ICU – At the Border between Life and Death [1]

A. Posing the Problem

How else could I begin my talk except by expressing my genuine gratitude for the honour of being asked to speak at your conference? It may be that you, as intensive care specialists, have encountered the greatest ethical dilemmas and are confronted by the most intense medical challenges to the conscience, more so than your other colleagues. And we, as the Church, if we want a connection with our mission, are constantly involved in the tension created by the way each person is hovering between life and death- literally and metaphorically- unfailingly seeing death in life and constantly discerning the outline of real life in death.

The workplace of doctors such as yourselves is called Intensive Care or Intensive Observation. In effect, the ICUs are places of Intensive Medicine and Technological Intervention and, naturally, places of severe crises of conscience and intense moral reflection. There is perhaps no other medical specialty which experiences the tension of the borderline between life and death, respect for life and affection for people, the right decision and the wrong outcome, the need to extend our co-existence and the desire to provide fellow-feeling, hope for a life without pain, the struggle between extending life and the unwanted consequences of holding back death.

In particular, in the ICU, people experience the great problems connected with euthanasia, brain death and invasive treatment carried out with no hope but great sensitivity.

In the case of euthanasia, the moral struggle is between respecting the sanctity of life, which prevents us from taking it for any reason whatsoever, and empathizing with a loved one in unbearable pain, which makes us want to free them from the torture and the tyrannical phase of the last stage of life.

In the case of brain death, the moral problem lies in respecting the fact of imminent death, which, on the one hand, counsels us not to distress the person who is dead within a living body while, on the other, does not does prevent us from determining the moment of biological death ourselves, with criteria amenable to doubt, because they are different from those we come across in natural life free of technological interventions.

Matters may perhaps be less clear in the case of invasive treatment without hope but with sensitivity. Here, without the direct consent of the patient, we indirectly eradicate the perhaps very slight hopes, or, if there really aren’t any, still alter the time of the natural course of the patient towards death, either by intervening or by refusing to intervene with medication. Here knowledge is engaged in a struggle with love and sympathy. The question here is whether the effort to extend life in essence prevents the onset of death. In brief, up to what point and under what conditions are we justified in delaying death?

In my talk, I shall attempt, by analyzing as far as I can what is meant by life and death, to approach the borderline conditions in the ICU, where our inability to accept the death of a patient leads us to excessively invasive interventions, which provide a few days, but also life of a doubtful nature.

B. The Logic of Euthanasia – deeper causes

The obvious tension which today surrounds our potential to intervene as a right in the event, the process and the moment of death, as well as the problem of euthanasia in particular, is basically due to the following parameters.

a) Our society is becoming ever more healthy and wealthy, with the result that its resistance to situations involving pain is increasingly restricted. People can’t stand difficulties, pain, and pressure, nor can they wait patiently any more. The same is true of societies themselves; they no longer put up with non-productive members.

b) Extending the average life expectancy on the one hand and reducing the number of births on the other, an achievement and consequence of modern civilization, have resulted in ageing societies, which means that cases of chronic and painful illnesses have increased in frequency.

Thus, for example, in Japan the aged now make up 15.7% of the population and it has been estimated that this will rise to almost 27.4% by 2025. Indeed, it is reckoned that this population trend will continue for about another century.

c) Our health has become an intensely financial and excessively costly matter, and the way in which we treat patients is now rationalistically mechanical. It is to these economic interests that the centre of gravity of medical treatment and support of the sufferer has been shifted, away from love and respect.

d) The entry of technology into medicine into health more generally has very often had as a result an unheard of prolongation of the death procedure, with the hope for survival presenting characteristics and qualities of tyranny. The course of treatment sometimes leads by itself to pathological symptoms and ethical dilemmas which it is unable to resolve in any way.

All of this leads to the phenomenon of patients and their relatives begging for death and often enough, finding doctors who are willing to assist them in this. And so there is a kind of “euthanasia” thinking, morality and outlook which, on the one hand, facilitates the legal concealment of euthanasia and, on the other, introduces an unprecedented need for reflection concerning the way to handle borderline crises related to death. This is a particularly painful procedure, given the unique emotional charge of those moments and the enormous responsibility. It’s worth noting that, in Holland, on the basis of recent laws, one in every 32 deaths is the result of the implementation of euthanasia, which, if introduced into Greece as things stand at the moment, would mean 3,000 deaths by euthanasia a year.

In this talk we shall attempt to discern the boundaries of medical practice, in relation to those of respect for life and death, at the point where they meet, within the context of the given circumstances today in ICUs.