Giving life, giving death: ethical problems of high-technology medicine

High-technology medicine, such as dialysis and transplantation is limited and nowhere can all potential beneficiaries receive it. Although very successful, high-technology medicine sometimes makes dying to a cruel spectacle and patients whose lives depend on a machine want to stop. The resulting ethical questions revolve around just distribution of life support - giving life, and withdrawal of life support in giving death. We investigated distributive justice of life-support by setting the number of patients accepted for dialysis in relation to those who died of renal failure and by setting the transplanted patients in relation to those waiting on chronic dialysis. In both Sweden and in the USA, and in both dialysis and transplantation, older patients received less treatment than younger ones. Seventy-year old people had less than 1/10 the chance of 20-40 year old of receiving dialysis and less than 1/30 chance of receiving a transplant. Women had between 70%-90% the chance of men of receiving dialysis and transplantation in both countries. Black people were more often dialyzed, but less often transplanted in the USA. Neither in Sweden, nor in the USA has distributive justice been achieved in dialysis and transplantation. Similar problems have been reported in other areas of high-technology medicine. We studied withdrawal, i.e. passive euthanasia, in chronic dialysis patients and found that 10% of all patients who begun dialysis died because it was stopped, although there was no medical or technical reason. Stopping caused 22% of all dialysis deaths. Half of those who died because dialysis was stopped, made the decision to stop treatment themselves. The other half was incompetent and families and physicians decided to discontinue treatment and let the patient die. The competent and incompetent patients were similar and the decisions seem to have been made on the same ground in both groups suggesting that families and physicians are appropriate surrogate decision-makers for incompetent patients. Home dialysis patients withdrew from dialysis, three times more often than center dialysis patients. The decision did not seem to harm the surviving relatives, but the relatives complained of poor physician communication. Old patients had shorter survival on dialysis, were more often excluded from, and stopped dialyses ten times more often than young patients. However, the ratio of mortality on dialysis compared to the mortality in the population at large was higher in young than in old patients and the self-reported quality of life of the old patients was particularly high.(ABSTRACT TRUNCATED AT 400 WORDS)