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Ethics of the Cardiopulmonary Resuscitation (CPR)
Pbro. Lic. Damián Nannini
Catholic priest of Rosario Archdiocese,
Graduate in Holy Scripture for the Pontifical Biblical
Institute of Rome, Italy. Rector of the Church "Niño Dios" of Rosario City, Santa Fe, Argentina.
Professor in the Seminario Arquidiocesano "San Carlos Borromeo" and in the
Faculty of Sacred Sciencies and Philosophy "Card. Antonio Caggiano"
The Moderators of this Symposium on Emergency Cardiovascular Care with good criteria have incluided ethical analysis of Cardiopulmonary Resuscitation into the program.
They have therefore decided to invite Dr. Damian Nannini, who is a catholic priest to send us his message concerning this topic.
I consider the analysis of this subject of utmost importance. Its treatment enphasizes concepts - sometimes forgotten - concerning the acknowledgement that all men, as Dr. Nannini has point out, have a right not only to a dignified life but also to a dignified death.
The concepts stated by Dr. Nannini will, no doubt, be shared by everyone regardless of faith or religion.
Dr. Damian Nannini is a Catholic priest of Rosario Archdiocese, Graduate in Holy Scripture for the Pontifical Biblical Institute of Rome, Italy. Rector of the Church "Niño Dios" of Rosario City, Santa Fe, Argentina.and Professor in the Seminario Arquidiocesano "San Carlos Borromeo" and in the Faculty of Sacred Sciencies and Philosophy "Card. Antonio Caggiano". He is as well the son and brother of well known physicians (a neumonologyst and cardiologyst). This enables him to be well acquainted with the subject.
In the name of the Second Virtual Congress of Cardiology we thank him very much his contribution.
DR. FLORENCIO GAROFALO
BY WAY OF INTRODUCTION
Ethics is a practical science since the reality of human behavior is judged according to certain fundamental principles. The plurality of opinions in the field of the ethics is explained exactly by the divergences that exist when establishing these fundamental principles of working human behavior. The impression that these divergences cause is so strong that it has given place to a world phenomenon called ethical relativism and that, in the end, it supposes a giving up in the effort to reach trial approaches or of evaluation common to all men. Although we don't accept the relativism like a philosophical system we can not deny that in reality they exist as a plurality of opinions around the ethical topics. This situation invites us to a sincere and cordial dialogue in the search of the truth (1). And a basic condition for a truthful dialogue is to be aware of the own identity. For it, before beginning, we should declare that our ethical trial is based on principles that we consider of natural right, universal, that we have arrived to them thanks to the illumination that gives us the Christian faith. In other words, they are principles that we recognize to be of the rational order (recta ratio), at the same time that we believe in Christian inspiration.
FUNDAMENTAL ETHICAL PRINCIPLES AND THEIR APPLICATION
Already focalizing ourselves in our specific topic, the ethical valuation of the cardiopulmonary resuscitation (CPR), we will begin with the exhibition of the ethical principles that will base our work.
The man is a person and as such a subject of rights. One of them is the recognition of his dignity as person in all dimensions of his being a man and in the whole arch of his existence, from beginning to end. Therefore all men are entitled to a worthy life and a worthy death. Here we have in fact, the two fundamental ethical principles that interest in relation to our topic: the right to a worthy life and the right to a worthy death.
The first of these principles takes us to judge as good all that favors the human person's dignity and to reject as bad all that can attempt or impair it.
In general we think that applied to the CPR, it deserves a positive trial since the intention is to recover a life that is getting lost and its action is ordered to a good end because it is clearly in favor of the life. In relation to the means that are used to reach this end (heart massage, artificial breathing, etc.) it doesn't seem to have any objection since they don't suppose any lesion of the dignity of the human body. (2)
It is more difficult to know when it is necessary to apply these techniques and to what extent it is necessary to continue with them. That is to say, when it is necessary to give up their application or to cease them. In these questions the second fundamental ethical principle enunciated before is taken in consideration, the right to a worthy death. This right doesn't suppose the approval of any type of euthanasical practice on the part of the doctor, but the respect for the sick person's decision or that of his relatives who opt for the serene acceptance of an irreversible process that takes to the death as an unavoidable end of the human condition.
As for the first question, that is when is it licit to apply the techniques of CPR? we can respond saying: the application of the CPR is licit and even obligatory to the patients that have a presage of favorable life. This means that, once overcome the heart crisis by means of the application of the reanimation techniques, the sick person can recover his previous state. In the special case of doubt or not knowing the patient's current state, as in the case of emergencies, techniques of CPR (Cardiopulmonary Resuscitation) should be applied as the fundamental option in favor of the life and should guide all medical Acts.
The ethical trial is not so clear in the case of the terminal sick people and it will much depend on the patient's conditions and of his prognosis of life. (3) If his state is really terminal we can say that there is not an obligation of applying the CPR and that this doesn't suppose euthanasia. In this respect, the Pope Pio XII 24.XI.1957, in a speech to the Italian Institute of Genetics had already sustained: "if the reanimation tentatives constitute for the family a load, in consequence, they can not be imposed. The family can insist so that the doctor interrupts his intents, and the physician can consent it permissibly. In such a case either any direct disposition of the patient's life, or euthanasia doesn't exist."
It has recently been expressed in the same terms (1980) the Congregation for the Doctrine of the Faith in their Declaration on the Euthanasia, chapter IV,
"Before the imminence of the unavoidable death, in spite of the used means, it is licit in conscience to make the decision of giving up some treatments that would only offer a precarious and painful continuation of the existence, without interrupting however the due normal cures to the sick person in similar cases. For this reason, the doctor doesn't have to feel anguish, as if he had not paid attendance to a person in danger."
In the same line there is also the Declaration Some relative ethical questions to the serious sick persons and the moribund ones, of the Papal Council. "Cor Unum 27 of July 1981:
"The terrestrial life is a very fundamental but not an absolute possession. Therefore, the limits of the obligation of keeping a person alive must be individualized. The decisive ethical approach for the individuation of those limits resides in the distinction among the proportionate means, to which they must never be given up so as not to anticipate and cause the death, and the disproportionate means, which are those that one can and it is licit to give up, so as not to fall in the therapeutic obstinacy. In this distinction, the agent of the health finds a significant and assured orientation for the solution of the complex cases confined to his responsibility. We think in particular of the states of permanent and irreversible coma, in the tumor-like pathologies with disastrous presage, in the old people in serious and terminal conditions of life."
Dr. Brugarolas Masllorens takes these principles to the concrete of the medical practice: (4)
"In the terminal illness the possible treatment is impracticable or it is contraindicated. Indeed, in the terminal sick person, the advisable treatments in such complications as breathing failure, circulatory collapse, oligoanuria, sepsis, lung clot, metabolic coma, serious hemorrhages or sharp abdomen can not be made, because they are useless. When the approaches of the terminal syndrome of illness are completed, the surgical treatment, the cardiorespiratory reanimation, the use of artificial ventilation, the hemodialysis renal or other maneuvers in reason of the inefficiency and impracticability of the method should not and must not be indicated."
Summing up: In this document from the Church, in reference to the aid given to terminal patients, it must be distinguished among the proportionate therapeutic means that are owed to the patient and the disproportionate means that are not obligatory and therefore can be given up.
In the medical practices, in the specific case of a terminal patient, the CPR is considered natural and thus as a disproportionate or extraordinary means, not obligatory.
A different case would be stated if there is an explicit order on the part of the relatives of prolonging the patient's life applying the reanimation techniques, even when hopes of improvement do not exist. We think that the applications of these techniques under these circumstances are licit. There not being the patient's expressed will or that of the relatives the application of the CPR could be derived in a therapeutic savagery that is to say, "certain medical interventions no longer appropriate to the sick person's real situation, as they are disproportioned to the results that could be expected or, else, be too grievous for him or his family. In these situations, when the death is imminent and unavoidable, one can in conscience give up some treatments that would only offer a precarious and painful continuation of the existence." (5)
A practice that should be kept in mind is the one carried out in some hospitals of the United States, in those where there are established guidelines on when the reanimation must not be attempted. They are well-known as "Do Not Resuscitate (DNR) Orders." Although it is difficult, if not impossible, to prevent all the situations that the doctor will face, these guidelines elaborated by a pluridisciplinar team can constitute a valuable help for the professionals. (6) Of course, there is always the difficulty of the interpretation and application of these orders of DNR. A road suggested to overcome this difficulty is the discussion on the part of the whole professional team of the ICU on the approaches in that DNR order is justified. Another important instance that would clear many doubts would be an open honest dialogue with the patient and his relatives on the topic. (7) In fact the statistics demonstrate that conflicts usually generate between the practices of the doctors and the desires of the patients or of their relatives. (8)
It would also be necessary to keep in mind the legal aspects in some places as for example in the state of New York, where there exists a legislation in favor of the presumption of the consent of CPR unless the patient has filled the application of non resuscitation (DNR). (9)
There was left to us a second question that can be formulated in the following way: to what limits should the reanimation tentatives be prolonged? or else where does the forced therapeutic attention finish and where does the therapeutic savagery begin?.
The first clear limit is the patient's clinical death. On the determination of the moment of the death and over whom he concerns to make it, there have already been reached certain unanimity of approaches that include since some time ago, the opinion of the Catholic Church. The declaration of the state of clinical death concerns to the doctor and the approaches to determine the moment of the death are competition of the medical sciences.
On this topic, the Papal Academy of the Sciences in their Declaration about the artificial extention of the life and the determination of the moment of the death of October 1985 and confirmed in 1989, states as biomedical definition of the death the following one: "a person is dead when he/she has suffered an irreversible loss of all capacity of integrating and of coordinating the physical and mental functions of the body." As for the precision of the moment of the death it sustains: "the death happens when: a) the spontaneous functions of the heart and of the breathing have ceased definitively, or else b) if there is the certainty of the irreversible suspension of all cerebral function. In fact the cerebral death is the true approach of the death, since the definitive unemployment of the cardio-respiratory functions leads very quickly to the cerebral death." It is necessary to clarify that some prefer, for a bigger precision, to speak of "encephalic death."
The second limit is the verification, on the part of the professional that takes the reanimation ahead, of the uselessness of the carried out efforts, be it because it will only prolong the sick person's life for few hours, be it because the whole later process will not be able to compensate or to recover the patient for the real life. That is to say, that this situation is similar to the terminal patient's one already seen, and this is its ethical trial as well.
BY WAY OF CONCLUSION
The techniques of CPR constitute a great advance of the medical sciences and they deserve a favorable ethical trial since they allow to keep the life of affected people of a breathing cardio stroke. In the peculiar case of the terminal sick person whose process of death is foregone as immediate and irreversible, it would be contraindicated since they would only cause a momentary continuation of the life under low quality conditions. This general ethical approach should keep in mind other factors that can modify its applications such as the patient's will, that of his relatives, the normative of the assistance center and the legislation of the own State.
To Doctor Ana Fumagalli, neurologist, To Doctor Luis J. Nannini, neumonologist and to Doctor Diego Nannini, cardiologist for the given advice.
To Prof. Alicia Streicher for the english' translation.
1. In this respect Juan Pablo II says in his encyclical The Splendor of the Truth, n° 53: "It is certainly necessary to look for and to find the formulation from the most appropriate universal and permanent moral norms to the diverse cultural contexts, more capable to express the historical present time unceasingly and to make it understand and to integrate the truth genuinely."
2. "The current techniques of reanimation whose use is more every day in vogue, don't have in themselves anything of immoral", D. Basso, Nacer y morir con dignidad, 442.
3. "The decision in this matter is complicated. On one hand it must be taken quickly, because any delay in the recovery limits the possibilities of the success. If the beat doesn't recover in few minutes the brain suffers an irreversible damage. On the other hand, the recovery probabilities must be kept in mind. It should be understood not only as a mere continuation of the life, but also the conditions in which the patient is left", F. J. Elizari Basterra, Bioética (Madrid 1991) 186.
4. "La atención del paciente terminal", in Dr. Aquiline Polaino-Lorente (dir.) Manual de Bioética General (Madrid 1997) 385.
5. Juan Pablo II, Letter Encíclica Evangelium Vitae (City of the Vatican 1995) n° 65. In the Declaration around the terminal phase of the illness, adopted by the World Medical Association in their 35th Assembly, in 1983, the therapeutic obstinacy is defined as: all extraordinary treatment, out of which nobody can expect any type of benefit for the patient", mentioned by L. Ciccone, "La ética y el término de la vida humana", in Dr. Aquiline Polaino-Lorente (dir.) Manual de Bioética General (Madrid 1997) 433.
6. F. J. Elizari Basterra, Bioética (Madrid 1991) 186.
7. Cf. C. Marsden, "Do Not Resuscitate Orders and End-Of-Life Care Planning", American Journal of Critical Care Vol 2, N° 2, 177-179; and Shepardson L., Youngner S., Speroff T., O´Brien R., Smyth K., Rosenthal G., "Variation in the Uses of Do-Not-Resuscitate Orders in Patients With Stroke", Arch Intern Med/Vol 157, Sep 8,1997, 1841-1847.
8. Asch GIVES, Hansen-Flaschen J, Lanken PN. Decisions to Limit or Continued Life-sustaining Treatment by Critical Cara Physicians in the United States: Conflicts Between Physicians´ Practices and Patients´ Wishes. Am J Resp Crit Care Med Vol 151. pp. 288-292, 1995.
9. Snider, G., Withholding and Withdrawing Life-sustaining Therapy. All Systems Plows Not Yet "Go", Am J Respir Crit Care Med Vol 151. pp. 279-281, 1995.
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2nd Virtual Congress of Cardiology
Dr. Florencio Garófalo
Dr. Raúl Bretal
Dr. Armando Pacher
Technical Committee - CETIFAC
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