The Moral Permissiveness of Harms Associated with Extracorporeal Membrane Oxygenation (ECMO): Clinical Reasoning of ECMO Candidacy and the Principle of Double Effect Open Access

Lai, Annie Yi-Chun (2016)

Permanent URL: https://etd.library.emory.edu/concern/etds/fn106z736?locale=en
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Abstract

In the epoch of modern medicine, extracorporeal membrane oxygenation (ECMO), an advanced technology that is evolving in the field of critical care medicine, bears ethical significance as it challenges the moral permissiveness of extraordinary measures to sustain human life. ECMO is part of the extracorporeal life support (ECLS) armamentarium, employed when the heart and/or lungs of the critically ill fail. ECMO is offered to patients of a spectrum of ages, but is clinically indicated only when (1) the underlying medical condition leads to significant organ dysfunction, (2) the medical status is unimproved following the exhaustion of available clinical options, and (3) the pathogenesis of the underlying disease remains reversible. ECMO does not cure but rather 'buys time' against the imminence of death in order to allow organs to recuperate from exogenous or endogenous insults. Problematically, despite being regarded by many as a heroic, life-saving intervention, ECMO poses the potential of considerable patient harms.

ECMO treatment presents a profound fundamental moral dilemma: a tension between strict moral obligations "to save a life" and "to do no harm." This moral paradigm emerges in the practice of extracorporeal cardiopulmonary resuscitation (ECPR) in which patients in active cardiac arrest are emergently transitioned to ECMO support following up to an hour of cardiopulmonary resuscitation (CPR). Since its development, the efficacy of ECMO remains ill-defined due to marked limitations in conducting prospective, randomized clinical trials. Arguably, ECMO has yielded promising outcomes; yet, the means in justifying the ends requires ethical consideration.

This work examines the ethical paradox of choice during clinical reasoning (or double-effect reasoning) in determining ECMO candidacy. The salient factors in determination, particularly the harms-associated with ECMO practice, are described. Central to this examination is determining if the means of performing extraordinary acts that cause harm, in hopes to save a life, are considered morally permissible. Further, the practical translation of the normative theory, Principle of Double Effect (PDE), is assessed in a survey study-a tool commonly used in empirical bioethics. The survey assesses the attitudes of ECMO experts on the four conditions of the PDE. Results are presented and a discussion of the ethical implications on the future practice of ECMO follows.

Table of Contents

ABBREVIATIONS ( 1)

CHAPTER 1: INTRODUCTION TO ECMO TECHNOLOGY AND THE ETHICS OF ECMO PRACTICE ( 3)

Case (3)

Introduction (4)

CHAPTER 2: HISTORICAL DEVELOPMENTS IN EXTRACORPOREAL TECHNOLOGY AND CURRENT USES (16)

Early Conceptual Foundations and Device Innovation (Before 1950) (18)

From Testable Experiments to Extracorporeal Practice (1950-1970) (26)

Refining ECMO Practice (1970 - present) (30)

CHAPTER 3: CLINICAL REASONING IN ECMO CANDIDACY ( 37)

Part 1

Disease-Dependent Applications and Modes of the ECMO Circuitry ( 40)

Cardiac Failure and VA ECMO (41)

Emergent ECMO or ECPR (43)

Respiratory Failure and VV ECMO (44)

Age-Dependent Applications (45)

Neonatal ECMO (47)

Pediatric ECMO (49)

Adult ECMO (50)

Part 2

"High Risk" ECMO and Harm (52)

Mechanical Complications (54)

Patient-Related Complications (55)

Discussion ( 57)

Principle of Double Effect (64)

CHAPTER 4: THE SURVEY STUDY (68)

An Empirical Approach to Clinical Reasoning ( 68)

Moral Methodology (71)

Study Methodology ( 75)

Survey Development (76)

Piloting ( 79)

Survey Results ( 80)

Is ECMO practice morally permissible? (81)

Results ( 82)

Discussion (88)

Limitations (94)

Conclusion (97)

CHAPTER 5: ETHICS OF ECMO PRACTICE, FUTURE DIRECTIONS ( 102)

Works Cited (107)

APPENDIX: FIGURES AND TABLES

TABLES

Table 4.1 Survey study descriptive statements. (79)

FIGURES

Figure 2.1 ECLS Centers by Year. (35)

Figure 3.1 Total ECLS Cases Reported by ELSO Registry International Summary, January 2015. (47)

Figure 3.2 January 2015 ELSO Registry Report, International Summary of Overall Outcomes. (49)

Figure 4.1: Nature of the act. (82)

Figure 4.2: Agent's intention. (83)

Figure 4.3: Means and effects. (84)

Figure 4.4: Proportionality. (86)

Figure 4.5: Proportionality of overall outcomes. (87)

SUPPLEMENTAL DATA

Supplementary Table S.1 . ( 120)

Supplementary Table S.2 . ( 123)

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