Dear Editor

Without intervention, a small preponderance of female over male infants will be born, and female children will have a slightly higher chance of living to maturity. Thereafter, the female population will decline relatively sharply in consequence of death in childbirth. Historical evidence indicates that throughout the recorded history of Britain, there was a relative scarcity of women and men dominated social structures. This situation was only reversed in the early decades of the twentieth century, a time when three generations of young men had gone, in succession, to be soldiers. These wars were chiefly fought abroad, and too few returned to provide husbands for all the available women.

It is no coincidence that this era also saw the real beginning of equality for women. Circumstances dictated that women undertake roles previously considered male, and events proved their ability to do so. The surplus women continued in working careers, perforce, providing role models for those who came after. All the protests of the suffragettes were less effective than this brutal gender imbalance.

Dickens’ assertion that the present scarcity of girls in India, due to sex selection before and after birth, will lead to a future increased social value for daughters, may be true. However, this will in no way reverse the force of male dominance, since to have value as a wife and a mother is not necessarily to have value as a person. On the contrary, a shortage of wives and mothers will reduce opportunities for these future women to be anything else. Their chance of escaping the present lot of their mothers will be significantly less.

In the developed world, the birth rate is falling below replacement levels. A first male child is still preferred and a family of less than two children cannot be balanced. To this day, equality of the sexes has not been fully achieved. The injustice and oppression Dickens complains of are present least of all in prohibitions on sex selection.

Dear Editor

I read with interst the article by Cherniack [1] in October's issue. He questions whether or not more elderly people die with a DNR order beccause they are actually choosing to do so, and reviews evidence of doctors and patients knowledge and attitudes towards CPR decision making.

It is all very well talking about whether a patient would want to be resuscitated and Cherniack feels more studies should be done regarding how elderly people would prefer to be asked, but one has to look at whether CPR is actually going to benefit them or not. I agree that doctor and patient education is important, but I wonder whether emphasis should be placed on education to explain when resusciation would not need to be discussed with patients because it would be unlikely to benefit the patient (medically futile) and explain when it would need to be discussed, when it is likely to benefit the patient or when there is uncertainty on the outcome.

It is not a question of ignoring a patient's wishes, or age disccrimmination or denying patient autonomy, but to aim to promote the principles of beneficence and non-maleficence, and to do what is in the best interests of our patients.In other aspects of medicine we do not discuss treatments that will not be successful and CPR should be treated in the same way.

Dear Editor

I read Dr Cherniack's article regarding DNR orders with interest.[1] One of the problems with DNR orders is the patients’ assumption that if there is no DNR order they will survive resuscitative efforts. This of course is far from the truth. In my hospital these have been modified to "do not attempt to resuscitate orders". One cannot be truly autonomous without being informed. Long term survival, as measured only by being alive, following in-house cardiac arrest, is about 15 % over all age groups.[2] In sick elderly patients over 70 years of age who survive a cardiac arrest, the subsequent hospital mortality approaches 100 %. This fact and concerns about harm influence physician’s attitudes, particularly where the general public have wildly unrealistic expectations of the results of resuscitation as mentioned in the paper.[3] Significant neurological disability is common following cardiac arrest: up to 50 % of the survivors of CPR in one study.[4] Medical staff are clearly aware of hazards of resuscitation, doctors have been demonstrated to be highly selective as to when they would wish resuscitation to take place for themselves [5] and in one group of emergency workers few were found who were willing to undergo full resuscitation as "currently practised".[6] Whilst age per se is not necessarily a predictor of poor outcome of intensive care [7] advancing age is associated with an increasing incidence of systemic diseases, which do predict poor outcomes following arrest.[8,9]

As a society we seem to strive to prevent death pursuing the next line of treatment at any cost and this struggle against disease has been described as "trench warfare against death".[10] Patients and their relatives expect physicians, as fiduciary agents, to do everything in their power to help cure them and save their lives but there comes a point where not doing something is the better thing to do. Physicians tend to endeavour to do all that they can, as Morreim puts it " embracing a technological imperative that favours action over inaction".[11] However, the fact that we would not wish it upon ourselves says a great deal about what we think of resuscitation in the sick elderly patient. Dr Cherniack comments that when information about CPR is presented more negatively then fewer elderly will chose it. He seems to imply that one could be more positive if only one wanted to. I fail to see how one can be positive about brain damage, a stay on ITU and the near certainty of death. In certain circumstances CPR is simply harmful. Outcome statistics and the high incidence of morbidity have led one group to conclude that, "treating our elders this way is maleficient.[12]

It is a mute whether there is any moral obligation to discuss treatment options that are not really treatment options, particularly where the potential to do harm far outweighs any benefit. Survivors of resuscitation are transferred to intensive care units. Patients who have spent time on Intensive Care Units report nightmares, depression, high levels of distress and up to 40 % have recollection of pain.[13,14] Is this a beneficent act if survival is not a realistic possibility? I think not but of course a vitalist would disagree. By all means we should ensure that we respect patients autonomy by asking their preferences, but we have to be totally frank about outcomes. To not do so would be to infringe patient’s autonomy as much as disregarding their preferences.

References

(1) Cherniack EP. Increasing use of DNR orders in the elderly worldwide: whose choice is it? J Med Ethics 2002;28:303-307.

(2) Juchems R, Wahlig G, Frese W. Influence of age on the survival rate of out-of-hospital and in-hospital resuscitation. Resuscitation 1993; 26(1): 23-9

(3) Godkin M, Toth E. Cardiopulmonary resuscitation and older adults expectations. Gerontologist 1994;34:797-802

(4) Jaffe AS, Landau WM.Death after death: the presumption of informed consent for cardiopulmonary resuscitation--ethical paradox and clinical conundrum. Neurology 1993;43(11): 2173-8

(5) Hillier TA, Patterson JR, Hodges MO, Rosenberg MR. Physicians as patients. Choices regarding their own resuscitation. Arch Intern Med 1995; 155(12): 1289-93

(6) Hauswald M, Tanberg D. Out-of-hospital resuscitation preferences of emergency health care workers. Am J Emerg Med 1993;11(3):221-4

(7) Chelluri L, Pinksy M, Donahoe M, Grenvik A. Long-term outcome of critically ill elderly patients requiring intensive care. JAMA 1993;269(24): 3119-3123

(8) Bialecki L, Woodward RS. Predicting death after CPR: experience at a non-teaching community hospital with a full time critical care staff. Chest 1995;108:1009-17

(9) Gordon M, Cheung M. Poor outcome of on site CPR at a multi level geriatric facility: three and a half years experience at the Baycrest Centre for Geriatric Care. Journ Am Geriat Soc 1993;41:163-6

(10) Callahan D.Death and the Research Imperative. New Engl J Med 2000;342:645-656

(11) Morreim E. Balancing Act: The New Medical Ethics of Medicines New Economics. 1995 Georgetown University Press, p 13.

(12) Hilberman M, Kutner J, Parsons D, Murphy D. Marginally effective medical care: ethical analysis of issues in CPR. Journal of Medical Ethics 1997;23:361-367

(13) Leng C, Lawson A. Pain Management in Intensive Care, Recent Advances in Anaesthesia. 1998 London:Churchill Livingstone.

(14) Jones C, Griffiths RD, Humphris G, Skirrow PM. Memory, delusions, and the development of acute post traumatic stress disorder-related symptoms after intensive care. Crit Care Med 2001;29(3): 573-80

Dear Editor

At the time of writing there appears to have been no electronic submissions to the Journal of Medical Ethics. It seems appropriate, therefore, to begin electronic correspondence with a consideration of some of the ethical implications of this new form of ethical dialogue.

I have posted this response to Kenneth Boyd’s editorial on ‘Mrs. Pretty and Ms B’ [1] as this article may provoke debate far beyond the medical and ethical establishment. This issue may be of tremendous concern to patients or their carers who are presently suffering in circumstances similar to those described.

The electronic response forum of the BMJ has been in operation for over four years.[2] An editorial in the BMJ on physician assisted suicide [3] has attracted 125 responses at the time of writing. An important feature of electronic responses, particularly on items that generate a lot of debate, is that the contributions often refer to each other. These responses range from the scholarly and meticulously argued to distressing personal accounts of suffering. As both an avid reader of rapid responses to the BMJ and a physician, I consider both sorts of contributions to be valuable, but increasingly feel uncertain about what my written response to them should be when I wish to enter into dialogue with the author. I feel on sure ground when considering the scholarly submission that is clearly intended as a contribution to a peer reviewed journal, and have no qualms at drawing up a response to point out its weaknesses. Equally, as a family doctor, I hope that I am able to approach distressing accounts of suffering with a degree of empathy. However, it is sometimes the case that submissions clearly showing distress also contain dubious argument that any peer review process would severely deal with.[4] Where accounts of suffering alongside dubious arguments are posted from patients I personally feel squeamish about responding, finding myself caught between the roles of vituperative reviewer and empathic listener. As an editorial in the BMJ on the subject of electronic responses has noted, "We've begun to capture the opinions and experience of patien... and publish just about anything that isn't libellous or doesn't breach patient confidentiality."[2] Inevitably, such a broad range of responses will produce many that deserve to be challenged. Merely to ignore dubious argument infers that such opinions are correct. Furthermore, it is astonishingly easy to post an electronic response, and the process contains no warning that opinions expressed may be severely challenged. We should consider what the rules of debate on this journal of medical ethics web site should be.

To prevent any misunderstanding, I wish to state that this response does not issue out of intense personal suffering, and that I am prepared for the most stringent peer review of its contents. Say anything in response, but please don’t ignore me.

References

(1) Boyd, KM. Mrs. Pretty and Ms B. J Med Ethics 2002;28:211-212.

(2) Delamothe T, Smith R. Twenty Thousand Conversations. BMJ 2002;324:1171-1172.

(3) Doyal L, Doyal L. Why active euthanasia and physician assisted suicide should be legalised. BMJ 2001;323:1079-1080.

(4) McCracken L. It is time to learn the Hippocratic Oath indeed [electronic response to Roddy E et al. On Hippocrates .] bmj.com 2002 http://bmj.com/cgi/eletters/325/7362/496/a#25093 (accessed 3rd Aug 2002)