The problem of Paternalism in the context of intensive care

Research project P 14047 The problem of Paternalism in context of intensive care Peter STRASSER 06.03.2000 The research project concerning Persons and problems of paternalism in context with intensive and transplant medicine has the brain death convention as ist goal and deals with the resulting ethical and anthropological problems. According to the experience with brain dead patients and relatives, the resulting problems discussed in this study, can be divided into the following two questions: 1) Concerning brain dead persons themselves: Are persons who have suffered brain death to be treated as dying or deceased persons? 2) Concerning the relatives of brain dead persons: Can it be seen as a justifiable act of paternalism when the relatives of brain dead persons are not informed about the explantation. of organs, whereby secrecy concerning this matter is legal according to Austrian law? The goal of this study is to investigate the ethical and anthropological problems not yet satisfactorily discussed through specific cases in intensive care and transplant medicine in connection with the brain death criterion. Paternalism is generally seen as the intervention in the autonomy of a person P1 by another P2, whereby P2 justifies the intervention, because of its advantage for P1. We can only speak of paternalism correctly, if P2 contravenes the actual interests of P1 and/or when P2 acts in the longterm interests of P1, whereby P1 is at the moment not able to realize his own longterm interests or rights. Therefore, only persons who are able to respect their own interests can be addressees in a paternalistic sense. In context with intensive and transplant medicine, brain dead patients obviously can not be the paternalistic addressees. However, their relatives fall in this category when for example, the decision to use the brain dead patient as an organ donor, is kept secret. When dealing with brain dead persons, the question for doctors and nurses in the intensive care unit as well as for the realtives (first question) arises; which is the appropriate way to treat brain dead patients given that the person is actually dead (brain dead), even though he is still considered as a living, artificially respirated person? The meaning of the concept of death is distinguished between a personal death (brainstem death) and, at a later time, a biological death (death of the entire organism), as well as between a natural life supported by the brain stem (,,first hand" life). Furthermore, the resulting practical consequences, of the maceration of the concept of death is discussed on the basis of study of intensive care. How to inform or not inform the relatives of brain dead persons, since no legal guidelines are given by Austrian law, will be discussed along with the problems of paternalism (second question). In cooperation with the University Clinic for Neurosurgery in Graz, cases of brain death occuring in patients during the course of intensive care treatment were investigated. These patients were initially treated as living persons and after brain death diagnosis as deceased persons. The background of personal and paternalistic problems were documented medically and philosophically. The differentiation of perspectives, in which brain dead persons are described as "severly ill persons" (seen by the relatives) as ,deceased nursing cases" (intensive care personnel) who are to be further cared for, in order to maintain vital organs ("organ care"), or as ,artificially life supported deceased humans" (explant team), should be brought into accordance with philosophical-anthropoligical concepts, the ideals of value and dignity, and concepts of death. This study aims to reform intensive medical practices. In addition to the treating physicians, other persons should also be incorporated in the discourse after brain death occurs (analogous to witnesses in a trial), in order to decrease the pressure for the responsible persons and to avoid the brutality which could occur when the procedure with brain dead persons is too simple.