The Ethics of Saving a Life

Darla Strouse: So, let me get started. This, first of all, is the third in a series of science presentations that’s funded by Sinai and Synapses, the grant that we received through the John Templeton Foundation and the American Association for the Advancement of Science. I again want to welcome all the guests who are here, and I have tremendous naches and pride in introducing our science presenter, who is Jim – and my son Jim. You’re in this. There’s no way, no way you could not be included – David Strouse.

Dr. Strouse is a cardiologist and electrophysiologist. And for those who aren’t sure “What is an electrophysiologist?”, he specializes in procedures to correct heart rhythm problems. He is Chief of Complex Ablation at Medstar Washington Hospital Center and Associate Professor of Medicine at Georgetown Hospital.

Our third seminar is featuring both Dr. Strouse and Rabbi Linda Joseph in a presentation and discussion around the topic of the ethics of saving a life. And as you know, the way the grant was given to us and written, the rabbi has an important role, because the rabbi is bringing in the various texts, et cetera, that relate to any of the science topics that we have. This presentation is on the ethics of saving a life.

And David is going to explain his field of electrophysiology. He’s going to talk briefly about a few new developments designed to save lives. He’ll present an interesting case study, and Rabbi Joseph will discuss, through Jewish texts, what is permissible, and what is ethical, in Judaism when it comes to life-saving techniques.  

David Strouse: Great. Perfect. Well, actually, this brings me back, because I went to when I was growing up, we came to the meeting house for services with Temple Isaiah back in the day. It was here, and I was in this very room. And I remember sitting in the back there waiting patiently for the Oneg Shabbat to happen. So soon enough, I promise, I promise it won’t be too long. Okay, so in the next 15 or 20 minutes, I hope to kind of talk to you a little bit about some of the things that I do, and then frame it in a context of ethics, because a lot of what we do in medicine is thinking about ethics, and in particular, thinking about “What is the right thing to do?” And I think it kind of raises some important questions. 

And a lot of times when I give lectures like this, I give them to medical students. And when we were getting everything set up, my mom was saying, “Gee, do you think they’re too far away from the front? There should be more seats up here.” And I said, “Well, I’m kind of used to it, because when I give lectures to the interns and residents, they all sit in the back because they’re worried I’m going to call on them and ask them tough questions.” So you all are safe here. No problem. 

When I do give lectures, a lot of times there’s a very specific way we do it, and we often talk about patients, because at the end of the day, as clinicians, as we’re taking care of patients, we’re always thinking about patients. And I’m going to present a patient of mine who I saw in the office just this week, and I’m going to ask us all to think about this patient and think about it in the construct of “What would you do?” 

My grandfather used to always say that he went to doctors so often that he was a shtickle doctor, which means “a little bit of a doctor.” So today, all of us, with all of our education, we’re going to be that shtickle doctor, and we’re going to work together to kind of think about this patient and think about what you would do for the patient and think about it from this ethical construct.

A Young 92

Okay, are you all with me? All right, perfect. Okay, so this is this lovely patient. She’s 92 years old, and for 92, she’s what we would say is a “young” 92. She lives independently, she lives in her home of 50 years, and she does everything on her own. She cooks her own meals. She’s very active with her synagogue and her sisterhood, and she loves to garden, and she’s been very active like this her whole life. And she really has had very few, been blessed by having very few medical problems. She has only a history of hypertension, and for which she was just taking a very low dose of an ACE inhibitor, lisinopril. And she presented to the emergency room with what we call the sentinel episode of syncope, her first episode of a passing-out spell. At the time when we went to talk to her, she described the episode as being very upsetting. Obviously, she had never had this before, and the episode occurred in the morning. She was fixing some breakfast for herself before she went to the synagogue for a sisterhood meeting, and she had what she described as an abrupt loss of consciousness. 

What we’re always interested in a lot, in medicine, is the history. The history is really important to help us understand. And what she described in the moments beforehand was a relatively abrupt loss of consciousness. She didn’t have a lot of warning to kind of get herself to a safe place. When I asked her if she felt any symptoms of palpitation, she described some symptoms of some fast heartbeats right before it happened with a loss of consciousness. And she said that she had felt palpitations before, but she had never lost consciousness before. That was very unique for her. 

On physical examination, pretty unremarkable for 92. She had normal heart sounds; her lungs were clear. We were monitoring all sorts of things while she was in the emergency room. We noticed several things. One is, at one point, she was on a monitor, on telemetry, so we were watching her heart rates all the time. And we saw at one point that she went to the bathroom, and when she got up to go to the bathroom, she didn’t really have much of a very high heart rate. She’s not on any medicines to slow her heart rate, but her heart rate was really in the 40’s. And she said, “Gee, I feel a little bit tired. I feel like this sometimes when I’m gardening. I don’t feel like I have as much energy when I’m doing things.” But she never really thought to mention it to her doctor in the past.

We also noted, the following day, that on the monitor we saw some fast heartbeats in the lower chamber. So she had some slow heartbeats that we noticed in the upper chamber, and that’s called sinus bradycardia. And then she had some fast heartbeats in the lower chamber. Not that many, about six of them. And she said maybe she felt some palpitation with that, but she really kind of ignored it. It didn’t really mean very much to her, but she might have felt that.

Laboratory tests were really unremarkable. Ninety-two – doing pretty well. Kidney function is normal. She does not have any evidence of anemia.

But when we did an echocardiogram, an ultrasound of the heart muscle to look at the structure, we saw that the heart muscle, surprisingly, was significantly weakened. Her ejection fraction, which is a measure of how the heart squeezes, was about half or about a third as good as we might expect it to be. Ejection fraction should be around 55% to 60%. And here you can see it was 20% – so, markedly diminished. 

And it looked like on the echocardiogram that there were some structural differences, that the heart squeezed in a different way, suggesting that maybe somewhere along the way, she may have had some type of a silent heart attack. But at 92 years old, she never sought evaluation, and that’s the kind of information that we have.

So based on that information – 92-year-old patient, weakened heart muscle, having an episode that frightened her, scared her, a sudden loss of consciousness – she has some things that we are identifying that seem a little unusual. Her heart rates are a little slower when she’s getting up to do things – maybe some symptoms of palpitation. How do we think about this – of what we should do next? Because a therapeutic procedure was done. So the question is, “What is the therapeutic procedure?” What would you do if you were the doctor there, seeing her for the first time? So that’s what I want you to kind of think in the back of your mind as we go forward. 

What Does An Electrophysiologist Do?

Everyone with me? Okay. So we’re going to talk a little bit about what an electrophysiologist does, because this case hits on just about everything that we do in one form of another. So when I give this presentation to the medical students and the interns, this is something that they often will ask: “Well, what exactly do you do?” And so I would say, what I thought to say, is the electrophysiology service – what does the electrophysiology service [do]? Well, there are three syllables, E-P-S, right? So E stands for ejection fraction less than 35% – a weakened heart muscle. P stands for palpitations, and S stands for syncope. So you can already see our 92-year old-patient is exhibiting each of these three things. This is 95% of the work where an electrophysiologist can help a patient in need – this is where we can come in helpful.

So we’re going to talk a little bit about why those are the three main things where we can be helpful. So, “ejection fraction less than 35%” means that the heart muscle is weakened. And the number of 35% is just a statistical number, because in a number of clinical trials, when we showed that people with weakened heart muscles had an ejection fraction less than 35% – significantly more weakened than one might expect – those patients benefited from getting defibrillators. These are devices that are pacemakers, plus they can also protect folks from dangerous heart rhythms. 

You see, 400,000 people every year die suddenly, and that’s called sudden cardiac death. And identifying the majority of those patients is very hard. But the tip of the iceberg, the ones that we’re the most able to identify, the most at-risk, are the ones that have an ejection fraction less than 35%. That weakening of the heart muscle correlates very, very well with a greater risk of having dangerous heart rhythms. And multiple clinical trials have shown that; this is going all the way back to the 1980s, where we looked at two populations of patients.

 This is a survival curve. So what we’re looking at here is CMT. This is standard medical therapy. And if you look at people with weakened heart muscles, this is their natural life expectancy over the next three, four or five years – if their heart muscle is markedly weakened, less than 35%, the chance of dying is substantial, even if you give them really good medications. But in this population, if you also gave them a defibrillator, their mortality was better. People still died, but less of them died. There was a mortality difference. And in medicine, that’s very rare. There are very few things we can do in medicine that have a mortality difference. And this was proven over and over again to have that mortality difference.

One Intervention: A Defibrillator

So giving folks with a weakened heart muscle a defibrillator seems, in that population of patients, to make people live longer. But I ask you, we’re thinking about this 92-year-old patient. She’s 92 years old. Is that the right procedure? Her ejection fraction is low. Should we just give her a defibrillator? Maybe. But maybe, maybe not. Maybe that’s not the right decision. She’s 92. Maybe we shouldn’t do such an invasive approach. Something to think about.

 This is what a defibrillator looks like. So it has wires here in the heart muscle. This is, you can see a wire here into the ventricle, in the right ventricle, and there’s actually an additional wire into the left ventricle, because in some patients who have certain forms of conduction abnormalities, adding an additional lead to what’s called biventricular pacing actually makes an additional benefit, additional mortality benefit, as well as a morbidity benefit. So their quality of life is better, and they even live a little longer in a certain population, a subset. Okay, so that’s the ejection fraction. Less than 35%.

Okay, the next one we’re going to talk about is the palpitation. And that’s a lot of the work that we do. There are a lot of folks who come in to see us who just feel fast and rapid heartbeats, and it’s our job to kind of understand what that could be. Our patient had symptoms of palpitation. They didn’t make her pass out, as far as we could tell, but she had them. Maybe there’s something related in this 92-year-old. Well, how, for one, do we evaluate palpitation? 

Visualizing Heart Problems

Well, I’m going to show you some tracings of a patient who had palpitation, who had a weakened heart muscle, who had had a heart attack, who had documented arrhythmia. And this was an ablation procedure that I did just the other day. 

What you’re looking at here now is an illustration of the heart muscle. What we’re able to do is, we’re able to create a three-dimensional reconstruction of the heart muscle. So, this image here is of the body. This is the orientation of the left ventricle. And here, this is the aorta. So what we’re able to do is create a three-dimensional structure, and as we move the catheters, we can see wires inside of the heart muscle in real time. So, in real time, we’re looking at the electrical system of the heart, and we’re looking at wires inside of the heart muscle. 

So what are you looking at here? You’re looking at a lot of squiggles, a lot of electrical signals. And these are really defined electrical signals, signals of what’s going on in the heart, where the catheters are sitting. So what you’re looking at is in the ventricle. And what you’re looking at is an image of the patient in clinical tachycardia. So what you’re looking at is a lot of electrical activity. And where you see a lot of what we call this crowding, where you have a lot of electrical [activity]. There’s a lot of color right here, in this very center. That’s because there are a lot of electrical things happening right there. Out further away, there are not many electrical things happening here. There’s a lot of electrical activity occurring in that narrow space. And that’s an area that we’re really interested in, because that often is where the tachycardia is coming from. 

And this is just another image now, looking at the voltage – and you can see that this gray area here is an area of scar. So there’s no electrical signal there. This is where this patient had had a heart attack. And when you put all that together, and you’re looking at the ventricular tachycardia, this is the scar, and this is all this area of electrical excitability. And that’s where we are going to focus our attention. What you can actually see in tachycardia is the electrical signals moving through the tachycardia.

So here are what we call vectors of electrical signals. And you can see the vectors are going through this area, and we can actually animate that for you. So you can see the signals now going through that scar. Can you all see that?

So this is this patient. We just did this ablation two days ago of a patient with VT going through an area of scar from a heart attack. Is this what our patient has at 92? She had palpitation. She’s had scar in her heart muscle – we think. Did she have the same type of arrhythmia? Should we do this electrophysiology study on her or not? And then what you can see here is another resonance, so you can see the electrical signal going through that and wrapping around. This is what we call a figure-of-eight reentry tachycardia. And what you can see, this is now a catheter here where we’re burning. We’re going to burn right in that area. This is what we call the narrow isthmus. This is the critical part where the tachycardia occurs.

And you can see we gave a bunch of lesions there. And when we did that, then the patient had no more tachycardia. So that’s called a ventricular tachycardia ablation. And this is really kind of kind of the kind of cutting edge of things that we can do for people with very potentially dangerous rhythms that are very symptomatic.

Syncope – Why Do We Faint?

Okay, so the “s” stands for syncope. Let’s talk about syncope. Our patient came in with syncope. Well, I will tell you that syncope is a really common reason that we’re called. A lot of times the folks who come in with syncope, they end up getting this enormous neurologic workup. And there’s a neurologic evaluation, there are brain scans and MRIs and electroencephalograms. But unless somebody has a really classic history of brain problems – being hit on the head, head trauma, things like that – the likelihood that our 92-year-old patient had a seizure is remarkably low. It’s almost always something related to the heart. 

In fact, syncope is extraordinarily common. If you look at patients over the age of 75, about 75% to 80% of them will have had one episode of syncope. And of that population of patients, 95% of them never have another one. So it’s a common diagnosis, and often hard to tease out.

What is syncope? Syncope is passing out, so, or “falling out,” some people will say. So you abruptly have loss of consciousness – abrupt loss of consciousness. That’s great. Any other questions?

Okay, well, let’s talk about the most common reason that people pass out. And the most common reason people pass out is what we call vasovagal syncope, or neurocardiogenic syncope. And the reason for that is that we’re not giraffes. (Laughter) So, we’re the only mammals that stand upright. And the reason for that is that the force of gravity is extremely, extremely hard to contend with. The blood in your body wants to pool in your legs, and your body has to do all sorts of machinations to keep the blood going back to your brain, because, you see, your brain doesn’t care if you’re standing upright or sitting, lying flat or upside down – it wants exactly the same blood flow, so it has to do all sorts of things constantly to regulate. And it’s amazing to me that we all don’t pass out every single time we get up. (Laughter) A giraffe has actually had such incredible neck musculature that it can bend down from the ground and go up to 27 feet above ground in a matter of seconds and never lose consciousness. But the musculature allows it to compress the blood so the blood flow to the brain is the same. That’s the most common reason for people passing out. 

And this gentleman here is in one of the guards – I forgot. What are the people in Buckingham palace who have the big hat? Beefeaters. So if you’ve ever been there, you’ll notice that they stand very still and they won’t move. Well, this gentleman had a history of passing out and he’s standing in here for a procession for Queen Elizabeth, I believe – this is a number of years ago. And if you ever look on YouTube for this video, look for the “beefeater passing out.” What you’ll see is that they were so attuned and standing straight, you can see him starting to wobble and he falls down. And all the other beefeaters don’t pay any attention. They just keep standing straight until somebody comes and attends to this guy. He had a common form of faint. He had neurocardiogenic syncope. He was a little dehydrated and he was fine.

Did our patient have this? Ninety-two years old, early in the morning, she’s fixing herself some breakfast. Maybe she was a little dehydrated. Maybe that’s the common faint, is the whole explanation for her episode of syncope. It could be any one of those three things. 

So we think about our patient. She has an ejection fraction that’s low, less than 35%. Should we give her a defibrillator? She has palpitations. Maybe [the] palpitations were enough to give her the passing out, the falling-out episode, the syncope. Maybe we should do an electrophysiology study and maybe an ablation procedure, like I showed you in that other patient. Or maybe she just has the common form of faint. Or maybe it’s the slow heartbeats that we saw that she had – maybe that’s the root cause. We’re left with those questions and the therapeutic procedure is performed. 

So your question now – you have to say, “What would you do if you were in my shoes?” All right. And with that, I’m going to. Thank you. Thank you very much. Now we’ll have Dr. Joseph.

Jewish Responsa on Medical Ethics

Linda Joseph: All right, so, the ethics of saving a life. What does Judaism have to say about all of this? Because as Reform Jews, or, if visitors, Jews whatever flavor you are, one of the things that we’re taught is that we should give our law, our tradition, a vote, though we don’t necessarily have to follow it if we’re reformed Jews; we can veto it if we don’t understand it. But if we’re making decisions as Jews, we should understand what Jewish tradition has to say. 

So what is the Jewish case for saving a life? Here is the same case that Dr. David Strouse presented with us. Ninety-two-year-old woman – she presents to the ER. We have history, all her history, the scientific stuff. And we were explained in greater detail what the options were. So, my job, if I’m trying to reach out and think about “What are the ethics of this?” is to say, “Hmm. Is this case similar to any other case that Jewish law has ruled on? Has there been somebody of elderly age that needs a procedure that may or may not be the best choice for them?”

And so I went looking through my books of responsa and pulled out this beautiful one here that’s old and a bit tattered, but still good with its contents, called Contemporary American Reform Responsa, edited by Walter Jacobs, who used to be the chair of the Central Conference of American Rabbis Responsa Committee. Now what is responsa? Responsa, or teshuvot in Hebrew, is when somebody, a rabbi or a person just like you, wants an answer to a Jewish question. So they’ll write to a series of rabbis who will research that question. And then we’ll present their research and the possible answer or opinion on that question. So when you have a responsa, they go through all the different sources.

And in this book, I found this question from some rabbi in Illinois, unidentified. And what does it say? It says, “A 96-year-old woman who lives in a nursing home has recently been informed that severe hardening of the arteries necessitates the amputation of her foot.” 

It’s a different scenario, I know. But she needs some sort of help with a medical emergency.

“As a result of the shock of hearing the news, she’s become severely disoriented. Her family was subsequently advised of her situation and several alternatives were presented.” So, much like our 92-year-old patient, this woman needs some sort of medical intervention, and there are several alternatives that are offered.”

She may submit to amputation with a chance that her condition will be permanently corrected. However, there’s no assurance that she may not die during surgery or some time thereafter.  Is there danger? Is there not danger in surgery? 

“Furthermore, her other foot may be similarly affected, or her rehabilitation may not be successful. The alternative is a slow and painful death, which can be partially relieved by sedation. The family wants the mother to make the decision. She refuses to sign the release for surgery, but as her lucid moments are brief, it’s not clear whether that is what she actually wishes. Should there be surgery, or should matters simply be allowed to take their course?”

Now, this is a different situation. However, when I read that, I was like, “It’s going to take me through the ethics of when to do surgery and when not to do surgery.” What does Jewish law have to say on that?

So, here are our commonalities. We have elderly patients, 92 years old, 96 years old, and surgery might be life-enhancing and life-saving – or will it? That’s our big question. Is it better to do nothing, or is it better to do something for that person?

Not Standing Idly By

So our first text in the responsa that it brings from us is from Sanhedrin 23a. And rabbinic tradition, from Talmudic times onward, has encouraged the utilization of all possible medical procedures for life-threatening situations. Sanhedrin 23a advocates this direction on the basis of the following biblical verse in Leviticus: “You shall not stand idly by the blood of your fellow.” And also in the Talmud, in Bava Kama 85a, it bases itself on: “He shall cause him to be thoroughly healed,” which is a verse from exodus. So it sounds like just from the beginning of this response that, yes, in both cases, if surgery is going to help, it should happen.

Nachmanides, who lived in the 13th century. And in his commentary on Leviticus, chapter 25, verse 36 – “And your brother shall live with you, agreed with this.” He followed this path, which was earlier proposed by Hai Gaon in the 10th century. So now we can see this is not just in the Talmud, but even later commentators believe that if there is surgery that is going to help, or medicines that are going to help, or some sort of intervention that’s going to help – “Yay, do it.” Yehudah Leib Zirelson, who lived in the 20th century, applied this line of reasoning to less dangerous, non-threatening situations – so, even if what you have is a minor ailment, it is permissible to do the intervention.

So the majority opinion is “thumbs up,” do it, right? Medical intervention should be used. But we have an elephant in our room. He has giraffes – I have elephants. (Laughter) The elephant in our room is when somebody reaches the age of 92 or 96, which is getting up there. I know some of you are closer to that, but it is. Sorry if I’ve upset you. It’s getting up there. We have to ask the question: is surgery a risk? Right, that’s the elephant in the room. And then a further question we should ask from Jewish tradition is: is there an age limit beyond which tradition would not advocate medical intervention? Does there come a time when you’re so close to that period of perhaps dying that you should just let it be? 

And another question we need to ask is: will this prolong her life – it’s “her,” in both these cases – in a meaningful way? And should it matter? Should quality of life matter? Is that something we should take into account? What will the quality of life be?

The Talmud On Risky Medicine

So that leads me to another text, which is from the Talmud, from Avodah Zarah 27b. And the text is on our left, where the bold lettering is, that’s what’s actually written, the translation of what’s in the Talmud, and the material that is not bold, the rabbi’s commentary, if you like, on that section in the Talmud, how they understand the passage.

The Gemara asks, And from where do you say that we are not concerned with the value of temporal life? As it is written with regard to the discussion by four lepers outside a besieged city: “if we say we will enter into the city, then the famine is in the city, and we shall die there; And if we sit still here, we will also die. Now, therefore, come and let us fall unto the host of the Arameans; if they save us alive, we shall live, and if they kill us, we shall die.” (2 Kings 7:4)

 The starving lepers decide to risk premature death rather than waiting to die of starvation. The Gemara asks rhetorically, “But isn’t there temporal life to be lost, in which case it would be preferable for the lepers to remain in their current location? Rather, is it not apparent that we are not concerned with the value of temporal life?”

Now, what has this got to do with our question? The Talmud uses this discussion to show that in life-threatening situations, one might place oneself even in the hand of idolaters. In other words, if somebody who you’re not so sure and trusting of can save your life, you are allowed to trust them for that.

In modern times, because this passage is written in a larger discussion about medicine in the Talmudic times, this particular passage is cited in order to permit the use of drugs whose side effects might be hazardous. So we are allowed to undergo a procedure even if there is danger within that procedure.

So there are further discussions about the use of hazardous drugs when the chance of survival is low. Eliezer Waldenberg feels that a 50% survival rate was necessary to recommend the risk – iIf there’s 50% of a chance of recovery or a better life, do it. 

And others, like Moshe Feinstein, who you may have heard of because he writes a lot on medical matters, feels that hazardous procedures and drugs may be used even when there is only a remote chance of survival. So let’s just say there’s a 5% chance of survival or a 2% chance of survival. He says, “Go ahead. Do it.”

Now, other people debate about this matter. It’s quite clear, however, that the use of medical procedure, even with a high risk, has been encouraged by traditional Judaism whenever there might be an opportunity to save a life.

But what about age? Is there an age limit beyond which this should be applied to? In this responsa, they also say: “Let’s have a discussion about when it’s time to let go.” We know what the traditional sources say, but in ancient times, or even in your parents’ time, people weren’t living to ages like 92, 96, 105, 108. That wasn’t the regular. That was the exception, not the rule. “If an individual is close to death, she should be permitted to die peacefully, and it’s not necessary to subject them to needless pain through therapy which cannot succeed.” ¹Sefer Hassidim #723; W. Jacob, American Reform Responsa #79.

The Length and Value of Life

So the question is: is this going to be helpful, or has the person’s time really come? And that’s a judgment call, right? That’s a judgment call of the doctor. It’s a judgment call of the family. But, says Jewish tradition, if there is a chance for success, it should be undertaken. 

So you’re weighing up again: is there a 50% chance, a 70% chance, 2% chance? 

Although the lifespan throughout the rabbinic and Biblical period was low, the psalmist’s ideal of three score years and ten, or by reason of strength, four score years, ²Ps. 90 and Moses’s life of one hundred and twenty with his “eyes undimmed and his vigor unabated,” ³Deuteronomy 34:7 as well as the ages of the patriarchs and others, point to the ideal of an advanced age. As medical practice has advanced and made a longer life possible, we, too should encourage medical procedures on individuals who’ve reached an advanced age.

In other words, a responsa from our Jewish tradition is saying, “You know, there’s value to older life.”

A modern concern is the psychology of the patient. Rabbis are not quite so much concerned about psychology, but psychological factors are concerns in our day and age. Dr. David Strouse already told us that this was an active patient who had a full life – gardening, cooking, Sisterhood. The chances of success of the surgery, what percentage would you put it at?

David Strouse: All of them would be very high.

Linda Joseph: All of them would be very high. So above 50%? More than that, 95%? It’s a good percentage, right? Psychology of this patient – very happy with their life. Just a little concern that they passed out while gardening. So what would the Jewish advice to the doctor be? What would Judaism say we should do in this case? “Do it. Do it, do it.”

The Doctors’ Decision

David Strouse: Okay, so what? “Do it,” huh? Do everything. Well, the truth is that what I’ve learned over the years is that, you know, listening to patients is always the key, because everyone has a different perspective. And you’re absolutely right. Actually, in the medical literature, it’s actually defined. There are recommendations for, for example, giving a patient a defibrillator. And interestingly, if the patient meets clinical criteria, which means the ejection fraction is less than 35% and there is not any evidence that it’s going to get better all of a sudden with good medication – so, on optimal medical therapy – you can give them a defibrillator regardless of age, as long as you think they can live. You’re expecting them to live more than a year. So anything more than a year, the consensus is that that patient would be eligible for a defibrillator. She would have also been eligible for an ablation procedure to study her heart muscle as well. 

But in the end, what we did was we talked to her and we said, “Look, we can do all these sorts of things. You’re 92. You know, you’ve lived a long life. What would you like us to do?” And I’ve often found that that’s usually the key, because folks are usually pretty thoughtful about things. And what she said was this. She said, “Look, I’ve lived a great life. I don’t expect to live forever, but my quality of life is really important to me. And I’m able to do things, I’m able to live independently. I’m able to garden. And that was really what I want to be able to function and do. Anything you can do to kind of optimize my quality of life would be really of value to me.”

 And so what we had documented was that she had bradycardia – slow heart rhythms – and she was symptomatic from that. And I think, in retrospect, she has been probably symptomatic from that for a number of years. Additionally, a pacemaker, a very specific one, one version of it, can help with a common form of faint. And to be honest with you, I’m pretty sure that’s what she had. It was just an unusual presentation of a very common faint. But this pacemaker could actually help with that as well. It has an algorithm to help with that specifically.

What we decided to do – the therapeutic procedure – was we gave her a pacemaker, because we figured we could use that information to help, maybe, preventing her from passing out. We could help her quality of life so that she can be able to do gardening and do the things she really loves to do, but without necessarily doing more invasive and complex procedures, such as an invasive electrophysiologic study and a possible ablation. And that turned out that’s what she actually wanted. And so we actually just saw her in the office this past Tuesday, and she actually feels much better. She has more energy when she’s gardening. She hasn’t passed out. She’s been drinking lots of fluids, because that’s actually the most important thing you can do for folks who have a tendency to deal with dizziness is to keep yourself really hydrated. So we’ve really focused on that for her, and that has made the difference.

The Upshot, and Prognosis

Linda Joseph: So, David, what would happen if you looked at a patient and everything you could do was much less of a chance to be helpful – that they might not get a year out of the pacemaker. What sort of process do they go through in the hospital, as you’re talking about the ethics of it? I mean, clearly Jewish ethics says “If there’s a chance, do it.” But from a medical standpoint, from the ethics of medicine today, what do you discuss? How do you weigh this up? Do you go to the patient and say, “You might not live longer than six months, but let’s try this anyway?”

David Strouse: Well, in her case, I didn’t think it was a mortality difference. I thought it was a symptomatic difference. And I thought we were going to help her clinically with the pacemaker, and we would also have a lot of more diagnostic information. So I think in the end, if we were to identify her to have sustained fast heart rhythms and she’s continuing to live her life, we would explore doing an ablation procedure to try and fix those fast heart rhythms so that she wouldn’t have those symptoms. She would be eligible for that. Or we could try medications.

I mean, there are lots of different ways you can deal with fast heart rhythms other than an invasive potential therapy or curative procedure – so, different ways that you can approach it.

Linda Joseph: Right. So I think, to sum up, knowing what the consequences are or what the chances are, and making choices for what you understand quality of life to be is both a medical ethics question as well as a religious ethics question. Rig ht. We’re not so dissimilar in terms of what we think.