proxy consent, but does this proxy consent hold the same value as informed consent from the individual? (Especially if the individual is of an age at which he/she can fully reason and make decisions for himself/herself). Consent was given, but what if the consent was not in accordance with the wishes of the patient? (As we have seen with cases such as Terry Schiavo, and other patients, often the desire to maintain the life of a loved one overshadows the treatment that may be considered “in the best interest” of the patient). Then do we move to a violation of autonomy? Or does proxy consent rule all and prevent the patient from his or her own desires?
And to Bramstedt’s comments, I just wanted to clarify that I was not saying that quality of life is decreased only in older patients, but simply that often times it is in older patients that adverse side effects are more significantly felt. LVADs have actually been shown to improve quality of life for selected patients, and are being moved from a form of last minute treatment to a long term treatment for general cardiac problems.
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