LEGAL AND ETHICAL ASPECTS OF RESUSCITATION

JON LUNDEVALL

The aspects of resuscitation are closely related to the concept of death, which should be defined as clearly as possible.

Death occurs when vital functions come to an irreversible end. Single cells, or single organs, may die without fatal consequence to the individual as a whole, but there are certain organs, such as the heart, the brain, or the liver, without which the individual cannot exist independently. When one or more of these organs cease to function, the other vital functions stop, too, and the individual dies.

By an old definition, an individual is dead at the moment when he is unconscious, and his heart beat and respiration have finally stopped. It is true that beyond this moment some cells and organs may temporarily retain vital activity-sperm cells move about, muscles respond to electrical stimulation, and mitotic activity occurs in cells-but these activities are only fragments of complex life. The individual as a whole is dead.

Usually, it is not difficult to fix the moment when the heart and res- piration stop. It can be very difficult, however, to determine whether the condition is reversible, because under certain conditions, it is possible to make the heart beat again after it has stopped, and to restart respira- tion. This is resuscitation.

The conditions for successful resuscitation are, first, that the vital organs are intact. If the contractile elements of the heart are extensively destroyed by infarction, or if great areas of the brain are ruined by trauma or circulatory disturbances, resuscitation in its strict sense is usually not possible. It may be that, by means of advanced technical measures, the body can be maintained in a living state for a long time, in spite of ex- tensive and irreversible brain damage. The patient is then in a state of vegetative life, and resuscitation is incomplete.

From the Institute of Forensic Medicine (Head: J. Lundevall) University of Oslo, Norway.

358

The second condition is that the physician has the necessary knowledge and technical means for resuscitation. The procedures of artificial respira- tion and external heart massage are commonly known, and may be prac- tised without special equipment. Refined and more effective means and methods may be available in hospitals.

As resuscitation in a given situation must be undertaken immediately and on the spot, a standard procedure can hardly be outlined; the means and methods must depend on the circumstances.

The third condition for successful resuscitation is that it must be applied within a certain time after the heart and respiration have stopped. A re- vival after the lapse of this period is resurrection, which is beyond the reach of man.

The chances of a successful result are better the earlier resuscitation is started. The period during which resuscitation is still possible varies from case to case. It is longer for the patient who is dragged unconscious out of the ice-cold sea than for the patient who collapses from a heart attack, but it is hardly possible to define the time accurately in a given case. It is necessary to allow a reasonable safety margin, both for how late resuscitation can be started and yet succeed, and for how long it should be continued.

To determine if, and when, resuscitative effort should be applied is not only a question of medical knowledge and technique, but also of medical ethics. By the WMA declaration of 1948, the doctor shall “maintain the utmost respect for human life.”

Taken literally, this means that every effort should be made to save a patient by resuscitation, regardless of the patient’s life exceptancy, and whether resuscitation will be complete or not.

In practice, however, doctors will consider what can be attained by resuscitative attempts. For instance, no-one would hesitate to try to save the life of a patient whose heart stops during surgical anaesthesia or after a sudden unexpected heart attack. But when the patient has advanced cancer and bronchopneumonia, most doctors will be reluctant to restart the arrested heart. In some cases, it is obvious that the situation is hopeless, and to restrain death would be merciless.

Pope Pius XI1 considered these problems at a doctor’s congregation in 1957. His opinions were as follows ( 1) :

The anaesthesiologist ordinarily has the right, but not the obligation, to use special technical measures for resuscitation, even in the hopeless cases. However, he has no right to act without the patient’s direct or indirect consent, and if the relatives of an unconscious patient are opposed to the

application of resuscitative means, the doctor may not apply them. Re- animation is not in itself immoral, but the physician is not morally obliged to employ extraordinary means for resuscitation.

The Pope further stated that a respirator may be switched off before blood circulation stops, provided that the soul has definitely and per- manently left the patient’s body.

If circulation and respiration are maintained only by artifical means in an unconscious patient, and if the patient’s condition is not improved after several days, the Roman Catholic Church cannot state authoritatively whether the patient is alive or dead. I t must be up to the physician’s judge- ment to decide the question. The Pope said, however, that life continues as long as the vital functions, including the spiritual functions, go on. The difficult thing is to determine whether they do or not.

I n my opinion, there are also other considerations. To maintain every such patient with a vegetative life only as long as possible and at any cost, would be prohibitive for questions of economy and personnel. On the other hand, one must proceed carefully in these matters in order to main- tain the public’s confidence in the medical profession, and there are also the sentiments of the hospital personnel to consider.

In my country, it is the doctor who must take the decision when to start resuscitation and, in case, when to stop. The patient’s relatives may have their opinions on the matter-and express them with vigour-but relatives are often emotionally or otherwise engaged, and have limited medical insight. The doctor should listen to what they say, and keep them oriented, but it would be unethical of him to put the decision to them.

The doctor’s legal resposibility in these matters is of less practical im- portance. Theoretically, a doctor may be charged for punishable criminal negligence, even intended homicide by omitting resuscitation, but I do not know of any such case having been brought before court in Norway.

Signals from America indicate, however, that the public has become in- creasingly conscious of the possibility of financial compensation in cases where tardy resuscitation has left the patient with permanent brain dam- age. I n actual cases, heart arrest occurred during anaesthesia for trivial operations, and open-chest heart massage was started too late ( 2 ) .

T o establish liability by a doctor in such cases, it must be shown that he has deviated from normal practice, i. e. that he has not acted with ordinary care. The court’s decision rests mainly on the opinion of expert witnesses and what relevant evidence appears in medical literature. Thus, it is the medical profession itself which determines the direction of legal practice at any time. I n any new case, the doctor may be confronted

360

with unexpected problems for which there is no established practice; he must take his decision, and be ready to defend his way of acting if necessary. It is the duty of professional men to take risks, but they must be well calculated.

REFERENCES

1. Ethics in Medical Progress. Ciba Foundation Symposium, J. & A. Churchill

2. Evans, F. E.: Some Facets of Medical Malpractice-Pertaining to Liability in Ltd., London, 1966.

Cardiac Arrest. Amer. 7. Proctol. 1966, 17, 313-318.