SIR

There are some important flaws in Michael Ardagh's reasoning.¹

1. Cardiopulmonary resuscitation (CPR) is a “blanket term” for different interventions. Curative and supportive treatments have different ethical contexts and cannot be discussed at the same level. It is imperative to ascribe curative interventions within CPR (defibrillation, pneumothorax drainage, etc) the same status as any other curative intervention, such as antibiotics for infections or surgery for appendicitis. Then we will be able to discuss the ethical context of purely supportive measures such as chest compressions. To address the “ethics of CPR” is a dangerous misnomer.

The preferences of emergency personnel² suggest the willingness to undergo curative interventions early during CPR, but not protracted supportive interventions. Conversely, withholding curative interventions during CPR should only be considered when any curative treatments would also be withheld.

2. Cardiopulmonary resuscitation is performed to offer the patient a benefit. However, CPR as a whole is only marginally effective.³ Separating patients who had a curative intervention from those who had only supportive procedures, the difference in the outcomes of different CPR settings becomes evident (for example, survival: ventricular fibrillation 19%, Asystole 2%⁴), and efficacy is important for the ethical content of the act of resuscitation.

Supportive measures are needed if there is to be maintained resuscitability while the patient is assessed for curable illness. It is necessary to define those CPR interventions which have been proved to be curative, and to assess the patient focusing on the indication or otherwise to perform such interventions. Everything else must be ascribed research status. Only then can we discuss what the supportive interventions are intended to do.

3. Central to Ardagh's article is the capacity for surrogates to make decisions. A surrogate is an individual caught between his or her personal drives (socially acceptable decision regarding other relatives and acquaintances, professionally acceptable decision, etc) and the identity the surrogate assigns to the patient (for example, a loved one, an instance of cardiac arrest). The result is a subordination of the patient's autonomy to the drives of the surrogate chosen. Professional detachment equates to addressing a stereotyped patient instead of the real one.

The surveys of emergency personnel² show that we do not wish for ourselves what we daily do to our patients. This is the basic flaw: I may well wish to preserve my loved ones when I would not wish to be preserved myself.

4. Principled ethics are a particular approach to ethics. Beauchamp and Childress⁵ also refer to other approaches, and relation-based ethics is particularly relevant for a profession defined around the doctor-patient relationship. Relationships are a source of bilateral duties and expectations which carry an ethical content from the moment they are established. Regarding the medical relationship, the “duty of care” is immediately established, as is the expectation that the patient will accept such care. The flaw is to forget that the cardiac arrest patient did not necessarily accept the establishment of the relationship, and the duty of care is imposed on the patient.

In medical relationships where clearly the patient has no power—psychiatric incompetence, child protection, etc—are concerned, the framework of the medical intervention is socially defined, and has little to do with ethics as the expression of autonomy, but rather has to do with a social discourse about ideological coherence—the principles of ethics in their “power discourse” mode, enabling the medical profession to make unilateral decisions in the patient's name. Within this framework there is no space for autonomy, the individual is not called to define himself: society assigns an identity to individuals and regulates the mode of action to be observed.

5. Interestingly, Beauchamp and Childress concluded “that we should abandon substituted judgment insofar as possible in law and in ethics…” .⁶

6. Western culture lives within the opposition between life and death. Malpas⁷ argued for the necessity of death to create the “unity of a life”, the life project which ultimately enables autonomy. Consequently, our attitude towards death has implications for the expression of our autonomy. It is important to define the characteristics that allow the denial of death, which justifies intervention as a default, in contradiction of the medical ethical framework (which demands patients' consent). This contradiction is so profound that we must search for the reason why, before affirming a common ethical framework.

In summary, so-called CPR ethics is a dangerous misnomer for a particular discussion of the ethics of life-supporting treatment, in a context where decisions have to be made very rapidly. To situate the discussion properly, defining its scope and expressing the limitations of the action and conceptual models used, will be helpful.