How many life-and-death decisions does the average doctor make in a day? Many, we may presume, even without statistical evidence. They begin even before treatment. Who gets treated? On whom would treatment be wasted? That, too, must be decided, and it’s an agonizing decision, the more so now, with medical systems, personnel and equipment stressed to the breaking point.
You’re an intensive care unit physician. Two patients are brought in, one young, the other old. You can’t treat both. Should the young one get priority? For obvious reasons, yes – and yet, the elderly too has claims on life.
How much simpler the choice is – and how much less the emotional toll on the hyper-strained physician – if the elderly patient carries a card saying something like, “If I am brought to an emergency ward, treat a young patient ahead of me.”
Shukan Post (May 22-29) introduces an Osaka doctor’s experiment with such cards, and asks whether Japan as a whole should do something similar.
The COVID-19 pandemic has exposed woeful weaknesses in Japan’s medical infrastructure. Germany has 29 intensive care unit beds per 10,000 population. Italy has 12. Japan has 5. Artificial respirators are in correspondingly short supply.
That gives the general idea. Not everyone who needs treatment can be treated. Who is taken, who refused? Cardiovascular doctor Fuminobu Ishikura began distributing cards to the elderly under the stress of the circumstances. The cards are not legally binding, but potentially at least – it’s too early in the experiment to assess how they’re being received – they smooth the triage process.
“As a young doctor,” Ishikura, 64, tells Shukan Post, “I worked with heart transplant patients; also in emergency medicine. Back then, we had the technology to do heart transplants, but ‘brain death’ was an ethical hurdle Japan had yet to clear.”
Brain death was not enough – the heart had to stop for death to be official – by which time the heart was no longer suitable for transplant. “I watched young patients die before my eyes,” Ishikura recalls, “who could have been saved by a heart transplant – had a heart been available.”
The system now in effect recognizes brain death as death if the patient carries a card signifying consent.
“There are arguments on both sides,” Ishikura concedes, but considers this one decisive: “Past 60, the immune system weakens. You may think you’re fine, but you could die any time. With resources as strained as they are, maybe it’s time to think about giving the elderly the choice of allowing younger people with their whole future ahead of them to be treated first.”
That’s a start but it doesn’t go far enough, Shukan Post hears from noted journalist Akira Tachibana, 61. The prior treatment of younger patients should not depend on the self-sacrificing generosity of the elderly, he says. He advocates precise rules that apply to everyone, proposing Holland as a model. Under the pressure of the pandemic, Tachibana says, Holland lowered the maximum age of eligibility for intensive care from 80 to 70. Individual facilities in Amsterdam decline to admit patients deemed unlikely to live more than a year, or those with certain chronic illnesses.
How do elderly people in general feel about that? Answers no doubt span the spectrum. The arguments in favor are undeniable. So, unfortunately, is at least this one which reflects hesitation, though not outright disagreement. It comes from economic writer Katsuhiro Miyamoto, 75, who tells Shukan Post, “Life is precious to all of us, young and old.”© Japan Today