Scientic Reviews

Living and dying with medical technology

Daniel Callahan, PhD

Medical technology is a two-edged sword, capable of saving and improving life but also of ending and harming life. Finding the right stance toward technology requires great balance and sensitivity. It has seductive powers because of its expected benets, the social and professional pressures to use it, and a frequent confusion that results from confusing the sanctity and value of human life with a supposed imperative always to use technology.

The aim of good critical care medicine should be to establish a meaningful tension, particularly in the care of those patients threatened with death, between the aim of preserving life, on the one hand, and making possible a peaceful death, on the other. Any automatic bias in favor of using technology will threaten that latter possibility. (Crit Care Med 2003; 31[Suppl.]:S344 S346) KEY WORDS: technology; death; decisions

ry as we might, it is hard to escape two ancient and hard truths. One of them is that there is no free lunch. The other is that the road to hell is paved with good intentions. The discoverers of those insights are anonymous and unsung, but they were clearly onto something. For if those truths apply to most of life, and just about every technology one can think of, they apply with a special intensity to medical technology. That technology can save our lives, but if not used carefully, it can also end our lives. It can, in individual cases, lower the cost of healthcare, but in health care systems constant technological innovations can come near to bankrupting them. It can reduce pain and suffering, but also increase them. Medical technology can also seduce us and lead us to regret it. Intensive care units are lled with patients who swore, earlier in life, that they did not want to end their life in the company of tubes and machines; but there they are; and who, swearing they will never go through that experience again, come back for more when the next health crisis arrives. Then, of course, there are those physicians and families who, after the fact, rue the useless effort they made to save a life that could not be saved, which they knew in

From The Hastings Center, Garrison, NY. Address requests for reprints to: Daniel Callahan, PhD, The Hastings Center, 21 Malcolm Gordon Road, Garrison, NY 10524 5555. Copyright 2003 by Lippincott Williams & Wilkins DOI: 10.1097/01.CCM.0000065122.55187.22

their hearts but not in their professional, routine-oriented heads. For medical technology, the insight that there is no free lunch plays itself out when it is discovered that it can do good as well as do harm; or, that too much of a good thing can soon become a bad thing. The notion that the road to hell is paved with good intentions means, in practice, that a promise to oneself and others to use the technologies in a careful and prudent manner often turns into a slavery to those technologies, which seem to use us as much if not more than we use them. Well might we ask: just who is in charge here, our rational selves or the far more seductive technologies, promising free lunches as a reward for our good intentions? There is often no clear answer to such a question. I pose my approach to medical technologies and critical care medicine in great part as simply as a token of the problem of technology in general. How might we best think of the use of medical technology in light of the two ancient, but homely, truths I have described? The question is particularly acute in critical care medicine for an obvious reason: the patient is in dire straits and the standard, well-engrained response is a full court press with the best available technologies and specialists trained to use them. That is taken to be the very point of a critical care unit. For your sprained ankle, go elsewhere. For drawn-out palliative care, look some other place. For your dementia, well, forget about it. The modern critical care unit is a showcase of technology, ready to give your body what it needs, fast and furiously, using the best and the lat-

est drugs, machines, and assorted other wizardries. The most fundamental problem with technological medicine is two-fold: that it can give us a longer life and a slower dying and that it can keep us alive when we might be better off dead. Historically, when infectious disease was the leading cause of death, the estimate is that death came in 23 days. If a person contracted a lethal disease, its course was rapid. Not so, of course, with modern chronic diseases for which it is just about impossible to nd an average length of dying, or for that matter, to even nd a bright line between living and dying. As for the quality of a life that has been extended by technological medicine, we know that in many cases, it can be terrible. The body has been preserved, but as a body in poor condition, doomed to be burdened for the remainder of its life by pain and disability. To be sure, for many people, a poor quality of life is better than no life at all, and they are glad to be still alive. But, that fact should not distract us from noting that the saving of life in critical care medicine may be a pyrrhic victory. The fundamental question that emerges, I would suggest, is this: how can we better understand the pull and power of technology, while at the same time, keeping it under control and using it in a way that serves our most humane and rational aims? Put another way, how can we be masters of technology and not its slaves? If that is a fundamental question, I want also to suggest that it is a fundamental error to assume that technology is a neutral tool, to be used or not used as we freely choose. In the narrowCrit Care Med 2003 Vol. 31, No. 5 (Suppl.)

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est sense of the term neutral, that may be true; that is, it is true if we abstract technologies from their cultural context, treating them as free-standing objects and techniques, as if they are just lying passively about waiting to be used as we see t. On the contrary, however, technologies take on a life of their own when they are embedded in a culture and begin to shape the way that culture is to be interpreted and lived in. Do we really have a choice in most of American society to drive a car or not, to use the internet or not, or to raise our children free from television? In each of those cases, the technologies have come to win over the culture, and we are stuck with them whether we like it or not; we resist and rebel at a high price to our integration into the culture. We may well think that it is a good thing to have those technologies and, for the most part, it is but it is much harder to see how we are also their captives, something that becomes clear only when we try to get away from them or think about living a different kind of life. Medical technology is no exception. The beginning of wisdom about technology is to perceive its power to shape the context of our lives and, in so doing, sway our judgment in powerful ways, often out of our control. One of the most seductive powers of medical technology is to confuse the use of technology with a respect for the sanctity of life. By that I mean, it has become all too easy to think that if one respects the value of life and technology has the power to extend life, then a failure to use it is a failure to respect that value. Let me try to tease out the reasons for the power of technology and why it is so difcult to control. The overriding reason is clear enough: technology brings us great benets, so much so that it soon becomes difcult to imagine living without it. How often we nd it hard to recall what it was like to live before the introduction of a new technology, one to which we have become accustomed and that has become part of our professional life. Habituation, then, is one of the ways technology begins to control us. Social expectations are still another: we are expected by our friends and colleagues to use the available technologies everyone else does and so should we. Available technologies invite use and activity, a use reinforced by their effectiveness, as an intrinsic value, and by the
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social expectations they create, as an extrinsic force. All of those pressures, fed by professional training and acculturation, daily reinforcement, and an inability to imagine not using them, stack the deck heavily in their favor. How often does clinical training, or daily interchange with ones colleagues, guide one when it is best not to use otherwise routinely used technologies? I have in mind here diagnostic technologies, particularly in those cases in which the diagnostic information will make little or no difference in the actual treatment of the patient (but can well create anxiety and discomfort for the patient). A great but little noticed problem is what I call technological brinkmanship, all the less noticed because it seems so commonsensical. By that term I mean, the belief that the best way to use technology is to apply it fully when there is still some prospect of benet, even if small, and then instantly stop it the moment it appears futile or counterproductive. But the seemingly commonsensical quality of that view conceals some serious difculties. One of them is that there is rarely any perfectly clear line between benecial and futile treatment; and the line gets harder and harder to nd as new technologies offering marginal possibilities for improvement appear. It is all too easy to go too far in seeking that line, which may never appear or pass unnoticed. The other difculty is that clinicians, on the one hand, and patients and families, on the other, can and do differ about what counts as futile or useless treatment. It is a well-known truth that with critically ill patients, the various subspecialists brought in for help can see some benet to some organ system with the kind of therapy they can provide; and there well may be. But, anyone standing back from the scene even a little bit when and if there is such a person can see that the patient as a unied organism is dying, even if more can be done for that patients dysfunctional liver or failing heart. However, does not evidence-based medicine offer, at least in theory, a solution to such problems, a cleaner, tidier way of cutting through such difculties and disagreements? In theory and much conrming practice, it does, which is why it is worth pursuing. But, good evidencebased medicine requires time and money for its evaluative work, and there is no adequate source of funds anywhere to

carry out all the needed studies. Thus, only a small proportion of technologies can be fully investigated, much less every new and slightly improved iteration of a technology. A more important and inherent obstacle is one intuitively familiar and complex for any clinician: that of making the move from probabilistic knowledge of a general kind to making a judgment about the care of an individual patient. Evidence-based medicine cannot tell a clinician how to treat a particular patient. All it can provide with a given technology is evidence of its efcacy with a population of patients; it is, put another way, population (rather than individual) oriented. The evidence can indicate that for most patients with X or y condition, a therapy will be effective for (a) none of them, (b) some of them all of the time, (c) all of them all of the time. Unfortunately, (b) is likely to be the most common outcome. When that is so, a whole range of new, not easily answerable, questions arise. Is it worth treating every patient a certain way when it is known that only a portion of them will actually benet (and all the more complicated a questionif the treatment will be painful or otherwise burdensome)? Is it worth treating a patient when benet can be expected if the benet is marginal for most but great for some? If the life of a patient is at stake, is it worth it to use a treatment with low probability of success simply because there is no other alternative course available? I phrased each of those questions using an ambiguous term, that of worth it. It is ambiguous in two possible senses. One of them is ethical. What does the doctor morally owe the patient in the care provided? To do everything possible? Or only everything reasonably possible? And, just what does that word reasonably mean? I mentioned above the way the supposed imperative to use available technologies has been confused with the idea of the sanctity of life, as if a failure to use it is tantamount to a denial of the value of a life. That confusion, abetted by social and family pressures, means that it can be exceedingly hard to make wise use of evidence-based medicine, even if the probabilistic data are perfectly solid. A second sense of worth it is economic. Critical care medicine, like every other branch of medicine, has to deal with resource scarcity. A therapy that is valuable to only one in 100 patients may, some might think, be morally required
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because of the value of the life of that person. And, in an economically rich context, the odds of one in 100 may be well worth accepting (assuming no great burden to the other 99 patients treated with no benet). Such a treatment is, at best, economically marginal, with little population benet. Moreover, it is understandable that an health maintenance organization (HMO), even of the kindly type, may resist reimbursement for it. The HMO can almost surely nd some other way, with more benet for more patients (although with some entirely different pathology), to spend its limited money. Critical care medicine, in a word, forces to the foreground an important debate: nding the proper balance between an individual-centered and a population-centered medicine. The individual patient has historically been at the center of traditional medical ethics, going back to Hippocrates. Critical care medicine is solidly within that tradition. For good reason, it has never been part of public health, population-centered. It cares about the health of individual patients and has been willing to invest great efforts and much money in caring for them and caring in particular for those who are usually the sickest, most needy of all. If the moral problems of evidencebased medicine turn on the value we should give to individuals and what we, so to speak, owe to them technologically, the economic problems turn on the best ways of helping sick populations, not sick individuals. Critical care medicine raises both kinds of questions, and the use of technology is the practical crux of each of them. If almost all of the technology problems for critical care medicine I have so far mentioned bear on the treatment of all patients, it would be useful at this point to make some distinctions. There are those patients who are in critical care units because, while in need of special-

ized, intense services, they are expected to recover. That is the majority of patients. About their care, it is possible to raise all of the ethical and economic issues outlined above. Then, there are those patients who are critically ill and directly threatened by death those cases, that is, in which the quality of the care can make a decisive difference for life or death in the outcome. I want to focus the remainder of this article on the use of technology in those cases. The main benet of technology in the most serious cases is that it may save a patients life. The main hazard of technology in those same cases is that it may increase the pain and suffering of a patient who cannot be saved, making the end of life more miserable than it need be. But, how can it be known in advance which is the most likely outcome? Of course, that cannot be known with any certainty. But, the argument I want to advance is that each outcome should be taken with equal seriousness in determining the course of treatment and the use of technology as part of it. I stress the word equal for two reasons. The rst is that the force of technology, for the reasons sketched earlier, creates a powerful presumption in favor of its use. That presumption needs to be neutralized sufciently so that it does not succeed in controlling the situation, creating its own force and momentum that are hard to stop. The second reason is related to the rst: the welfare of the patient is the whole purpose of the treatment, and if that treatment brings needless suffering, then the whole purpose of medicine has been defeated. Taking these two reasons together, nothing less than holding the need to cure and the need to avoid useless suffering in full tension will be sufcient to keep the power, for good and ill, in check. In particular, it is necessary to keep in mind that the idea of the sanctity of life does not entail a singleminded use of technology to preserve life.

Most clinicians know this well enough, even if the point is not articulated. But, it is precisely because so many factors conspire to force an aggressive use of technology that a counterbalance is necessary. The most important counterbalance is simply the recognition that at some point, every patient will die, must die. It is for that reason that the tension between the use and nonuse of technology must be serious and equal. The natural tendency in modern medicine is to act as if the time of death both can be, and ought to be, deferred. But, that is because medicine is profoundly ambivalent about the place of death in human life, treating it as a biological accident that research and better treatments can cureand thus to be denied as a reality. But, the critically ill patient will eventually die, if not this time then at some other time. But, precisely because it may be this timeand thus the only chance a clinician may have to help assure as peaceful a death as possiblethe balance I am arguing for becomes all the more important. Put another way, when a critically ill patient is threatened with death and there is serious doubt about a good outcome, then the physician should understand that he has a choice on his hands, one that can validly go one way or the other. Such is the power of technology not a neutral force in a critical care unit because of the intrinsic and extrinsic value socially and medically assigned to itthat it can too easily obscure the need for choice and for a balance that allows a wise choice to go either way. A decision not to use a technology can be as valid as a decision to use it. Once that is understood, then patients will have a good chance to die well, just as they had a good chance of living on. Both are good decisions. It all depends is a bit of old wisdom also.

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