Public debate on issues of life and death.

The issues of when and when not to resuscitate after cardio-pulmonary arrest, and when not to withdraw 'extraordinary means of life-support' from a patient who is judged clinically to be on a trajectory leading to imminent death (or who may actually be dead already according to some definitions), have been publicly de bated for at least a decade and a half. In England in 1968 the medical director of a hospital in North London (Neasden) was hounded by the media for the guidelines he issued to house-staff on the kinds of clinical situations in which it would be appropriate to write NTBR ('Not To Be Resuscitated') on a patient's chart. He was vilified by some commentators as though he were the commandant of a Nazi internment extermination camp. In the same year in America a prestigious Harvard committee issued its famous re port (1) on circumstances of irreversible coma where one could legitimately declare that death had already occurred. In those circumstances, said the report, it would be permissible to withdraw respirator and other life-sustaining supports prior to or even after removal of fresh and indeed still living organs for the purposes of transplanting them into a needy patient. The debate has continued ever since, both in private and in public and with fluctuating intensity. The name of Karen Ann Quinlan is almost a household phrase. People are often astonished to learn about her current clinical condition. The usual response is one of distress and even horror. One rarely meets anyone who thinks of her continued survival as a cause for joy or gratitude for the 'miracles of modern technology' that supported her cardio-respiratory systems at a time when they would almost certainly have ceased to function if nature had been allowed to take its course. The recent charge of murder against two California physicians (2) focused intense light both on these issues in general and, more especially, of course, on the speci fic circumstances of the death of Clarence Herbert in California on September 6, 1981. His death had fol lowed on a post-operative cardio-pulmonary arrest on August 26 and the subsequent disconnection, at the family's request, of all life-support systems. The preliminary hearing, previously set for Decem ber 3, 1982, finally began on January 18, 1983 in the Los Angeles County Municipal Court before Judge Brian D Crahan. The evidentiary portion, which was very closely followed and was widely reported in press, radio and television, concluded on February 16, when the defence rested. Judge Crahan requested prosecu tion and defence attorneys to file written briefs by February 25. The oral arguments were heard at the beginning of March, and on March 9 the judge issued a thirteen-page Decision in which, after summarising the facts and some of the testimony (mostly for the prose cution) he posed 'The issue: Have the People produced sufficient evidence to hold the attending physicians to answer to the charge of murder, or to the second charge of conspiracy to commit murder?' The Decision continues with statements and clarifi cations of the law, and with summaries of some of the testimony of witnesses for the defence. Prominence is given to the testimony of Father John J Paris, SJ, Chairman of the Department of Religious Studies at Holy Cross College (Worcester, Massachusetts) and Professor of Medical Ethics at Tufts Medical School. Fr Paris had argued that physicians have no obligation to give intravenous fluids to a patient who has no hope of 'recovery' which he defined as staying alive without intolerable suffering or, in the case of a comatose patient, returning to a state of awareness. Reports of this testimony in the Los Angeles Times gave rise to sharp exchanges between Fr Paris and a representative of the Archdiocese of Los Angeles and theologians from Loyola Marymount University. The Catholic position is uncertain, and the Catholic Hospitals Asso ciation is currently drawing up its own Guidelines. The judge states the issue boldly: 'Should one prolong the living or the dying process by heroic efforts?' He states the pros and cons and concludes that