Medical ethics pioneer discusses advances
Medical ethics pioneer discusses advances
Cranford played critical role in Schiavo case
When Ron Cranford became a doctor in the 1960s, hospitals didn’t have ethics committees. There were no ethics consultants, not even any case law addressing such issues as physician-assisted suicide. "Persistent vegetative state" hadn’t been coined, and Terri Schiavo was just a toddler.
Cranford, a longtime editorial advisor to Medical Ethics Advisor, recently retired as senior physician and assistant chief of neurology at Hennepin County Medical Center in Minneapolis. Among those involved in end-of-life research and care, he is considered one of the foremost experts in the field, admired and reviled, depending on who is asked.
When Cranford was a young physician just out of the Air Force, the idea of patients being in a persistent vegetative state (PVS) was first described. At Hennepin, Cranford was a member of what is considered one of the nation’s first ethics committees — the "thanatology committee" — and began fielding inquiries from people wanting to know just how prevalent PVS was.
"So, I sat down and gave it some thought, and came up with the figure of 5,000 to 10,000," he says. "In a way, I just made it up, even though I tried to be accurate. But the media doesn’t like ranges like that, so they just said ’10,000,’ and I started being quoted as saying there were 10,000 people in a vegetative state, and that became the standard.
"But we really didn’t know then how many people were in a vegetative state, and we really don’t know now, either. We just try to make good estimates."
While estimating PVS numbers is still apparently a specialty in progress, the field of medical ethics, particularly end-of-life ethics, has made incredible strides during Cranford’s career.
"One thing people don’t understand — even people on ethics committees — is how much progress we’ve made since the 1970s," he says. "We still have a long way to go. The next 20 to 30 years will be much more difficult and complex than the last 30, I think. We’re just in the early stages of coping with end of life in a meaningful way."
Making end-of-life decisions in the early 1970s, when cases like Karen Ann Quinlan’s were only beginning to come to public notice, was uncharted territory, Cranford says.
"We had no training, no law to back us, no ethics guidelines. We were just winging it by the seat of our pants," he says.
Hennepin’s thanatology committee "didn’t know what it was doing, but nobody else did, either. If you had an ethical dilemma, you had nowhere to turn."
The growth, both in number and in scope, of hospital ethics committees has been a tremendous advance in health care in the United States, Cranford believes.
"Ethics committees are not perfect, but they do serve a purpose, and now people can turn to an ethics committee to help when there is a dilemma. The importance is that they grow from a standpoint of need and vary from hospital to hospital and locality to locality, so they address the needs of the individual hospital and are locally driven, not federally driven, and that’s really important," he says.
Even people who know little of end-of-life issues, palliative care, terminal sedation, and ethics committees got to know Cranford early in 2005, when the debate over the life of Terri Schiavo spread from within her family to the floor of Congress.
Cranford examined Terri Schiavo, served as an expert in the case, and was a staunch supporter of Michael Schiavo’s quest to carry out what he insisted was his wife’s desire to not be kept alive in a persistent vegetative state. His role in the Schiavo case won accolades from many, and generated scorn and threats from those who saw him as a proponent of euthanasia.
Cranford says the Schiavo case is not really all that different from many others in the United States, except that the state of Florida, Congress, and the president got involved.
"There are hundreds and hundreds of Schiavo cases out there, where families disagree. Stopping the feeding tube is a very common practice in the United States, notwithstanding all the controversy," he says.
"The state and federal governments made fools of themselves by intervening in Schiavo. Some decisions [to withdraw food and water from patients in PVS] are made at the state level, but most are made at the local and community levels, by families," Cranford adds. "In a lot of states — Minnesota, Washington, Colorado, Oregon — there are very few court decisions because these things are handled collegially. But some have crazy decisions, one after another, and only in a state like California or Florida would you have some of the insanity that you saw in the Schiavo case."
A case like Schiavo’s would not have been handled well in the 1970s either, he says. "We wouldn’t have thought of stopping feeding in the 70s, and stopping a respirator would have been huge back then."
Strides in aggressive palliative care
An area of advancement that Cranford believes may do away with disputes over many end-of-life cases is aggressive palliative care. When families see that their loved one is not in pain at the end of life, discussions of physician-assisted suicide and withdrawal of food and water don’t arise as often.
"In the 70s and 80s, physicians were fearful of giving too much [pain-relieving] medicine because of legal liability, but doctors now are less concerned with legal liability and more concerned with doing the right thing," he says. Aggressive palliative care, hospice, and terminal sedation are much more accepted practices, relieving patient pain at the end of life and easing families’ pain, as well.
"Medicine has become less paternalistic and more patient-driven. Families’ rights have become more important, too, and that’s one of the most important shifts I’ve seen, is to realize that families suffer sometimes as much as the patient does and should be as much of a concern to the physician as the patient, and that’s as it should be."
Expected faster progress
Though happy with the progress he’s seen, Cranford says that he is surprised that American medicine hasn’t moved forward more quickly.
"I underestimated how long it takes to educate people in these areas," he says. "I would have thought that brain death would be better accepted. I didn’t think 30 years ago that DNR would be controversial. It was called playing God’ in the 70s, and that charge is still there, but it’s not nearly as controversial as it was."
Cranford sees dementia in the elderly as a much greater ethical challenge for physicians in coming years than cases like Schiavo’s.
"The vegetative state is relatively simple and pretty straightforward," he says, though not always entirely predictable.
Cranford gained some notoriety in the early 1980s when he determined that a Minneapolis police officer, David Mack, who had been shot in the late 1970s, was in a persistent vegetative state. For reasons Cranford says he has never determined, Mack woke up 22 months later, and though gravely disabled, lived until 1986.
"In the elderly, dementia is more common than the vegetative state. What are we going to do with humane care for the elderly? One-third to one-half of people over the age of 80 will have some form of dementia. The neurological dilemmas will be far more common and far more complex."
Cranford was diagnosed with liver cancer two years ago and underwent surgery, but shunned chemotherapy. He says he feels great now, and plans to spend the rest of his life teaching, lecturing, and educating his colleagues and the public on end-of-life issues.
In September, hundreds of Cranford’s friends and colleagues celebrated his career with an international conference on some of the most notable brain death and right-to-die cases that arose during his career.
"Schiavo was kind of the culmination of my career, but I will continue to work. There are enormous changes in the area of medical futility, and hundreds of families out there who can’t accept the reality of medical futility. There’s nothing wrong with that, because the idea of futility runs against the grain with patients and families. So it’s a good thing to work on."
When Ron Cranford became a doctor in the 1960s, hospitals didnt have ethics committees. There were no ethics consultants, not even any case law addressing such issues as physician-assisted suicide. Persistent vegetative state hadnt been coined, and Terri Schiavo was just a toddler.Subscribe Now for Access
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