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Extending Life vs. Right to Die

Published December 06, 2007        by Nicole

candleIn the scheme of right-to-die cases in the I970s and I980s, the development of the modern respirator in the mid-1950s was the most significant technological development. Respiratory failure, particularly the paralysis of the muscles of the lungs caused by epidemics of poliomyelitis, had long been an agonizing problem for physicians and families. In the I920S, one US physician, Dr. James Wilson, had written as quoted in the writing of Philip Drinker and Louis Shaw, the inventors of the iron lung:

Of all the experiences the physician must undergo, none can be more distressing than to watch respiratory paralysis in a child with poliomyelitis - to watch him become more and more dyspneic [breathless] using with increasing vigour every available accessory muscle of the neck, shoulder, and chin - silent, wasting no breath for speech, wide-eyed, frightened, conscious to almost the last breath.

The iron lung, which encapsulated the patient in a steel cylinder with the head exposed, had been invented by the Boston scientists in 1928 and its technology rapidly spread around the world. Pumps raised and lowered the pressure within the chamber which in turn forced the lungs to contract and expand. It saved numerous lives, but the problems of the technology became increasingly apparent: it was ineffective for the most severe form of polio; in an epidemic there were never enough iron lungs to go around creating ethical dilemmas about who should have access to one; regular turning and nursing of the patients was difficult if not impossible creating a problem of bed sores; and many of those sustained by the machines could not be weaned from them, becoming imprisoned by the very technology that had saved their lives.

A devastating polio epidemic in Denmark in 1952 proved the impetus for a better method to be found. When the twenty-eighth patient admitted with polio to Copenhagen's Blegdam Hospital died of respiratory paralysis, the head epidemiologist implored the head anesthetist to try to sustain the mounting number of patients by manually forcing air into their lungs with a ventilation bag, a method commonly used for short durations during surgery. It worked even better than the iron lung but it was extraordinarily labor intensive. During the Copenhagen epidemic seventy-five patients were kept alive during their acute medical crisis by teams of 250 medical students doing round-the-clock manual bagging, 260 nurses providing bedside care, and twenty-seven technicians looking after the equipment. Within a year of the Copenhagen group's report in The Lancet, companies around the world were coming out with a positive pressure, electrically-driven ventilator that would replace the manual bagging with a reliable machine. The respirator was born, and it was soon discovered that this little piece of technology could keep a person alive almost indefinitely, even when they were in a persistent coma or irreversible respiratory failure.

At about the same time, other groups of scientists were looking for ways to rescue a flagging heart. Before the 1950s, there was little that could be done if a person's heart went into cardiac arrest, its muscles no longer pumping blood through the body in a steady rhythm but quivering and twitching ineffectively in a state called ventricular fibrillation. Nor could much be done if a blood clot threatened to block important vessels, or if coronary artery disease was slowly strangling the blood supply. External cardiopulmonary resuscitation was unknown. Back then, the only known technique to restart a fibrillating heart was to open the patient's chest and grab the wriggling mass of muscle by hand, give it a series of forceful squeezes in the hope the heart would return to a steady beat. Understandably, the method enjoyed a dismal success rate. In the early I950s, however, Dr. Paul Zolllearned of some Russian research in which an electric current had been applied on the outside of the chest wall to correct a fibrillating heart. Zoll did animal experiments and then in 1952 applied a series of shocks to two patients in ventricular fibrillation. One died but the other recovered. Cardiac defibrillation was born, another of the rescue technologies that could stave off what before was certain death. Further help for diseased hearts came one year later, in 1953, when it became possible to temporarily by-pass the heart and let a machine take over circulation and aeration of the blood, for the first time enabling surgeons to operate on a motionless heart. The heart-lung bypass machine suddenly opened up a whole area of cardiac surgery, paving the way for cardiac by-pass and cardiac transplants in the late I960s.

Effective medical rescue of the kidneys came on stream by the early 1960s. Earlier attempts to get a machine to do the job of filtering the metabolic waste products from the blood failed largely because medical scientists didn't know how to prevent the blood from clotting or what medium to use for filtration. In I940S Holland, Dutch physician William Kolff produced the first successful dialysis machine using the drug heparin to prevent clots and cellophane as the dialysis membrane. His first sixteen patients in acute renal failure died, but the seventeenth was sustained for eleven hours until her own kidneys recovered. Continued problems with blood clotting, filter medium, and methods to attach the patient to the machine slowed the widespread use of dialysis in the 1950S. But in 1960, a Seattle scientist introduced a Teflon tube that could be inserted permanently in a patient's vein, enabling him or her to be readily connected and disconnected to the machine for the three or four sessions of blood cleansing needed each week. Dialysis then became a realistic method to sustain lives of patients in renal failure. Thus, at the beginning of the 1960s, all the rescue technologies were essentially in place. Intensive care units were created in hospitals to concentrate these machines, the skilled staff needed to monitor them, and the very sick people who needed to use them. Patients, who just years earlier would have died, could now be saved, many to resume an active life. It was miraculous; but over the next few years it began to dawn on people that miracles can sometimes have a down side.