Defining Death

Society has always expected that hopelessly ill patients would be allowed to die in hospitals and has hoped that doctors would practice certain forms of euthanasia, says Dr. Alexander Leaf, who as Jackson Professor of Clinical Medicine directs medicine at the Massachusetts General Hospital. Where society has abdicated, he says, is in failing to give explicit approval to the practice or in defining just which patients should be allowed to die.

The committee on Optimum Care to the Hopelessly Ill at Mass General should be commended for its efforts to produce explicit guidelines for doctors when deciding such cases. Its recommendations, which were accepted by the hospital in September, advise that patients whose brains do not function and who show no prospect of recovery should be taken off expensive life support measures. The report argues that if a patient has no brain function--even if he breathes and has a pulse--he is dead. The committee accepted as its criteria for death the Harvard standard, developed by a committee at the Medical School in 1967.

Last week a New Jersey judge failed to make that standard a legal one when he ruled that the parents of Karen Ann Quinlan could not allow her to expire. Quinlan is comatose and cannot speak or think. She also cannot live without the mechanical support of an artificial respirator; by the Harvard criteria she is dead.

A more subtle and established practice of passive euthanasia, for which the Mass General committee did not set guidelines, is the labeling of certain patients "Do Not Resuscitate," or DNR. The designation applies to dying patients who are apt to suffer cardiac or respiratory failure. Doctors justify the practice because resuscitation only prolongs a patient painfully and at great expense. Cardiac arrest, they say, is only the last organ failure in a dying patient and to resuscitate him is not to allow nature to take its course.

Keeping resuscitated but dying patients alive can cost as much as $500 a day, hospital administrators say, and a hospital can incur more severe costs by allotting its special but limited equipment to such hopeless patients. Allowing such patients to die is a necessary and humane process, they argue.

Still, the designation of DNR patients is of dubious legality and hospitals do not give official approval of its practice. Without criteria clearly designating moribund patients for DNR classification, doctors are operating within a grey area. In ambiguous cases, they have no standard guidelines for this crucial judgment.

Hospitals should establish criteria for DNR patients in the same way that Mass General instituted guidelines for patients on artificial support. In turn, the standard should be subjected to a legal test so that society will have an explicit voice in matters that have traditionally not been talked about. And, next time, the judge must not demur.