You are the Critical Care attending in the ICU this week. One of the ICU patients, Mr. X is an 87 y/o male with end stage carcinoma of the bowel that has failed several courses of chemo and radiation therapy. He landed in the ICU for what was originally thought to be a reversible respiratory failure, that turned out to be not so. He is now ventilator dependent and his clinical condition is rapidly dwindling. He has palliative support orders and the family has been very cooperative. The patient's family calls a conference and informs you that the patient is a member of a cryonics group and is to be prepared for freezing shortly after he is pronounced dead.
You are asked to leave all lines in (including, and especially, the subclavian placed on admission) and it is explained to you that the cryonics team will take over when legal death occurs. They have a signed Authorization of Anatomical Donation and Consent for Cryopreservation from the patient: both of which were executed for the first time nearly 10 years before, and were updated shortly after the patient's diagnosis. The family is very supportive of the patient's wishes, but is at pains to point out that "this not for them", it's what Dad wanted and we're honoring his wishes.
Your evaluation of the patient some time later reveals that he is very near death. He is unresponsive except for a faint grimace to deep pain. He is breathing only three or four times a minute in agonal gasps. His blood pressure in not obtainable by cuff. His SaO2 does not register on the monitor. A cryonics tech appears at the behest of the family and places an automated cardiac compression device over the patient's sternum and sets out an array of IV medications near the bedside. He states that he willtake over preparation of the body as soon as you certify that the patient is legally dead.
As you stand by the bedside, the patient's heart rate progressively slows and becomes obviously agonal. The cryonics tech tells you that it is most important for him to have access to the body as quickly as possible after you certify death. You examine the patient and find no signs of meaningful life. You look at the nurse and say: "patient is dead at 1652 hrs". That fact is quickly noted on the chart and the cryonics tech quickly swings into action. He endotracheally intubates the patient and begins manual bagging. The automated cardiac "thumper" device begins to rhythmically compress the patient's chest at 80/minute. The cryonics tech injects something you think might be epinepherine into the patient's IV. Suddenly, the patient begins agonal ventilations again and you think you may have noticed some spontaneous foot movement. The cryonics tech thanks you very much for your effort and quickly begins to move the patient out toward a waiting van where he tells you there is an ice bath waiting, with the thumper in motion and an IV with unknown medication running.
What do you think about this? Is this patient dead or alive? Do you have any further responsibility?
As you point out, the issue of what happens when you start CPR immediately after legal death has been pronounced using cardioresopiratory arrest as the criterion is an interesting one. I once was sitting in handcuffs while a deputy coroner screamed at me: "You didn't even wait 5 minutes before you started...!" I asked "Well, exactly how long should I wait? Ten minutes, twenty, an hour? And what happens when patients are being recovered after 15 minutes of cerebral ischemia? Should I wait longer still?" His response was a pause (about 5 seconds) follwed by an angry "I don't know, but more than two minutes, a reasonable period of time!" "And what," I asked, "is reasonable period of time? Any time you are arbitrarly feel comfortable with?" Not a very useul response on either side.
I publically documented the first time I saw return of agonal gasping and motor activity. I then altered the protocol so that in virtually every case, simultaneous with the start of cardiopulmonary support (I do NOT use the word resuscitation) I give KCL and Nembutal. Both are given in doses that prevent the return of any cardiac, respiratory, or EEG activity. Since the patient is already legally dead, I can't very well be accused of killing them if I maintain the status quo *and* restore circulation and gas exchange. For instance, if you pronounce someone and then someone injects a large bolus of cyanide and does CPR on them, he's hardly guilty of murder, right?
To me the issue here (and this what the court decided sloppily) which unfortunately was NOT confronted by the CCML docs, nurses and others, is the issue of prognosis and patients' wishes in the equation of determining or, rather, pronouncing death. You are in fact not determining in any meanigful sense that a no-code patient (with a brain still viable by contemporary standards) is REALLY dead. What you are saying is: me, (maybe, hopefully,) the patient, and/or the patient's family/DPOA have decided that this is the time to stop medical intervention to restrore homeostasis, for however long or short a period that homeostasis might be maintained. That is critically different than really determining death (irreversible loss of function).
Think about this from another perspective: You have a 35 year old woman with end-stage adenocarcinoma of the breast. She has tallked with you about her wishes and filled out a DPOA for medical care indicating no-code status. She is down to under 100 pounds from a healthy weight of about 145. She has been in a lot of pain requiring sedation, and has basically refused all food and all but about 50-100 cc of fluid for about 10 days. She goes into shock (tachycardia, low BP) without tachypnea and experiences cardiac arrest.
You are close to this patient and her family and you are with her when she arrests. You pronounce her. Sitting out in the hall, next to her door is a code cart with defib, epi, code drugs, and fluid for rehydration. An intensivist, a critical care nurse, and two competent floor nurses are about 15 feet away in the nurse's station discussing another case.
As it turns out, *if* you call a code this patient will respond (biologically, NOT psychologically) quite well to it. She has a large bore, multi lumen Groshong still in place. If CPR is started and she is given epi, atropine, and rehydration she will pull out of V-fib and rapidly recover a normal pressure. She will regain consciousness within about an hour of the code. If you start TPN and vigorously support her she will, in fact, live about 5 more months! Meticulous pain management will give her some quality conscious time during this period without too much direct discomfort (i.e., so-called physical pain).
Now, here is your dilemma as you stand there after having pronounced her: for a period of time, lets say three minutes, this woman could be restored to life and consciousness in every meaninful and generally accepted sense of the word. But, because she has requested that you not do so, you allow ischemic injury to her brain and other organs to proceed to a point where you and the resources available to you can no longer reverse them. She never recovers spontaneous heartbeat or EEG activity. A short while later she is taken to morgue of this (a teaching hospital) and circulation is briefly restored as she embalmed (as she had previously requested) so that she can be used in the associated medical school's anatomy and/or research or training program for med students.
Now, consider an alternative scenario. Everything is the same except the patient has requested cryopreservation. She arrests, you pronounce, I come in, start CPS and give my first two push "meds". The patient never recovers spontaneous heartbeat, breathing or EEG. However, instead of her CNS tissues remaining reversibly viable (by today's techniques) for 3 minutes, they remain so for about 5 hours as ECMO support and deep hypothermia are induced. After five hours, perfusion with cryoprotective drugs followed by freezeing renders the patient irrecoverable by any contemporary medical technology.
What's the difference. In each case the outcome is at least on the surface the same: the patient is irrecoverable by current technology. The only significant difference is the *period of time, 3 minutes versus 5 hours,* between these events. And, of course one other difference: the patient's wishes and perhaps a significant impact upon her chances for restoration to life in (by contemporary standards) the distant future.
Steve Harris, MD on cryonics-
I see aging as the price of gross differentiation and specialization in large organisms, with the caveat that even in a well-differentiated complex animal the rate of aging is highly malleable. There is indeed "metabolic wear and tear" on "one shot" non-dividing devices like glomeruli and muscle and nerve cells, but I don't think we know the limits of upkeep for these in the face of this limitation, even so. Some bats, for example, live more than 25 years and some of the longest lived ones (the fork-tailed fruit bat) don't even undergo diel torpor, which means they run mouse-plus metabolic rates continuously for decades and thus accumulate a lot more heartbeats and breaths over a lifetime than even the big-brained primates like us, who are the lifetime- metabolic-load champions among the terrestrial mammals. Birds also in general do very, very, well, too, lifetime-metabolically. Thus, we see that wings are even better than brains for avoiding predation, so good upkeep routines becomes even more evolutionarily worthwhile for fliers than thinkers (a humbling thought), and Mother Nature accordingly provides it.
That being said, I don't think that anything in nature exists which could keep this up forever, simply because nature has never had to come up with any system to keep it up for more than a relatively short time (a few centuries), conditions for animals being what they are. I see no theoretical reason why continuous and perfect forever-repair of an animal is impossible-- but I don't believe in immortal fish just because the aging rate for them is very slow, and it seems certain to me that we'll get such repair only if we invent it de novo. Still, there's no reason why one could not be able to keep a car going forever, and indeed forever "like new," if one is allowed to replace parts ad libitum. The same is true for a body in which one is allowed to replace cells ad libitum, anywhere in any tissue.
To be sure, at some point for the repaired car, one will object that the original car has been entirely replaced and no longer exists. Does it matter, though? In the case of a repaired person we are helped by the realization that the "person" is not the molecules or even the cells that make up the brain hardware (wetware). A "person" is rather the cell connections-- the hard wired "software." (Short term memory and moment to moment consciousness is electrical, like a program running in RAM, but it is only a small part of the persona, since it can be erased temporarily by shock or anesthesia, without wiping out the "person").
I don't know how many of the atoms in my brain were there five years ago, for instance, but I suspect that the fraction is not large. So far as I know there is no way to "turn over" the DNA in my neurons, but if that kind of thing did happen during aging or repair, I see no reason why the % of atoms in my brain now that are new from five years ago could not be reduced to zero, and yet STILL have no effect on me or my memories. I'm NOT the atoms, after all, but rather the patterns they are arranged in. I'm an "information being". Thus, I'm the novel, not the book; the nonphysical story, not the physical ink and paper. So long as the atoms in my brain are replaced subtly and slowly without disrupting the pattern, I'm still here, no matter how much turnover in gross matter there is. It seems to me that the same would also apply if there were a way to repair the brain by bringing new cells on-line and into connected-ness, without disturbing the patterns of connections that determine memory. Again, doing something like this would require more subtlety than anythinq that exists in nature, a bit like replacing all the pieces of a chess game while the game is in progress. In a massively parallel computer with much redundancy built in (like the brain), if the machine was built of discrete components one could theoretically replace all the transistors and resistors one by one, even while the machine was in the process of solving a problem. Why not?
I'm guessing that in the future there will be a way to repair brains to youthful function, and bodies, too, just as any automobile can be restored to perfect mint condition if there is no limit on how much parts replacement and bodywork is allowed. How much of the old memory will be left afterwards in such a restored human will depend on how much brain damage there had been previously, and how good the machines are which infer what WAS from what IS in the structure of the frozen and damaged brain. Questions of identity loss arise with too much memory loss, of course, and there are differences between trying to avoid aging and trying to reverse it; between trying to repair while retaining memory and trying to recover "lost" memory. The recipe for a working, youthful brain is in the DNA, however-- only the memories are not there. The end result of total brain and body repair using the DNA recipe will thus be at minimum a physiologically young and healthy person, even if most or all the memories do not survive (in this case, it will not be the same person, but rather an identical twin (clone) in need of education).
If such a state of restored youth (hopefully with some memory intact) was not the goal and the expectation of cryonic preservation, there would be little point in cryonics for many people, and in particular cryonics would be pointless-perhaps even ghoulish-- to consider in the case of very old and decrepit people. Nobody wants to be "old and tired" in a new age-- you're absolutely right. Most of us therefore have left testamentary directions not to attempt to revive us until something better than that is available. I have a hunch that 100 years of memories and experience would be quite a trip if one had a 30 year-old body and brain to store it in. At the very least a century of experience would be quite an aid to ordering at restaurants.... In the absence of any effective repair for the revenges of aging (as in today's world), there comes a point at which treatment costs rise steeply without any real progress being made in function, just as happens in the life of automobiles. In a society of limited resources, this leads inevitably to problems of cost-return ratios, and inter-generational resource allocation conflicts (child vaccinations vs. extra ventilator days).
Decisions here are never easy, but when the dead hand of government removes the markers of prices which ordinarily convey vital information in decision making in a market, decisions in such spheres can become totally irrational, as you well know. In particular, as you point out, the "unfunded mandate" of senior care and indigent care imposed by the Feds has lately resulted in cost-shifting which is presently rapidly destroying the rest of the medical system, which fact is being used as an excuse by government for further intervention into the market in order to fix the problems which are the direct result of previous intervention. "Crisis and leviathan" is what Hobbes named this process, and we libertarians know it well.
It is important to point out, however, that the goals of cryonicists are not necessarily in a direction which exacerbate the problems of the "modern" government plagued medical system, and this is true independently of whether or not it ever proves possible to reverse aging in the far future. If anything, cryonicists are generally in harmony with viewpoints (like your own) which attempt to compensate for today's lack of market forces by means of brute-force top-down ethical and economic planning (a wise and efficient commissar, can, after all, keep the system creaking along, even in a socialist state). Too many overly wasteful treatments for the elderly are aimed at keeping the heart going past the point where the deterioration of the brain has become rapid and the quality of life is poor, and these treatments would be opposed by cryonici its in any case, for brain sparing if not directly cost sparing reasons. Cryonicists for obvious reasons "never" want to see "brain death" diagnosed under any circumstances in a cryonicist; instead they generally want to avoid the ventilator support which allows even the possibility for this disaster ever happening. Nor are cryonicists generally enthusiastic about keeping demented persons alive through life-threatening illnesses such as pneumonia, renal failure, and soon.
While it is true that dying cryonicists would probably like closer monitoring of vital signs than would be consistent with absolutely minimum cost in care at the end of life, it is also true that cryonics' rejection of ventilators, dialysis, and ICU care per se for terminal people probably mitigates more than 90% of that "elastic" possible extra cost that "unreasonable" people/families may incur by failing to do what you call the "right thing." Cryonicist passive euthanasia also contributes to "cheap" deaths, as compared with the average. Moreover, the cost of cryonics itself (the surgery, freezing, storage, etc) does not come out of the medical/insurance system. My sense is, then, that doctors who are concerned with medical waste at the end of life ought to view cryonics and cryonicists as fellow travelers worthy of encouragement and help, even in the absence of any belief on the doctor's part in the possibility of ultimate technical workability for the cryonics procedure. After you've seen a few real cryonicists die yourself, I'm confident that you will eventually come to this conclusion, too, even if you don't get to there fully on the basis of just these conversations.
Simon Brown-
I have major ethical problem. Cryonics provides a 'chance at immortality', if you can afford it. What about those who can't? In a "fair" world this chance should be offered to all. I do not believe that medical care should be provided on the basis of how much money someone has- a major problem with US health care (but also other countries including my own, to lesser extents).
Doesn't the world have enough mouths to feed? What gives these people the right to a second slice of the cake? There must come a point where the rights of society come first. We all pay for this ridiculous, selfish / egocentric waste of money. Lets be realistic- the money is being diverted from the economy, and thus social/health care (indirectly).
Has North American society become so insane that society does not have rights over individuals? As physicians we should confront these moral issues. "Because we can" doesn't mean we should. Any physician indulging in such a (to me, morally bankrupt) business could be accused of ignoring his/her responsibilities to society as a whole. Perhaps if it was part of sound clinical research..... (even then I would have my doubts)
On a lighter note, wouldn't it be a bummer if we all underwent re-incarnation, and this cryo business just left you in a hell-like limbo!
Roger McSharry-
Mike Darwin-
I will make several points, keep them brief, and not expect to change your mind (but hell, it's worth a try.
"Dumb" animals are pawns of natural section. Natural selection is a pawn of the random chaos of the universe: during the Permian extinction 99% of all lifeforms were wiped out. When the dinosaurs got hit, no lifeform with a body weight of more than 25 kg. survived. The universe doesn't care. There is no grand order, or right or wrong to things based on natural law. Natural selection just chugs out variations and what works, works and the sole criteria are survival and reproduction. For some species, super protection of the individual and very long lifespans are workable (bristlecone pines, ocean sturgeon). Wings are better than brains: birds live longer and at a higer metabolic rate than mammals ( but we (man) are gaining on them).
There is, in short, no preordained order or law that men should get old and die at 85 or 105. In fact, nature (natural selection) created a creature with BRAINS and the drive to use them to extend his lifespan, to understand the mechanics of his being, and to take control of the machinery of his body and brain and reshape them intelligently without the blind waste, cost and misery of "random" selection. Many will not be equal to this task. They will die and disappear just as have all other lifeforms than haven't cut the grade. And probably nobody will give a damn, certainly not nature, the hospital ethics committee, or your minister.
If you prefer to not use your brain and/or feel compelled to die, I assure you, I have no problem with this whatsoever and will do what I can to help you achieve your wish within the confines of the law (I don't want to go to jail) and your specific instructions. I would, however, remind you that, recently, at least in the Western World (of which Australia is something of a part) people are allowed to spend their money and conduct their lives as they choose. Granted, you aren't obligated to help them. The alternative is Eastern Europe and Soviet Russia where someone else (read Simon Brown?) gets to make all or most of your decisions for you, including tell you how long to live. But then, given your oath and profession, you'll excuse me if I find THAT really sick.
The take home messages:
Which way is best? Go figure.
David Crippen-
It seems to me that the cryo question whithers down to two arguable points:
I think that the answer to the first question is "probably yes". If the brain structure and the DNA plan can effectively be preserved intact indefinitely, there is no reason why technologic advances of the future cannot bring it back to function. Technical ability is exploding exponentially. It has been less than 100 years from the first flight of 100 feet at Kitty Hawk to regularly scheduled double supersonic flight. 1980 I got the first Radio Shack TRS Model 80 with a whopping 4 Kbyte of memory and all programs had to be imported from a tape cassette. (Accidentally ran in a Led Zep tape one day and blew the thing up.) The thing was only good for playing chess (ponderously). Now, 15 years later I have a powerMac with enough power to dim the lights in Boise, Idaho when I turn it on in the morning. That's 15 years, folks. What will be available in 200 years?
However, the answer to the second question is more difficult. Clearly, all of our societies, even the wilds of Australia ;-) allow their citizens to spend their money pretty much any way they see fit, no matter how dumb (unless they use those resources to harm others). That's why there are Yugo showrooms and Ferrari factories. So, if a well heeled member of society desires to blow their life insurance resources, previously paid for I might add, on something that Simon and George think are dumb, that is life in the big city. To regulate these expenditures otherwise has already been tried....like in the former Soviet Union...and you know the outcome of that.
Now the question becomes....Should society allow self indulgent expenditure that impinges on the living space of others......('scuse me, I just ran down to the garage real quick and hugged phineous....). That is what it boils down to. Should those with the resources to take a shot at mortality be allowed to do so if their second life takes up space and resources of those still on the first go around? I don't know that we can formulate an answer to that because we don't have enough information. What will life in 300...500 years be like? Will technology solve "living space" problems. Will the entire world be just like downtown Tokyo? I don't know the answer to any of these questions, so I cannot postulate.
Therefore, since there is no good prediction of what any of these 600 folks might face if / when they wake up in the future, or even if there will be a future, I am inclined to let people spend their disposable income as they see fit. I probably spend my disposable income on things they might consider dumb as well. Which one of us is right? More to the point, which one of us should regulate the others resources. They might try and tell me how to dispose of my income....'scuse me again....had to run down and hug Phineous......
Another interesting question that has not been addressed is: how has the real possibility of waking up in the future been pitched to them? Has this been a "land in Florida" pitch? If so, then the entire complexion changes and the questions of fraud enter into the discussion.
Mike Darwin-
I find the questions being asked interesting, but confess to being a little disappointed at how straightforward they are. The contemptuous tone of some of them I anticipated (I've been doing this for over 20 years). I'll deal with each physician's question or comment(s) seperately except where there's overlap:
Dr. Alwin Hawkins makes a remark about paying out of pocket for cryopreservation services and how that should nip a lot of abuse of the technology in the bud. I couldn't agree more. I worked in an acute care medical setting doing hemodialysis. If people incapable of making the most commen-sense decisions can't make them, nothing will guide them to the right choice (thus the comments on Dr. Crippen's questionnaire about futile treatment). Money, however is an excellent place to start the education process of such fools. Damn few people would sell the farm, eliminate their evenings out for sushi or to McDonalds, forego their kids' educations, or even an occassional call girl if they HAD TO PAY for such useless and medically inappropriate treatment described in Crippen's questionnaire. You can put the blame for such nonsense squarely where it belongs: on government programs that disburse money for things they have no business paying for in the first place, and for which they have insufficient information to make intelligent choices about such disbursements when they do.
As to cryonics: it is typically paid for by life insurance, most of the 600 people signed up (note: not 600 already cryopreserved) have made advanced arrangements. Their average age is 40, most are college educated, better than 1/3rd have advanced degrees and over 5% are physicians. I am just now beginning to cryopreserve people I have known (and who have had arrangements for it) for 25+ years. I am currently 40 and got involved in cryonics when I was 13- years-old. One of the last cases I did was a man I'd known since 1969. About 15-20% of patients presenting for cryopreservation are "last-minute" or already terminal cases. In such cases we use an independent psychiatrist to evaluate competence and we do extensive pre- procedure interviews on videotape to establish informed consent. We also take very few of such cases for obvious reasons.
Dr. Beals wants to know if we plan to reanimate the corpus or the personality, or both. The answer to this question is complex. Current cryopreservation techniques cause serious injury that would prevent resumption of function if cryopreservation were reversed today. The question is, is such injury reversible or irreversiblein the long-run? Right now physicians judge the reversibility of injury (and the pronouncement of death) based on several things: 1) The available technology and its inherent limits (i.e., if someone has a leg crushed you can't regrow one for them or induce their body to do so, although many vertebrates can do this trick). 2) Their own level of skill (rarely admitted either personally or publically). 3) Cost-benefit tradeoffs in terms of the patients' wishes, quality of life, financial and personal resource and so on.
As you can see, the criteria for the reversibility of injury (including "death") are all relative in these examples and, with few exceptions are not rigorous. Physicians today thus pronounce people dead on the basis of their abilities, motivations, and technologies. These are RELATIVE criteria. They have in the past and likely will in the future change from place to place and time to time. Anyone doing third-world medicine will understand about the place to place issue. Anyone reflecting on the status of an MI patient in VF 50 years ago will understand about how criteria for pronouncing death have changed (varied) from time to time: that time to this time.
Whether an inury (or pronouncement of death) is absolutely irreversible is not dealt with in medicine today at all. This is because virtually all contemporary physicians have not thought about what really constitutes irreversibility or what really constitutes death (in an absolute, rather than a relative sense). This is, in my opinion, a serious error. Tearing a book into pieces damages it. If the book is in a foreign language which you cannot read, even if the pieces are big, you may have great difficulty reversing the damage. But, as long as the pieces are unique, there is no fundamental irreversible loss of information, and, if you have the technology, you can put the book back together again, either semlessly repairing the original, or, extracting the information and reimplementing the book on clean new paper (perhaps more durable, more desirable paper in the bargain). On the other hand, if you burn the book and stir the ashes (and it's your only copy) then all bets are off. You have irreversibly injured the system.
The best evidence we have so far is that current cryopreservation techniques applied under good to optimum conditions are not causing "non- inferrable" or irreversible injury. On the macro, histological and ultrastructural level there is substantial preservation, and in patients treated with a high enough concentration of cryoprotectant, such injury is confined to denaturing some enzymes and making relatively minor alterations in the structure of some cell membranes. It is hardly a process of total destruction. Synapses, long processes, neuronal membranes, synaptosomes, etc. are well preserved.
Thus, the well cryopreserved patient can be seen as a mass of locked-up information (like a bad hard drive with all you files on it), damaged, nonfunctional, but not (from an information theory criterion) irreversibly damaged (although said patient cannot be rescued now). So, in one sense what we are preserving is a pretty good representation of the molecular pattern that comprised the individual: information. We are, after all, information beings: the particular atoms that make us up change all the time (every time we eat or take a drink of water). Thus, we are not our specific atoms so much as we are the pattern they are arranged in. That pattern decays or is degraded only slowly after cardiac arrest. And, while we cannot access that pattern (read: information) now, there are many sound reasons to believe we will someday be able to.
Granted, a very sophisticated technology will be necessary to undo the damage, and such technology may never be developed. But, the point is, a careful analysis using current physical law shows no barrier to such a technology being developed. After all, in nature whole bodies and brains are built de-novo from simple 4-base instruction tape called DNA. Clearly, manipulation of atoms and small groups of atoms is possible. In fact, it has already been done. There are now devices called scanning tunneling microscopes (STMs) and atomic force microscopes (AFMs) which allow us to manipulate individual atoms purposefully and to image them. A few years ago TIME magazine published a picture ofthe letters IBM speeled out with xenon atoms on a nickel crystal at 77xK (this was done by IMB at its Almaden, CA Research Center).
Once we can purposefully manipulate matter at the atomic level we can fabricate devices to atmoic precision. This means we can build cell-repair machines. In fact, rigorous proof that such technology is possible (including many designs for things like nanosclae motors, bearings and computers) already exists. For a lay-level exposition of this emerging technology I would refer you to ENGINES OF CREATION by K. Eric Drexler (Doubleday) and for a rigorous physical proof, to NANOSYSTEMS: Molecular Machinery, Manufacturing and Computation by K. Eric Drexler, John Wiley and Sons, New York, 1992.
To directly answer Dr. Beals' question: Yes the objective is to return ther patient to a state of full function in a healthy young body. Having said this, it is also important to point out that what we are (currently) most preoccupied with is the information that constitutes identity, memory, and personality. Since this information is present almost exclusively in the brain, many individuals choosing cryopreservation (including me) currently have opted for cryopreservation of the brain alone (actually the head, since its makes a convenient and protective package).
Ted Rogvein gives his easy solution to the problem of a cryopreservation patient presenting in an ER: simply don't allow it to happen, throw him out on the street. Actually, most cryonicists want to die at home and we typically operate via home hospice when we have that option. I have put people on fem-fem bypass within 80 minutes of pronouncement (using ACDC and high impulse CPR begun within 60 seconds of cardiac arrest as a bridge) in their living rooms and in two cases in their garages (which were converted to MASH-type facilities in anticiparion of the patient "dying" at home). I have a late-model Leader, Modular ambulance and sitting inside it as a cart with a Thumper and full ECMO capability; we can be on-board with a blood pump- oxygenator as fast as I can get the patient cut down and the cannulae placed.
But not everyobody is so lucky. Some people in hospice, like CASE #18 end up acutely rehospitalized because of a problem that is not manageable at home (massive hemoptysis, esophageal bleeding, etc. and the accompanying panic reactions from air hungry patients or distraught caretakers). Others come in with what may at first be seen to be a treatable problem and then rapidly decompensate and die. I have seen AIDS patients who were in good condition with slight SOB on arrival in the ER white-out in a matter of hours and arrest very quickly and with little warning. COPD cases go even with less warning. If such a patient is "sent home" and is not in hospice s/he will become a coroner's or ME's case resulting in long delays and exposure to a significant risk of autopsy.
And you, Dr. Rogvein, would then get your proverbial butt sued off in US. And you may find yourself in a difficult position in Canada as well. Incidentally, this kind of callous response to a critically ill cryonics patient has already occurred in the US. Unfortunately for the hospital and the treating physician the patient lived long enough for the cryonics group to go to court. The court ruled the hospital could not refuse access to the patient or throw him out into the street. In fact, they manadated specifically that the hospital cooperate to the extend of leaving in lines, promptly pronouncing using the same clinical criteria they would use on other non-respirator dependent patients, and that they allow the cryonics team immediate access to the patient so that they could begin external cooling and mechanical CPR. Ultimately, this ruling was appealed to the California State Supreme Court which refused to hear the case letting the lower court's ruling stand.
Dr. David Ryon observes that the procedure is "grisly" and asks if anyone has survived it. I find this amusing coming from a critical care physician who probably pronounces people brain dead and sends them off to have their organs carved out them to be sewed into other people. I find median sternotomies and CABGS potentially grisly on the aesthetic level (although when I do a median sternotomy and get cannula in and have nice orderly field, and I believe I am helping to save someone's life (often someone I know well) I find it quite beautiful). And I'm sure that ALL of these procedures could be portrayed as grisly now (if shown in graphic detail to the general public in the wrong context) and I am CERTAIN that such procedures would have seemed unthinkably grisly and abhorrent to our 19th century ancestors. Much of plastic surgery is grisly beyond description. The difference between opening someone's chest with a skill saw in anger and doing a coronary revasculation are the skill, the rationale, the motivation and the anticipated outcome.
The point here is that the outcome is what is important. Dr. Ryon, would you refuse to save a patient's life who rolls into the ER with a gunshot wound, a hole in his LV and tamponade because sliceing his chest and percardium open and sticking your finger in the hole is unaesthetic? Give me a break, guy. Aren't you the pot calling the kettle black? As to has anyone survived it? Well, the short answer to that question is: We don't know and won't for many decades (and for today's patients) probably not for 100 to 150 years. However, these people are in no hurry: at - 320xF, - 196xC, 77xK they have all the time in the world. A second at liquid nitrogen temperature is truly an eternity.
To correct Dr. watson's misperception, there are about 600 people (almost all healthy) with PRENEED arrangemehts for cryopreservation. This number is growing roughly exponentially and has been for about 6 years now. There are about 60 people currently cryopreserved (i.e., in liquid nitrogen storage). And, lest you think this a California phenonenon, about 25 are in Phoenix Arizona and about dozen are in Clinton Township, Michigan, a suburb of Detroit.
Finally, an important dictum of medicine is "First, do no harm." Actually the dictum means "do as little harm as possible or, more accurately don't do things which will not result in the improvment of the situation, but rather, make it worse. When confronted with a patient who has experienced cardiorespiratory arrest which you cannot or choose not to reverse, and when such patient has an intact brain, which of these options do you think best fits that dictum:
Arthur Caplan-
I have no idea whether cryonics will ever be possible. From the debate on this list I am not getting far in forming one either.
But, issues of justice aside the real question about cryonics is whether it would actually be acceptable to wake up long into the future, bereft of any family or friends, completely out of touch with the mores and technology of the day, viewed as an oddity or a freak and still enjoy being there. As many authors have argued from Dan Callahan to Leon Kass in modern times back to Plato in some of the Socratic dialogues, part of what gives our experience meaning and punch is that it is finite and contingent. Would anyone on this list really want to go to an eternity of departmental meetings, motor vehicle registration bureaus or tax accountants. This may be the only recognizable features of the future in two or three hundred years!
Immortality--its overrated.
Todd Dorman-
I'm confused! I'm all for the patient autonomy, but this has gotten carried away. You state no one has survived because no technology exists, and according to your comments, the technology may never exist. In essence then you are performing procedures without any evidence of benefit. You compare the theory to torn books and computer hard drives. This belittles human nature.
I am not against your right to work as you see fit or for you to discuss these concepts in this forum or others. However, if the technology may never exist to reverse the process then your high priced procedures boarder on fraud. I understand your attempts at psychiatric consultation and video taped consent to be your protection under the law. Once again, you and those that follow your lead may practice as you desire, but lets call it what it is. NOT SCIENCE. NOT SCIENCE FICTION. "Plain old speculation" I'm board certified in Internal Medicine, Anesthesilogy, and Critical Care Medicine and for me to use drugs in "new", "speculative" ways I must use rigorous techniques to justify myself and convince others that my "heretical" thoughts are in fact true. Many thought the world was flat until they did not fall off. You may indeed be right about cryo, but until you can show more than pods of frozen "POPS" you will not win this human over. I am not trying to end these discussions as I find them fascinating and enjoyable.
First do no harm. Let's get real...how can you be completely speculative without any facts and consider this not doing harm. Who makes the rules governing cryo. The FDA? If this patient were preserved and some formidable disease process was eradicated form the face of the earth in the next century and unbeknownst to anyone this patient were a carrier would we have done mankind a favor be preserving then reanimating this soul? If we found out before thaw that he had this eradicated disease who would decide whther he could/should be thawed? Talk about slippery slopes!!!!!! We are struggling with futility as it is.
Mike Darwin
Ted Rogvein gives his easy solution to the problem of a cryopreservation patient presenting in an ER: simply don't allow it to happen, throw him out on the street.
Ted Rogovein
I apologize for the glib nature of my primary response. I have read all of your (very long) posts since my Original 6 line blurb. You obviously strongly believe in what you do. We, however, have an important difference of opinion which I will touch on once I comment on your response. Firstly I run an ICU not an ER. I have NEVER "thrown" a patient anywhere. If a patient has an advanved directive that says no rescuss. they don`t receive critical care...they get appropriate palliative care...in the hospital or at home...according to their wishes. I will expedite these wishes to the best of my and my team`s abilities keeping within the boundaries of our personal, institutional and societal moral and ethical values. I understand that these boundaries can change. Presently, I think you are outside those boundaries and I cannot help you take that step.
Mike Darwin:
Actually, most cryonicists want to die at home and we typically operate via home hospice when we have that option. I have put people on fem-fem bypass within 80 minutes of pronouncement (using AC/DC and high impulse CPR begun within 60 seconds of cardiac arrest as a bridge) in their living rooms and in two cases in their garages (which were converted to MASH-type facilities in anticiparion of the patient "dying" at home). I have a late-model Leader, Modular ambulance and sitting inside it as a cart with a Thumper and full ECMO capability; we can be on-board with a blood pump-oxygenator as fast as I can get the patient cut down and the cannulae placed.
Ted Rogovein
Its this business of doing CPR on my newly pronounced patient where we have our problem. You have stated that you believe this pateint is not dead. You call your cryopreserved clients "patients" because you feel they are still, in some way, alive. At this point in time, I do not accept this. Therefore I have a great concern about this gray area of you doing CPR. Crippen`s case suggested some return of cardiac electrical activity while CPR was being done. I assume this will stop with your infusion. I have a problem with that. You resume cardiac activity to stop it again. I have been called "narrow-minded" because of this concern...perhaps I am. If you could do your cryopreservation where there was NO CHANCE of cardiac or brain activity related to the preocedure itself..I would still be unhappy about you doing cryo in my unit...but it would proceed.
A few techical questions. Since open chest CPR would give better brain perfusion why do you not insist on "cracking" the chest? Are their legal concerns there or do you feel you would get less ccoperation or is it simply not necessary? Why do you need to do CPR in the first place? Could you not "preserve" using an exterior pump alone??
Mike Darwin-
And you, Dr. Rogvein, would then get you proverbial butt sued off in US. And you may find yourself in a difficult position in Canada as well.
Ted Rogovein
What a wondefully AMERICAN response..litigation. The Canadian legal system has its problems but its not the circus you guys have. Your "threat" is an empty one. I ran your comment by 3 malpractice lawyers ( true 2 are friends of mine but they represent patients not physicians)they all zeroed in ( without prompting) on this business of doing CPR on a pronounced patient. They all felt it was appropriate to stop you if there was ANY CHANCE that spontaneous cardiac activity occured during the initiation of cryo. They also felt that the "case"(you? the family? the deceased?) would file would likely never see the inside of a Canadian courtroom. Actaully the interesting question posed by all of us was wether you could be charged with "murdering" the patient. Since you do not believe the pateint to be dead you have no problem with all of this. I do. And that is not even touching on the topic of wether you should be doing this...others have already addressed this.
Aviel Roy-Shapira-
Mike Darwin responds eloquently and makes scientific arguements which, I feel, are generally sound. I do however have a major ethical problem. Cryonics provides a 'chance at immortality', if you can afford it. What about those who can't? In a "fair" world this chance should be offered to all. I do not believe that medical care should be provided on the basis of how much money someone has- a major problem with US health care (but also other countries including my own, to lesser extents). Without going into the scientific moral issue of cryopreservation, I would point out that medical care is already provided on the basis of how much money someone has. Either individual money or community money. Medical care in Australia, I presume, is much superior to the care in Somalia. Hospital care in the US is superior to care in Israel. In many countries you have to wait for elective operations or semi-elective operations, say CABG or even Hernia, or varicose vein surgery. (which is not always cosmetic).
Just as other joys of life go first to the Haves, and not to the have nots, so does quality or exceptional medical care. It is unrealistic, if not a bit hypocritical, to claim otherwise. Doesn't the world have enough mouths to feed? What gives these people the right to a second slice of the cake? Because they can afford it. That's why. Some among us cannot even afford bread, let alone cake, on the first time around. There must come a point where the rights of society come first. That is a very difficult question. While this sounds very convincing, it poses a question: who will determine the rights of society? In all of our history, this ended up as the crucial question and the bane of utopia. One way or the other the dream always shattered by unscrupulous men who usurped the right to determine the rights of society to themselves.
Only societies that protect the rights of the individual, and places these rights ABOVE the rights of the society, have endured as just and free societies, they have also perished when they stopped. for this ridiculous, selfish / egocentric waste of money. Lets be realistic- the money is being diverted from the economy, and thus social/health care (indirectly).
How about money that is being diverted from the economy to purchase caviar and champagne? or fancy cars, or fancy dresses, would you limit that too? Has North American society become so insane that society does not have rights over individuals?
North American government is assuming more and more rights over the individuals. I am not sure this is wholly bad, but it is certainly not wholly good. Any physician indulging in such a (to me, morally bankrupt) business could be accused of ignoring his/her responsibilities to society as a whole.
As physicians, we are responsible solely to our patients, not to any given society or social structure. I don't know of any command, oath or moral demand from physicians, as physicians, to society. In many instances, physicians have in fact placed their society above their patients. In most of these cases, we eventually prosecute these physicians as criminals, as in the case of Dr. Mengale.
I am sure Dr. Brown has good intentions, but his argument is dangerous, and he is treading on a very slippery slope.
Aviel Roy-Shapira-
Perhaps a few more words are in order. Some of my words to date appear to have been very poorly chosen. :-)
On the subject of "rights" I would like to respond to one point made by Dr Roy-Shapira: As physicians, we are responsible solely to our patients, not to any given society or social structure. I don't know of any command, oath or moral demand from physicians, as physicians, to society. In many instances, physicians have in fact placed their society above their patients. In most of these cases, we eventually prosecute these physicians as criminals, as in the case of Dr. Mengale. Sorry mate, but I don't wholly agree with this one. I will not respond in length to the bringing up of Dr M, sufficient to say that I am offended. (Don't worry, I'll get over it.)
Of course I was not compating anyone to the Nazi monster. I brought him up by way of Reductio ad Absurdum. I appologize if I offended you.
Yes, we do have a primary responsibility to our patients, but our responsibility to society is also well recognised, by virtue of the factm that all individuals in a society are "our patients". Do you not inform the police of a poorly controlled epileptic who continues to drive? I am not sure we should. Lawyers and Priests don't divulge to the police about criminal behavior of their clients. Our obligation to our patients is not different. Or is it?
What about the elderly (but still with a small chance of survival) ICU admission you refuse, despite protests from the family, because you then wont be able to accept the 15 y.o. injured patient who has a good chance of intact survival? This is a tough one. In our ICU we have a first come first served policy. But in fact, there is an age bias (We published this in Theoretical Surgery earlier this year) where we showed that those not admitted had a 40% mortality, as opposed to 11% in APACHE II matched patients.
In theory, however, this has nothing to do with society rights. It has to do with just allocation of scarce resources, and one approach is to give them to those most likely to benefit. The decision is difficult, and in my 5 bed unit, I am forced to make every day I am the unit attending (about twice a week), but it is not really a society at large decision.
Barry P. Markovitz-
Another interesting question that has not been addressed is: how has the real possibility of waking up in the future been pitched to them? Has this been a "land in Florida" pitch? If so, then the entire complexion changes and the questions of fraud enter into the discussion.
It's obvious, isn't it, that these 600 "souls" are the only Western inhabitants who have not seen Woody Allen's movie "Sleeper". For those of you unfamiliar with this cult classic, it features a health food store proprietor from the 60's who emerges from his cryopreserved (we presume; he's actually just wrapped in tin foil!) state far in the future, where we learn that smoking and eating chocolate have actually been proven to be heathy pastimes! Heaven help history's view of our epoch if characters like Allen's are the one's choosing this "pickling"!
I too was going to jump on the "why waste money on this immortality chase when there are so many more pressing issues" bandwagon, but Mike Darwin has raised some cogent points regarding perspective. Indeed, as long as we have critical care docs blowing money on Ferrari's ;-) and Bill Gates building mansions that are visible from outer space, who are we to say that this tiny investment of the human drama is inappropriate? Furthermore, one can readily imagine potentially "concrete" benefits from the development of this cryonics technology: for example, better organ preservation technique for transplantation.
I have but one question: is "Darwin" your real name ;-)
Simon Brown-
I promise that I will not post any more messages on the "cryo cotroversy" after this one (and even this post is very remote to cryo). Furthermore, if any one wants to slam me on this post, I will keep my mouth shut and take it with good grace.
Do you not inform the police of a poorly controlled epileptic who continues to drive? I am not sure we should. Lawyers and Priests don't divulge to the police about criminal behavior of their clients. Our obligation to our patients is not different. Or is it? I agree that the ethical conflicts are hairy, and I have only occasionally been faced with this issue. So far my patients have been pretty sensible (believe it or not!), but recalling the suffering of MVA victims I would not hesitate to involve licensing authorities if a patient continued to be unreasonable (and I would always let the patient know in advance)- not to inform on criminal activities, but to protect others. Perhaps I'm about to be sued....(read on) BTW, we do (by law) also have to notify police of gunshot wounds, stab wounds etc. Also the Ambulance services in some states are obliged to "inform" on people who prang their cars (to enable breath alcohol testing). In the latter case, some doctors will follow suit (I have done so once, when the driver concerned had killed two other people whilst pissed out of his skull). This was an action as an individual, not as a doctor though (I was really pissed, but not because of alcohol!)
An unusual problem (a first for me) I faced recently was a young woman (occasional drug user) presenting with quite a severe illness following the injection of "bad shit" (probably amphetamine cut with bleach or something). She provided us with the remains of the packet. My concern was the dealer- how many other young "experimenters" would suffer- possibly die- as a result of this particular dealer's actions. I decided to tell her I would ask the Police to interview her (she agreed- but then I did not give her a great deal of choice), and gave them the sachet of substance she had given me. There was no chance of her being prosecuted as the Police did not find the substance on her, and I certainly will not testify that she gave it to me (she didn't- I picked it up of the ground!). By law I was obliged to do this, as I was in possession of a prohibited substance (or was it just bleach?). Even so, I was happy to comply with the law, as I felt that other young lives came first.
Did I do the right thing? In retrospect I think that I did not - she will doubtless now be on the Police "list" of users (and the Queensland Police are well known for their heavy-handed tactics). I doubt the dealer will ever be caught. Maybe the answer is that we should make all possible efforts to convince the patient to do the right thing, and then behave like a priest at confessional. (but for sanity's sake, not like a lawyer!). In the personal cases I describe above, you would probably be justified to criticise me for acting brashly (like a good keen citizen, rather than after careful thought).
What about the elderly (but still with a small chance of survival) ICU admission you refuse, despite protests from the family, because you then wont be able to accept the 15 y.o. injured patient who has a good chance of intact survival?
This is a tough one. In our ICU we have a first come first served policy. But in fact, there is an age bias (We published this in Theoretical Surgery earlier this year) where we showed that those not admitted had a 40% mortality, as opposed to 11% in APACHE II matched patients. In theory, however, this has nothing to do with society rights. It has to do with just allocation of scarce resources, ....
Yup, I was digressing (the basis of a great progressive argument???). Apologies. But I was just trying to make the point that the (individual) "patient comes first" attitude can be a little unrealistic in these days of high cost, high technology and low finance. I might even hazard the "hippocrite" slam (that has been used against me) to those that claim the individual patient always comes first! :-)
Nevertheless, I still reckon that the allocation of scarce resources does relate to society rights- we are trying to give the best, cost effective, care to society for its cash that we can, so that the greatest number may benefit. (ie all our patients, not just one).
Go on Avi, just admit that you're really a commie like me ;-)
(Continued in Part II)