LIFE AND DEATH - ETHICAL DILEMMAS
Paul C Y Chen

With power comes responsibility. The power that the doctor wields over life and death places a heavy responsibility upon him. Consequently, in the course of his work, the doctor often must choose between two or more alternatives none of which seem to be a satisfactory solution to the problem. The choice is difficult enough for an older experienced doctor but is a nightmare for the young inexperienced but conscientious physician. Examples of such ethical dilemmas abound. Thus in respect of the incurable patient, the doctor is often faced with the dilemma of whether the truth may lead to the loss of "will to live". Consequently, some doctors deliberately deceive their patients. Another dilemma concerns euthanasia. Should the doctor preserve life when he knows that the patient's existence will be without human dignity and be a burden to his loved ones? Is not the quality of life more important than the prolongation of life? Should he intervene to save a severely deformed neonate with low survival potential? Yet another dilemma revolves around the allocation of priorities. Should one category of patient or another have greater priority when it comes to the use of scarce resources such as renal dialysis, the respiratory and intensive care? Should limited financial resources be channelled into an expensive therapeutic or diagnostic procedure such as renal dialysis, radiotherapy and CAT when large numbers of rural people have difficulty in obtaining even simple primary medical care provided by the lowest category of paramedical or auxiliary? These are but three examples of the ethical dilemmas faced by doctors in the course of their work.

The Dying Patient
The medical profession's pre-occupation with saving lives and postponing death has left many doctors both unwilling and ill-equipped to deal with the dying patient. Undoubtedly, the hearing of bad news can bring on severe depression and the loss of the "will to live". Consequently, many doctors are unwilling to disclose the true seriousness of an illness particularly in the case of cancers. In the case of a small number of patients, a disclosure would be an act of needless cruelty. However, according to Gerle et al (1960), a large proportion of patients have a positive reaction. Further, Kubler-Ross (1969) demonstrated that nearly all of 200 dying patients in a Chicago hospital came to realize what was happening even when efforts were made to conceal information, and that with adequate assistance, the denial, depression and anger could be replaced with hope and acceptance. However, it would need a sensitive and patient doctor or nurse with sufficient time on his hands to adequately assist the incurable or dying patient to adjust to the truth. In the face of competing demands on his time, the doctor seldom can put the dying high on his list of priorities. Nevertheless, this problem cannot be ignored or brushed aside.

Euthanasia
The term literally means a "good" or "easy" death, even though in the modern sense it often means permitting death. A severely damaged cerebral cortex may leave a patient in coma with no likelihood of recovery of consciousness. Only his brain stem sustains his life. To his relatives, he is dead. If such a patient develops pneumonia, should every effort be made to treat him? Would it be better to withhold treatment? Should a severely deformed neonate with low survival potential be sustained for a few months by intensive treatment or should treatment be withheld? Should the patient with severe pain from cancer be provided with dosages of drugs that relief pain but which might "hasten" his death?

Decisions to withhold treatment or provide near lethal doses of pain-killing drugs can lead to death. It would seem that this is contradictory to the doctor's duty to preserve life. However, is the doctor's duty purely to prolong life irrespective of the quality of life? Surely the duty of the doctor is to respect life and to contribute to the quality of life. However, the definition of what constitutes a "good" quality of life is in itself a philosophical question.

Priorities
In medicine, resources are almost always scarce. At the doctor-patient level, every diagnostic and therapeutic procedure has to be distributed among those demanding for these. In the case of the common inexpensive procedures and therapies, it is easier to meet almost all demands. However, many procedures are prohibitively expensive. Renal dialysis, organ transplants with attendent need to monitor immunological reactions, and intensive care, are but a few of the more expensive procedures that drain the National Health Budget out of proportion to the benefit that accrue out of their use. Intensive care requires three times the equipment and five times the staff needed for normal patient care. Consequently, the demands for these very expensive procedures and therapies cannot be fully met even by the National Health Budgets of the most developed countries. Doctors are thus compelled to decide which of several patients requiring an expensive but scarce resource has greater priority than others - an ethical dilemma most would rather avoid.

In such a situation, one is often tempted to seek and obtain a larger allocation of the National Health Budget for these expensive procedures in an attempt to meet the demand. However, the dilemma is even more acute when it is realized that such expensive procedures will benefit only a few urban patients, perhaps at the expense of large numbers of rural people many of whom do not even have access to simple primary medical care. Illich (1975) notes that large-scale random samples have been used to compare mortality and recovery rates of patients served by intensive care units with those of patients given home treatment, with no indication that there are any advantages in intensive care. National Budgets are always limited. Expenditure on one expensive procedure such as a renal dialysis machine, intensive care, or CAT must necessarily mean that there are less funds for other programmes. Nevertheless, allocation decisions are ethical dilemmas that demand careful examination of all available data and a choice of one of several alternatives none of which seem to be a satisfactory solution to the problem.