How ECMO is redefining death(newyorker.com)
newyorker.com
How ECMO is redefining death
https://www.newyorker.com/science/annals-of-medicine/how-ecmo-is-redefining-death
160 comments
Hello - it's your friendly neighborhood health economist (and I have worked on a topic adjacent to ECMO machines).
ECMO is unambiguously cost effective (even at US prices!) for the infant. (I'm not defending US prices - needless to say if anything is cost effective at US prices it's passed the hardest cost effectiveness test.) It's also cost effective (even at US prices) for the older patient. Honestly the cited figure of $213,000 is nothing compared to the value of a statistical life (for the infant) or a bit under half of one (for the adult)
There should be more of these machines and they should be in wider use. The possible impact on heart attack mortality alone is enough to justify wider investment and exploratory use more broadly, even if the precise effects end up being smaller than that's cited in the article.
This is a great example of technological change pushing the boundaries of what's possible in health care. (And frankly... even though I am not defending US health care prices, a high price for this new technology is exactly the kind of signal you want to send to entrepreneurial types, several of whom appear in the article. If ECMO can be taken out of the ICU (by some future version of the machine) that seems highly likely to generate huge benefits.)
Sure, there are some moral issues to be worked out. Those issues would be much better worked out while a bunch of patients who would otherwise died are plugged into ECMO machines...
ECMO is unambiguously cost effective (even at US prices!) for the infant. (I'm not defending US prices - needless to say if anything is cost effective at US prices it's passed the hardest cost effectiveness test.) It's also cost effective (even at US prices) for the older patient. Honestly the cited figure of $213,000 is nothing compared to the value of a statistical life (for the infant) or a bit under half of one (for the adult)
There should be more of these machines and they should be in wider use. The possible impact on heart attack mortality alone is enough to justify wider investment and exploratory use more broadly, even if the precise effects end up being smaller than that's cited in the article.
This is a great example of technological change pushing the boundaries of what's possible in health care. (And frankly... even though I am not defending US health care prices, a high price for this new technology is exactly the kind of signal you want to send to entrepreneurial types, several of whom appear in the article. If ECMO can be taken out of the ICU (by some future version of the machine) that seems highly likely to generate huge benefits.)
Sure, there are some moral issues to be worked out. Those issues would be much better worked out while a bunch of patients who would otherwise died are plugged into ECMO machines...
If we want to look at this purely in terms of economics then we have to "discount" the life years saved with a quality adjustment. Most elderly or chronically ill people who undergo ECMO treatment are never able to live independently again even if they are able to get off the machine.
I'm not saying that we shouldn't use ECMO in those cases. But we need to be realistic about probable outcomes and not expect anything like a cure.
I'm not saying that we shouldn't use ECMO in those cases. But we need to be realistic about probable outcomes and not expect anything like a cure.
You are correct and I’m happy to discount. The older of the two patients in the original example was under 50. That’s a lot of QALYs. Even at an implausibly high discount rate it makes sense.
The outcomes reported in the article are suggestive of a large decrease in mortality due to heart attack. Even assuming the effect is much smaller than reported, more widespread use of ecmo machines makes a lot of sense.
The outcomes reported in the article are suggestive of a large decrease in mortality due to heart attack. Even assuming the effect is much smaller than reported, more widespread use of ecmo machines makes a lot of sense.
I’m not a domain expert, but I haven’t seen ECMO offered to ‘old’ patients (over ~70). Do you have data on ECMO recipients’ age?
> premature infant that weighed a little over 600 grams at birth [...] and is thriving today
I'm very glad this turned out so well.
Survival rates for infants that premature/small are ~60% (up from basically zero 50 years ago), and many of those who survive have serious long-term issues. Still, since the standard of care started improving in the 1990's, some are now healthy adults.
But many premature babies get weeks or months of distressing care, only to die or become permanent wards. It's extremely difficult for the family, the caregivers, and the child.
It seems a bit off if the health economists only value the lives saved, and do not discount for the pain and suffering of others.
ECMO is the main driver of this. The main issue with prematurity is the underdevelopment of the lungs, and ECMO can give them time to develop minimally.
The law and physician/family relations are the other driver. The presumption to continue best available medical care is extremely strong medically and emotionally, and it's hard to overcome even with sober and clear-eyed participants.
ECMO the machine provides choices that are really, really hard to handle, and it makes working in the NICU a life-altering choice.
I'm very glad this turned out so well.
Survival rates for infants that premature/small are ~60% (up from basically zero 50 years ago), and many of those who survive have serious long-term issues. Still, since the standard of care started improving in the 1990's, some are now healthy adults.
But many premature babies get weeks or months of distressing care, only to die or become permanent wards. It's extremely difficult for the family, the caregivers, and the child.
It seems a bit off if the health economists only value the lives saved, and do not discount for the pain and suffering of others.
ECMO is the main driver of this. The main issue with prematurity is the underdevelopment of the lungs, and ECMO can give them time to develop minimally.
The law and physician/family relations are the other driver. The presumption to continue best available medical care is extremely strong medically and emotionally, and it's hard to overcome even with sober and clear-eyed participants.
ECMO the machine provides choices that are really, really hard to handle, and it makes working in the NICU a life-altering choice.
I stopped tracking my cancer treatment costs (including surgery) after it broke the $600K mark. And my cancer was relatively common (colorectal) and only Stage II.
Wow. I wish you well. Was this out of pocket?
> Just the cost is almost twice that of a standard, expensive cancer treatment.
But unlike cancer treatment a lot of it is mechanical engineering and hence amenable to optimisation if the market were large enough.
But unlike cancer treatment a lot of it is mechanical engineering and hence amenable to optimisation if the market were large enough.
But the cost of ECMO is not the machine, it's all things around it such as doctors and nurses, blood plasma, medication etc.
According to the OP link 82% of the cost is not machine related and also not reusable.
"On average, 82% of costs for the total hospital stay were related to personnel use, and blood products constituted 7%, lab and radiology 2.5%, disposable items 3% and medication 1.5%."
According to the OP link 82% of the cost is not machine related and also not reusable.
"On average, 82% of costs for the total hospital stay were related to personnel use, and blood products constituted 7%, lab and radiology 2.5%, disposable items 3% and medication 1.5%."
If the machine were better designed it would require less manual intervention and the manual work required would be simpler. This would require either fewer hours of expensive personell or it might allow the use of less expensive personell for routine work.
ECMO is not getting "optimized" any time soon. It is solidly a procedure that requires enormous human focus and labor to maintain the conditions that enable it.
And reusable
>Just the cost is almost twice that of a standard, expensive cancer treatment.
When you say that, do you mean one round of treatment or the whole treatment regimen?
My mother passed from cancer recently, and no joke: One round of chemo cost as much as a luxury car, at least a five figure sum; and in her case it was one round every one or twk weeks depending on her condition and schedule. The only reason we could afford it was because she was elderly and had Medicare and good insurance otherwise.
When you say that, do you mean one round of treatment or the whole treatment regimen?
My mother passed from cancer recently, and no joke: One round of chemo cost as much as a luxury car, at least a five figure sum; and in her case it was one round every one or twk weeks depending on her condition and schedule. The only reason we could afford it was because she was elderly and had Medicare and good insurance otherwise.
The link he used for cancer costs seems to exclude surgical costs. It also has some questionable hypotheticals, like:
If a cancer patient requires four chemo sessions a year, it could cost them up to $48,000 total, which is beyond the average annual income.
I, like your mother, had treatments weekly unless my white cell count was too low, or my weight loss for the week too low.
If a cancer patient requires four chemo sessions a year, it could cost them up to $48,000 total, which is beyond the average annual income.
I, like your mother, had treatments weekly unless my white cell count was too low, or my weight loss for the week too low.
I only wish the technology were better ten years ago when my father in law passed away. He was on one of these types of machines, but only after he had surgery and his heart and lungs were already failing for days and his body was weak. If they could have put him on the best and newest machine of today right away, then his body could have recovered a bit before they had to operate to fix his heart valve, which was faulty.
I do have to say, at the end when we visited him before they turned the machine off, it was absolutely a horror scene with huge clear tubes with blood flowing through them and the machine was fully clear as well, I assume to let staff catch any clotting early. When they turned off the machine I almost couldn’t help but look at the machine and the blood filled tubing, knowing that my father in law was given a second chance by it even though it failed. I used to have nightmares about the scene I saw there, but now I think of how great it is that we can replace some of the most important organs with machines, even if it’s still limited to hospitals.
Morally, we should advance this tech as fast as possible so maybe next people can use these in their homes, or as a backpack or something, then on to artificial organs inside the body. The people going on these machines today are pioneers and the things we learn today will help other down the line even better.
I do have to say, at the end when we visited him before they turned the machine off, it was absolutely a horror scene with huge clear tubes with blood flowing through them and the machine was fully clear as well, I assume to let staff catch any clotting early. When they turned off the machine I almost couldn’t help but look at the machine and the blood filled tubing, knowing that my father in law was given a second chance by it even though it failed. I used to have nightmares about the scene I saw there, but now I think of how great it is that we can replace some of the most important organs with machines, even if it’s still limited to hospitals.
Morally, we should advance this tech as fast as possible so maybe next people can use these in their homes, or as a backpack or something, then on to artificial organs inside the body. The people going on these machines today are pioneers and the things we learn today will help other down the line even better.
> I used to have nightmares about the scene I saw there, but now I think of how great it is
So many people are not able to get over the grief (or fear, or guilt, or a hundred other emotions) that are usually associated with this sort of equipment, so they're forever seen as a sort of necessary evil - perhaps similar to military technology: something we know we have to have and have to develop, but not something we want to use, or embrace. I wonder if more people looked at these technologies and their potential applications with a bit more optimism, how things might advance.
So many people are not able to get over the grief (or fear, or guilt, or a hundred other emotions) that are usually associated with this sort of equipment, so they're forever seen as a sort of necessary evil - perhaps similar to military technology: something we know we have to have and have to develop, but not something we want to use, or embrace. I wonder if more people looked at these technologies and their potential applications with a bit more optimism, how things might advance.
The only reason I got over it was I worked at a medical device assembly factory and saw firsthand how amazing it was that hundreds of people worked together to design test and build life saving devices. I stopped caring about the blood and started rooting for miniaturization, like how computers my mother used were in rooms and today everything has a computer in it. It’s hard though because our natural and trained response is to be grossed out.
Not to downplay the dilemmas we face today, it seems to me that the main problem is that the machine is too expensive, too complicated and too large to serve as a permanent heart/lung replacement.
We have an excellent record of making machines smaller, cheaper and simpler to operate. This machine will be the pacemaker of the future.
We have an excellent record of making machines smaller, cheaper and simpler to operate. This machine will be the pacemaker of the future.
It has very little to do with the size and expense of the machine itself. ECMO requires 24/7 human maintenance because humans are messy dynamic meatbags, and tubes clog with clots, blood changes pH, people have an annoying tendency to move, etc. Every hospital with ECMO literally has "an ECMO team" to support the thing. It's mind-bogglingly expensive in terms of human capital.
Other people on this thread are trying to imply that these things are like artificial hearts. That is true only in that the heart is one of the things that an ECMO machine attempts to replace. We don't have anything like an implantable artificial lung.
Other people on this thread are trying to imply that these things are like artificial hearts. That is true only in that the heart is one of the things that an ECMO machine attempts to replace. We don't have anything like an implantable artificial lung.
I used to deliver food in a hospital. I got to know a guy who had emphysema or something like that I served him food off and on for about two years. One day I saw that he disappeared and I thought he was dead, but he popped up a few days later with some gnarly staples on his chest and a much less hoarse voice.
After a few false promises over the years he finally got a new set of lungs, they gave him a new heart too because his was fucked from the strain that his damage lungs had put on it.
IIRC, he got a new set of lungs and a heart on Wednesday, was sitting up by Friday and was eating the pureed food that I served him by Saturday. I had no idea the recovery time was so fast for a procedure that involves splitting your chest open, ripping your heart and lungs out and sticking new ones in there and sewing it back up.
The unfortunate part of this all is that he probably isn't still alive today as I understand it because lung transplants still have poor prognosis, unlike something like a heart transplant. I believe it's due to increased infection inherent in the nature of the organ -- it makes direct contact with outside air and has an insane surface area, couple that with immunosuppressive drugs and the risk of infection you're looking at an increased chance of death.
But if we had some way to grow perfect stem cell organs for situations like this or ECMO that can keep a baby alive it changes everything. The US spends 1% of the GDP on dialysis alone, it's mind boggling.
We've found these treatments like ECMO that 'work' in a very tenuous sense that they can sometimes if you squint hard enough produce desirable results but it's in no way sustainable or scaleable.
Any technology that pushes us towards a future where we can grow and store organs will change the face of humanity in so many ways. It'll free up so many resources that we can then focus on other game-changing medical innovations, which I think will lead to a snowball effect of the eradication of so many maladies and a fundamental shift in the human condition.
After a few false promises over the years he finally got a new set of lungs, they gave him a new heart too because his was fucked from the strain that his damage lungs had put on it.
IIRC, he got a new set of lungs and a heart on Wednesday, was sitting up by Friday and was eating the pureed food that I served him by Saturday. I had no idea the recovery time was so fast for a procedure that involves splitting your chest open, ripping your heart and lungs out and sticking new ones in there and sewing it back up.
The unfortunate part of this all is that he probably isn't still alive today as I understand it because lung transplants still have poor prognosis, unlike something like a heart transplant. I believe it's due to increased infection inherent in the nature of the organ -- it makes direct contact with outside air and has an insane surface area, couple that with immunosuppressive drugs and the risk of infection you're looking at an increased chance of death.
But if we had some way to grow perfect stem cell organs for situations like this or ECMO that can keep a baby alive it changes everything. The US spends 1% of the GDP on dialysis alone, it's mind boggling.
We've found these treatments like ECMO that 'work' in a very tenuous sense that they can sometimes if you squint hard enough produce desirable results but it's in no way sustainable or scaleable.
Any technology that pushes us towards a future where we can grow and store organs will change the face of humanity in so many ways. It'll free up so many resources that we can then focus on other game-changing medical innovations, which I think will lead to a snowball effect of the eradication of so many maladies and a fundamental shift in the human condition.
Yeah but tech has 3 stages:
1) Make it work 2) Make it good 3) Make it scale
If this thing works, then probably it's in the process of being made good, and then it can enter the third phase.
It'll be implantable in 50 - 100 years if it works at all now.
1) Make it work 2) Make it good 3) Make it scale
If this thing works, then probably it's in the process of being made good, and then it can enter the third phase.
It'll be implantable in 50 - 100 years if it works at all now.
Yes and no.
We had the first artificial hearts 60 years ago, and were convinced they were a decade away from mass adoption then.
As another commenter posted, the human body is complicated.
We now take knowledge for granted that we didn't even know we didn't know when I started working on these things.
In order to solve the problem we have to just build hardware and put in in people, see how it goes and then iterate on it. This cycle takes years because it takes 2-10 years to get each device through design, regulatory, release. Sometimes once we get deep into it we realize that what we set out to do isn't even possible for reasons we didn't even know when we started. It's like you are having to make up new Greek letters for all the factors in the new equations you discover. It's hard to predict.
Source - I've designed many medical devices including several blood pumps and LVADs.
We had the first artificial hearts 60 years ago, and were convinced they were a decade away from mass adoption then.
As another commenter posted, the human body is complicated.
We now take knowledge for granted that we didn't even know we didn't know when I started working on these things.
In order to solve the problem we have to just build hardware and put in in people, see how it goes and then iterate on it. This cycle takes years because it takes 2-10 years to get each device through design, regulatory, release. Sometimes once we get deep into it we realize that what we set out to do isn't even possible for reasons we didn't even know when we started. It's like you are having to make up new Greek letters for all the factors in the new equations you discover. It's hard to predict.
Source - I've designed many medical devices including several blood pumps and LVADs.
Okay so 100 - 200 years then ;)
TFA says that they're currently working on a portable (external) lung replacement[0]. I see no reason that it couldn't be installed in the chest cavity with a port for the O2 bottle connection.
[0] https://archive.ph/0GP4F#selection-1103.0-1110.0:~:text=To%2....
[0] https://archive.ph/0GP4F#selection-1103.0-1110.0:~:text=To%2....
Even if "they're currently working on" meant "it's available now or practical in the near future" (it doesn't), that doesn't affect what I said about the immense costs involved.
The portability of the device is not the core issue here. It's a bit like arguing that you can build a quantum computer today, so therefore we'll all have one on our desktop soon.
The portability of the device is not the core issue here. It's a bit like arguing that you can build a quantum computer today, so therefore we'll all have one on our desktop soon.
A lab "working" on something is the equivalent of not having it. It should be not be read as an inevitable outcome.
Exactly, here are some more:
Fusion
Artificial XYZ
Fuel that comes from X
Airships
Exactly. This is progress. There is no ethical dilemma here, whatsoever. This is a technology that is keeping people alive. It's bulky, expensive, dangerous, etc, etc. But those things are not set in stone. In time it will become small, affordable, safe, etc. Until then, every little step should be celebrated.
It will, you are right. Anyone who wants to design hardware in the space feel free to reach out.
> This is a technology that is keeping people alive.
And in the meantime, let's have everyone who wants to walk around with a loaded gun.
And in the meantime, let's have everyone who wants to walk around with a loaded gun.
Yes. The first recipient of an artificial heart was tethered to a sizable amount of hardware and confined to an ICU. Now, implanted artificial hearts are regularly used.
That's definitely not the main problem. Risk of intracranial hemorrhage/strokes and other complications make it problematic.
But that isn't the problem from the article--the ethical issue of how to deal with a ton of people who are being kept alive on a "bridge to nowhere" when the machines might could be used in the interim to save many more people--as if you have an intracranial hemorrhage you are going to start down the road to actually dying. (And the article also talks about attempts to improve the bleeding problem anyway.)
To me it sounded like part of the problem is that people on ECMO cannot leave the ICU because at any moment they might have a complication that requires immediate emergency care.
So it's not enough to make them smaller and cheaper, they also have to be made much less prone to these complications. I am sure that will happen in time, but I am also sure we'll be able to grow people new lungs in time
So it's not enough to make them smaller and cheaper, they also have to be made much less prone to these complications. I am sure that will happen in time, but I am also sure we'll be able to grow people new lungs in time
Critical care paramedic: that's very much the bigger issue. Some life flight helicopters are being fitted for ECMO and there is NOT much space in a helicopter, once you fit in two providers, a patient on a gurney and care equipment (most HEMS units are Bell 429s and EC/H-135s - MSP uses much larger AW-139s).
https://live.staticflickr.com/3142/2639039443_ba623ddca0_b.j... shows the working space on a -135. Note that access to most of the patient is heavily restricted - only chest and head, really.
Still, to be clear, we are not really at the 'portable' stage either. There's about 65lb of equipment needed for an ECMO patient just for the ECMO itself, beyond other things like Lifepaks for monitoring.
https://live.staticflickr.com/3142/2639039443_ba623ddca0_b.j... shows the working space on a -135. Note that access to most of the patient is heavily restricted - only chest and head, really.
Still, to be clear, we are not really at the 'portable' stage either. There's about 65lb of equipment needed for an ECMO patient just for the ECMO itself, beyond other things like Lifepaks for monitoring.
Thank yoi for what you do.
If anyone wants to design a portable, integrated ECMO system reach out.
If anyone wants to design a portable, integrated ECMO system reach out.
My niece was on Ecmo several years ago after a serious accident. She’s applying to university now.
That’s what any non end of life treatment strives to achieve.
That’s what any non end of life treatment strives to achieve.
"A patient whose heart has stopped could potentially live on the machine for months, awake, able to walk and read the newspaper. But he might never leave the I.C.U."
The only ethical problem I see is other people deciding what life is worth living.
The only ethical problem I see is other people deciding what life is worth living.
Fully agree. They have this case study later in the article:
> Around a decade ago, a teenager who couldn’t be saved was admitted to a New England hospital. Like Shania Arms, he had cystic fibrosis. A previous lung transplant was failing, and his only hope was another transplant. He was put on ecmo while he waited. Two months later, doctors discovered that he had developed an incurable cancer. Now there was no way for him to leave the I.C.U. His lungs were beyond recovery, and the cancer made him ineligible for transplant. He was caught on a bridge to nowhere.
> Some members of the medical team thought that ecmo should be stopped. Transplant was no longer possible, and ecmo machines were scarce. As long as the patient was on the machine, it couldn’t be used to save someone else. It’s also expensive; according to a 2023 study, the median hospitalization charge for covid patients on ecmo was around eight hundred and seventy thousand dollars, and prolonged cases can exceed several million. These resources might be needed to help other patients, and the boy couldn’t live in the I.C.U. indefinitely.
> But others on the team disagreed. “He was texting with his friends,” Robert Truog, a pediatrician and bioethicist who was involved with and wrote about the case in The Lancet, said. He was spending time with family, and doing homework online. Because he could be awake on ecmo, he could still engage in activities that were meaningful. Situations like this represent a “profound ethical dilemma,” Raghu Seethala, an intensivist and ecmo specialist at Brigham and Women’s Hospital, told me. “The technology is ahead of the ethics,” another expert said.
The technology isn't "ahead of the ethics" as the one quote indicates. This is a simple case of some people apparently advocating for killing a living, conscious, interacting-with-the-world teenager because he wouldn't just hurry up and die, and they want to use his resources for something else.
I bet those same people would learn that over 80% of people aged 70-75 reside in a home they own, and immediately come up with a modest proposal for how to solve the housing crisis.
> Around a decade ago, a teenager who couldn’t be saved was admitted to a New England hospital. Like Shania Arms, he had cystic fibrosis. A previous lung transplant was failing, and his only hope was another transplant. He was put on ecmo while he waited. Two months later, doctors discovered that he had developed an incurable cancer. Now there was no way for him to leave the I.C.U. His lungs were beyond recovery, and the cancer made him ineligible for transplant. He was caught on a bridge to nowhere.
> Some members of the medical team thought that ecmo should be stopped. Transplant was no longer possible, and ecmo machines were scarce. As long as the patient was on the machine, it couldn’t be used to save someone else. It’s also expensive; according to a 2023 study, the median hospitalization charge for covid patients on ecmo was around eight hundred and seventy thousand dollars, and prolonged cases can exceed several million. These resources might be needed to help other patients, and the boy couldn’t live in the I.C.U. indefinitely.
> But others on the team disagreed. “He was texting with his friends,” Robert Truog, a pediatrician and bioethicist who was involved with and wrote about the case in The Lancet, said. He was spending time with family, and doing homework online. Because he could be awake on ecmo, he could still engage in activities that were meaningful. Situations like this represent a “profound ethical dilemma,” Raghu Seethala, an intensivist and ecmo specialist at Brigham and Women’s Hospital, told me. “The technology is ahead of the ethics,” another expert said.
The technology isn't "ahead of the ethics" as the one quote indicates. This is a simple case of some people apparently advocating for killing a living, conscious, interacting-with-the-world teenager because he wouldn't just hurry up and die, and they want to use his resources for something else.
I bet those same people would learn that over 80% of people aged 70-75 reside in a home they own, and immediately come up with a modest proposal for how to solve the housing crisis.
How much work should we expect a person to do to keep another person alive?
At a certain point, our obligations to another person have to end. At what point do we fault someone for not putting in work to delay someone else's death?
Obviously, withholding immaterial support is ethically deplorable. If it costs $1 of medicine to cure a child's life threatening illness and give them a high probability of living a typical human lifespan, you'd be a monster to not help.
But what if it costs $100,000 and has a low chance of healing them?
Or $10,000,000, with no probability of them ever leaving the hospital room, and their use of the room and machines will mean 10 additional deaths that could have been prevented?
I think we should be biased towards life over money because it's more humane and we'll probably learn useful things along the way that improve care in the future, but even with that overweighting, at some point it looks like a bad trade-off.
At a certain point, our obligations to another person have to end. At what point do we fault someone for not putting in work to delay someone else's death?
Obviously, withholding immaterial support is ethically deplorable. If it costs $1 of medicine to cure a child's life threatening illness and give them a high probability of living a typical human lifespan, you'd be a monster to not help.
But what if it costs $100,000 and has a low chance of healing them?
Or $10,000,000, with no probability of them ever leaving the hospital room, and their use of the room and machines will mean 10 additional deaths that could have been prevented?
I think we should be biased towards life over money because it's more humane and we'll probably learn useful things along the way that improve care in the future, but even with that overweighting, at some point it looks like a bad trade-off.
We as a society make a significant distinction between declining to provide something in the first place, and choosing choosing to take back something someone already possesses. To wit:
> At what point do we fault someone for not putting in work to delay someone else's death?
That isn't what is happening. I'm faulting someone for putting in work, to expedite someone else's death.
Sure, there's all sorts of math you can do to justify things either way. You can say "oh but it'll cost ten gajillion dollars and the equipment could have saved an entire ethnic group from extinction", as though you have as much certainty about hopeful future hypothetical benefits as you do about the person dying. On the other side you can say "oh for someone age 16 a week is the same proportion of their life so far as 3.5 weeks for someone aged 55, so if we can keep the 16 year old alive for another week that's better than keeping a 55 year old alive for 3 weeks".
It really all comes down to the difference between action and inaction, between causing harm and declining to prevent harm. Is someone who pushes someone in front of a bus no worse than someone who sees a bus coming at someone and doing nothing to warn them? That's a hard sell.
> At what point do we fault someone for not putting in work to delay someone else's death?
That isn't what is happening. I'm faulting someone for putting in work, to expedite someone else's death.
Sure, there's all sorts of math you can do to justify things either way. You can say "oh but it'll cost ten gajillion dollars and the equipment could have saved an entire ethnic group from extinction", as though you have as much certainty about hopeful future hypothetical benefits as you do about the person dying. On the other side you can say "oh for someone age 16 a week is the same proportion of their life so far as 3.5 weeks for someone aged 55, so if we can keep the 16 year old alive for another week that's better than keeping a 55 year old alive for 3 weeks".
It really all comes down to the difference between action and inaction, between causing harm and declining to prevent harm. Is someone who pushes someone in front of a bus no worse than someone who sees a bus coming at someone and doing nothing to warn them? That's a hard sell.
That's what makes it such a fascinating ethical issue!
Action/Inaction is an important distinction for ethical frameworks and our intuition, but this situation is so difficult to reason about because it forces us to ask when triage/lifeboat ethics apply. Even more tricky because the obvious solution to triage/lifeboat/trolley ethical problems (avoid getting into them) doesn't make sense here because the technology can save so many people!
How many lives can we ethically save in exchange for putting doctors and biophysicists into trolley problems? Entropy is why we can't have nice things.
Action/Inaction is an important distinction for ethical frameworks and our intuition, but this situation is so difficult to reason about because it forces us to ask when triage/lifeboat ethics apply. Even more tricky because the obvious solution to triage/lifeboat/trolley ethical problems (avoid getting into them) doesn't make sense here because the technology can save so many people!
How many lives can we ethically save in exchange for putting doctors and biophysicists into trolley problems? Entropy is why we can't have nice things.
> We as a society make a significant distinction between declining to provide something in the first place, and choosing choosing to take back something someone already possesses. To wit:
>> At what point do we fault someone for not putting in work to delay someone else's death?
> That isn't what is happening. I'm faulting someone for putting in work, to expedite someone else's death.
My understanding is someone on ECMO needs continuous monitoring and infusions of things. You could put in work to proactively remove them from ECMO, hastening their death. Or you could stop putting in the work to continue the treatment and let what happens happens. Are those equivalent?
Maybe the machine needs maitenance to continue functioning and you don't do it.
Maybe you designed the machine so that it must be disconnected every 30 days, so that the default is death after a month and the doctors have to actively choose to replace the machine every 30 days if death is to be avoided.
>> At what point do we fault someone for not putting in work to delay someone else's death?
> That isn't what is happening. I'm faulting someone for putting in work, to expedite someone else's death.
My understanding is someone on ECMO needs continuous monitoring and infusions of things. You could put in work to proactively remove them from ECMO, hastening their death. Or you could stop putting in the work to continue the treatment and let what happens happens. Are those equivalent?
Maybe the machine needs maitenance to continue functioning and you don't do it.
Maybe you designed the machine so that it must be disconnected every 30 days, so that the default is death after a month and the doctors have to actively choose to replace the machine every 30 days if death is to be avoided.
> additional deaths that could have been prevented
Imagine taking someone off ECMO to save others but they all die too. A bird in the hand is worth two in the bush.
Imagine taking someone off ECMO to save others but they all die too. A bird in the hand is worth two in the bush.
Seems like a real life trolly problem. I can’t imagine that anyone would be willing to throw the switch on a kid who’s living on the machine though. Even a psychopath who’s done the math and doesn’t feel anything would probably know that just the bad publicity alone wouldn’t be worth it.
I might agree with the decision to keep the one person alive, but right now we have limited numbers of machines and medical professionals to run them.
How many people would have to die because this one person is monopolizing the one (if any small N, even of one) ECMO machine before it’s unethical to keep them on it waiting to die of cancer?
How many people would have to die because this one person is monopolizing the one (if any small N, even of one) ECMO machine before it’s unethical to keep them on it waiting to die of cancer?
Like most things, it's not that simple.
Frequently these machines are used for things like surgeries, which frequently may not need to be done right this day while still being important. Keeping this one person on it may simply have decreased the number of such surgeries that could be performed per day, mildly increasing patient wait time.
How much of an increase in surgical throughput is worth killing someone for?
Frequently these machines are used for things like surgeries, which frequently may not need to be done right this day while still being important. Keeping this one person on it may simply have decreased the number of such surgeries that could be performed per day, mildly increasing patient wait time.
How much of an increase in surgical throughput is worth killing someone for?
The most ethical position is utilitarianism, up until the point where people who aren't weak or sick or poor or otherwise downtrodden have to sacrifice a single grain of rice, after which it's deontological ethics and how dare you infringe upon property rights. (And I'm not just criticising other people, here.)
It's a hard problem. We have different intuitions for large groups (do whatever saves the most people) and individual cases (how dare you even consider killing someone for spare parts!); and somehow, improving society somewhat – say, funnelling some of that yacht money towards lifesaving treatment – never factors in to these life or death decisions. So what can you do, with limited resources?
It's a coordination problem, more than anything. https://www.principiadiscordia.com/book/45.php contains about as much actionable advice as this here complaint of mine.
It's a hard problem. We have different intuitions for large groups (do whatever saves the most people) and individual cases (how dare you even consider killing someone for spare parts!); and somehow, improving society somewhat – say, funnelling some of that yacht money towards lifesaving treatment – never factors in to these life or death decisions. So what can you do, with limited resources?
It's a coordination problem, more than anything. https://www.principiadiscordia.com/book/45.php contains about as much actionable advice as this here complaint of mine.
But who is going to pay for it? There are more and more amazing machines, treatments and medicines available every year and soon it will be impossible for society to pay for it. And the longer our lifetimes extend thanks to one treatment, the more treatments we can use in a lifetime, and the cost increases even more.
It's for sure going to become a dilemma going forward (and already is today). Saying that costs will simply go down with volume will likely not be true. At least that is not what the trajectory for the last 50 years has been.
People would hesitate to pay these large sums themselves, if at all they could, and people don't like higher taxes.
It's for sure going to become a dilemma going forward (and already is today). Saying that costs will simply go down with volume will likely not be true. At least that is not what the trajectory for the last 50 years has been.
People would hesitate to pay these large sums themselves, if at all they could, and people don't like higher taxes.
The same person paying for it now?
In the case study above, they weren't suggesting taking the teenager off the machine due to non-payment.
In the case study above, they weren't suggesting taking the teenager off the machine due to non-payment.
Well my point is that healthcare is getting more and more expensive. At some point we will come to a limit where the money is not there or that the individual himself has to directly pay for it and take that decision. Will the kids work their asses off for the rest of their lives to give their dad another year? Or are we prepared to pay double the tax rate we pay today to cover all the new opportunities in healthcare? If more and more people live to 100 and beyond, then we will need more and more healthcare over a lifetime. Who will pay for that?
> because he wouldn't just hurry up and die
That is how I read it. One day he is texting and enjoying his friends (virtually) the next day it is just to expensive so they let him die. His friends wonder what happened.
That is how I read it. One day he is texting and enjoying his friends (virtually) the next day it is just to expensive so they let him die. His friends wonder what happened.
The largest part of the ethical dilemma here was caused by a simple, solvable problem.
Have enough machines. Make it so they're like ventilators.
Nothing in this story would rise to the level of "ethical dilema" if they had enough machines.
Have enough machines. Make it so they're like ventilators.
Nothing in this story would rise to the level of "ethical dilema" if they had enough machines.
This is almost becoming too much to respond to everyone in this thread saying this.
The problem is not the machine. It is the human labor involved in maintaining operation of that machine. Vents are also labor intensive. You can't just intubate a patient and push the on button.
The problem is quite literally that it takes time and effort from a limited group of people. Do you allow new admits to die because your staff is consumed with maintaining people indefinitely on ECMO?
The problem is not the machine. It is the human labor involved in maintaining operation of that machine. Vents are also labor intensive. You can't just intubate a patient and push the on button.
The problem is quite literally that it takes time and effort from a limited group of people. Do you allow new admits to die because your staff is consumed with maintaining people indefinitely on ECMO?
I know, I design these things.
What I'm saying is that in the 70s, when dialysis started, with those reusable parallel plate dialyzers, that assisting someone with dialysis was a full time job for a person.
Now, because of advancements in dialysis machines, a single person can care for a whole clinic.
We can do the same thing for ECMO.
What I'm saying is that in the 70s, when dialysis started, with those reusable parallel plate dialyzers, that assisting someone with dialysis was a full time job for a person.
Now, because of advancements in dialysis machines, a single person can care for a whole clinic.
We can do the same thing for ECMO.
Those machines need highly qualified personnel in order to save patients.
Unlike machines, people cannot be manufactured in large enough numbers, and there is an upper limit on people capable, skilled and willing to work in a high-stress environment like the ICU.
Unlike machines, people cannot be manufactured in large enough numbers, and there is an upper limit on people capable, skilled and willing to work in a high-stress environment like the ICU.
100%
We can work to make the machines easier and more effective to use, etc. Hopefully these will improve the day-to-day lives and throughput these caregivers are able to provide.
We can work to make the machines easier and more effective to use, etc. Hopefully these will improve the day-to-day lives and throughput these caregivers are able to provide.
Just so it's clear: Your preferred strategy is that once anyone is placed on ECMO, they should not be removed except through their consent under any circumstances. Is that true?
No, that's not it.
In the situation where they are on ECMO, and their removal from ECMO would result in their certain death (as opposed to, say, their recovery, or their transfer to a different life sustaining technology) then they should not be removed except with their consent.
That's an important piece of nuance.
In the situation where they are on ECMO, and their removal from ECMO would result in their certain death (as opposed to, say, their recovery, or their transfer to a different life sustaining technology) then they should not be removed except with their consent.
That's an important piece of nuance.
Understood. So in time, provided that such people exist in sufficient quantity and we don't avoid placing them on the machine, then we should expect that all ECMO machines will eventually be occupied. What happens to the next guy?
They go into the next machine to be made.
The scenario you describe happens if sufficiently many such people exist, and if they are all placed in machines, and the rate of new machine construction plus the rate at which the current patients die of other causes is higher than the rate at which such people are being born.
I don't think that's a plausible scenario.
The scenario you describe happens if sufficiently many such people exist, and if they are all placed in machines, and the rate of new machine construction plus the rate at which the current patients die of other causes is higher than the rate at which such people are being born.
I don't think that's a plausible scenario.
Not only is it a plausible scenario, it is the reality today. There are far fewer ECMO teams + machines than people who will die without it. In time this will improve, as technology advances and as more medical personnel are trained in maintaining one, but we are at the early stages and this conundrum happens all the time.
It is the current scenario. We have to dedicate both people and resources to this. Triage is a real thing. Resources are not infinite.
Build more ECMO machines before that happens?
It's already happening right now. And also, it's not just a manufacturing issue, you also need to train more personnel, and find more space in hospitals for one.
> What happens to the next guy?
This one’s real simple! They die.
This one’s real simple! They die.
Just a trolley problem in the end, eh?
Think about it long and hard enough, and every problem becomes a trolley car problem.
Indeed. All life is trade offs, which means it is interesting to me when people claim there are no trade offs. All resource usage competes with other resource usage.
Yeah I mean it’s pretty obvious.
If the resources that keep people alive are all taken and you’re not willing to take that resource from somebody using one, then the next person who needs one is going to be left out.
So either we get OK with pulling the plug, build more of the machines, come up with a new idea, or be OK with people who need these things dying.
If the resources that keep people alive are all taken and you’re not willing to take that resource from somebody using one, then the next person who needs one is going to be left out.
So either we get OK with pulling the plug, build more of the machines, come up with a new idea, or be OK with people who need these things dying.
Building more machines isn't sufficient. The limiting factor is expert human healthcare providers to operate the machines, and do the other things necessary to keep the patient alive.
Ok so add “get more people” to the list of options…
>able to walk and read the newspaper.
Reading the newspaper is a 'maybe' here, but the notion of patients just generally walking around while on ECMO treatment as we know it today is absurd. Letting a patient be ambulatory during ECMO treatment is still in the realm of very, very, very small-n clinical trials, and the risk of near-immediate death from things like a cannula dislodging are very high. Even if it was safe, you're looking at a massive cart of equipment and 1-2 dedicated personnel to walk around with the patient while tweaking its settings.
In general, nobody being treated by ECMO is 'reading the newspaper', if they're cogent and conscious at all. It has absolutely brutal effects on the body, and people are kept sedated while receieving the treatment for good reason.
Reading the newspaper is a 'maybe' here, but the notion of patients just generally walking around while on ECMO treatment as we know it today is absurd. Letting a patient be ambulatory during ECMO treatment is still in the realm of very, very, very small-n clinical trials, and the risk of near-immediate death from things like a cannula dislodging are very high. Even if it was safe, you're looking at a massive cart of equipment and 1-2 dedicated personnel to walk around with the patient while tweaking its settings.
In general, nobody being treated by ECMO is 'reading the newspaper', if they're cogent and conscious at all. It has absolutely brutal effects on the body, and people are kept sedated while receieving the treatment for good reason.
The article made it sound like it's commonplace. Thank you for this perspective.
> The only ethical problem I see is other people deciding what life is worth living.
It’s more complicated than that. If there’s only 10 ECMO machines available in a hospital, someone has to decide who gets those machines. Like the entire field of medicine, triage is necessary and sometimes ethics dictate someone should not go on that machine based on their chances of survival.
It’s more complicated than that. If there’s only 10 ECMO machines available in a hospital, someone has to decide who gets those machines. Like the entire field of medicine, triage is necessary and sometimes ethics dictate someone should not go on that machine based on their chances of survival.
Even more complicated is debating if it's ethical to take someone off the machine if it leads to savings more people. I know triage and giving up on treatment has precedent, but I'm not too familiar with forced removal of on-going treatment, knowing it will kill someone.
I wouldn’t be surprised if combat medics are trained in triage ethics adjacent to this. Dumb example: you only have one tourniquet, and it’s on someone who will probably die, and suddenly you have another person who will only die if they don’t get that tourniquet.
There's difference in removing a tourniquet from someone who will likely die even with the tourniquet verses taking someone off a machine who won't die while on it, but is permanently reliant on it.
Great example. I'm curious if anyone has experience with this or similar.
Another real world story on the usage of ECMO https://archive.ph/TZ90v . A snowshoer got lost around Mt. Rainier, fell, and had to be rescued. He was hypothermic and went into cardiac arrest, with not a high probability to survive, saved by ECMO and had a full recovery.
I don't know why the story doesn't follow up, but it appears Shania Arms died last summer: https://www.eppsmemorialfuneralhome.com/obituaries/shania-ar.... She apparently never got the transplant. Unfortunately, this was down a ways on web search compared to her GoFundMe, which is still up, so thanks to reading this after reading her self-told story of fighting so hard for 23 years while constantly being told she was about to die, I think I'm gonna disconnect from the Internet and go cry for a few hours.
There is some discussion about the long tail of patients who don't get better, but from the article, this machine seems like it has lead to some incredible outcomes. Better respiratory illness recovery for extreme cases, better ability to recover from some cardiac arrests, etc.
Additionally, for most long term patients, the reason they exist on the machine is because a lack of organs for transplant. There is little hope for more organs now, but in the future modified pig organs seem like a possibility for people that could really transform the ability to save peoples lives.
Like it is nice that we can have ethics questions about this machine, and hopefully it can give some terminal patients the chance to find their own peace.
Additionally, for most long term patients, the reason they exist on the machine is because a lack of organs for transplant. There is little hope for more organs now, but in the future modified pig organs seem like a possibility for people that could really transform the ability to save peoples lives.
Like it is nice that we can have ethics questions about this machine, and hopefully it can give some terminal patients the chance to find their own peace.
https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.122.0...
An interesting european study where patients with heart failure were randomized to ecmo or not ecmo, with no significant difference
Studies like this are not often run in the us because there isnt a national health service which can facilitate this sort of trial, and no industry corporation has an incentive to run this either
So when dealing with very expensive complex treatments which sometimes seem to “work” impressively, remember that it may be completely useless
An interesting european study where patients with heart failure were randomized to ecmo or not ecmo, with no significant difference
Studies like this are not often run in the us because there isnt a national health service which can facilitate this sort of trial, and no industry corporation has an incentive to run this either
So when dealing with very expensive complex treatments which sometimes seem to “work” impressively, remember that it may be completely useless
As others have mentioned, it's important to note that this is not a trial of ECMO vs no ECMO, but of immediate ECMO vs usual care including ECMO if needed, and that 39% of the control arm wound up receiving ECMO, which could have the effect of reducing apparent treatment benefit. Also, the 28% reduction in the primary endpoint could well reach statistical significance if the trial numbers were larger. Finally, this was for patients with cardiogenic shock, most likely predominantly heart attack patients. They likely represent a smallish portion of the patients who might be considered for ECMO, so one can't generalize to all scenarios.
You’re mischaracterizing their findings:
>” Immediate implementation of VA-ECMO in patients with rapidly deteriorating or severe cardiogenic shock did not improve clinical outcomes compared with an early conservative strategy that permitted downstream use of VA-ECMO in case of worsening hemodynamic status.”
They still allowed for the use of ECMO if things got worse, they just didn’t start early. I don’t know how enough to know how this trial’s treatment compares to standard practice.
>” Immediate implementation of VA-ECMO in patients with rapidly deteriorating or severe cardiogenic shock did not improve clinical outcomes compared with an early conservative strategy that permitted downstream use of VA-ECMO in case of worsening hemodynamic status.”
They still allowed for the use of ECMO if things got worse, they just didn’t start early. I don’t know how enough to know how this trial’s treatment compares to standard practice.
I’d be careful interpreting studies when you aren’t a domain expert. Even if the results are accurate (no reason to think they’re not in this case), subtleties of experimental design that a domain expert would see may be invisible to an outsider.
In this area, some groups are able to demonstrate a benefit and others are not. The thought is that hospital integration with field technicians is a big explanatory factor
In this area, some groups are able to demonstrate a benefit and others are not. The thought is that hospital integration with field technicians is a big explanatory factor
“Of the three published ECPR randomized, controlled trials, only one did not limit the intervention to people with shockable rhythms. That ambitious trial, in Prague, included patients whose hearts were in the same P.E.A. pattern as the St. Paul man’s. The study was stopped early when it appeared that ECPR wasn’t saving significantly more people than standard care was. These enigmatic cases that lack shockable rhythms are vexing: When the Prague data was reanalyzed without these patients, the findings were favorable for ECPR.”
https://www.nytimes.com/2024/03/27/magazine/ecpr-cardiac-arr...
https://www.nytimes.com/2024/03/27/magazine/ecpr-cardiac-arr...
>and no industry corporation has an incentive to run this either.
Are insurance companies not incentivized to measure cost effectiveness of treatments in the US?
Are insurance companies not incentivized to measure cost effectiveness of treatments in the US?
It reminds me of the situation people used to face when they got Polio. Often, they got stuck in an iron lung for a while and quite a few also never ever recovered lung function, meaning they were stuck for life as well.
I've worked in this industry, designed several pumps.
Check out Ventriflo, www.ventriflow.com
There is so much opportunity for innovation in this space, it's like 10 or 15 years behind of what's possible
Check out Ventriflo, www.ventriflow.com
There is so much opportunity for innovation in this space, it's like 10 or 15 years behind of what's possible
ECMO is a last resort type treatment that has common life altering side effects.
Yep. A good friend of mine who is a perfusionist (a relatively obscure midlevel med tech role focused on ECMO/CPB operations) has made it clear they would rather just be allowed to die than be subjected to either. The majority of cases they're involved with, but most especially the ECMO cases, per their account, are associated with what seems like unnecessary suffering pending death. Their opinion is that in most cases, it's probably not worth the extreme cost and effort, and that tracking 'survival' as the criteria for success is misguided given poor quality of life afterwards, and usually death related to long-term side effects/complications. They admit that their opinion may be clouded by the fact that they've self-selected into working in hospitals that are the most likely to take 'hopeless' cases, though.
ECMO is used by emergency service in Paris and they it bring to the patient wherever he is having a cardiac arrest. This is really changing how many people will survive a out of hospital cardiac arrest, as a lot of people saved can resume a normal life (about 40% from 6% without it)
If you understand French here is a video of how the procedure is done. https://youtu.be/bX5yZFM2Dn4?si=h0hod5XXgWCWrfLa
If you understand French here is a video of how the procedure is done. https://youtu.be/bX5yZFM2Dn4?si=h0hod5XXgWCWrfLa
Je le parle :)
SAMU's program is impressive and shows a lot of promise as a bridge treatment, and it's completely unlike anything available here in the US today (where myself and the friend I mentioned earlier live).
SAMU's program is impressive and shows a lot of promise as a bridge treatment, and it's completely unlike anything available here in the US today (where myself and the friend I mentioned earlier live).
They even did it in the Louvre!
I'm a paramedic, and in between seeing quality of life issues post resuscitation, ongoing care challenges and, unfortunately, the state of some skilled nursing and rehab facilities, myself, and I would say a "very very large percentage" of my peers are absolutely on the same page.
Unless full recovery with no to minimal deficits is likely, not so much.
Unless full recovery with no to minimal deficits is likely, not so much.
I have heard the sentiment before that ICU doctors would rather die than go through the ICU. Couple this with PTSD being a common side effect from ICU care and it starts to make a picture that maybe death is just the way to go.
I spent a month in the ICU many years ago. I have the benefit that the trauma was front-loaded (motorcycle accident) so not too many horrible things happened to me in the last three weeks (although getting re-intubated ranks pretty high up there), but I don't have any hint of PTSD from the experience. N=1 and all that...
Doctors live very stressful lives from which there is often no escape until they finally retire someday.
It does not surprise me that many would choose to just die ASAP if something bad happened to them.
It does not surprise me that many would choose to just die ASAP if something bad happened to them.
No. This is not at all a representative opinion among ICU docs.
Definitely not a universal opinion. But it seems pretty common among my physician friends to have fairly specific advance directives that choose death over prolonged (or any) ICU stay in worst-case type scenarios. They keep bugging me to set something up like that for myself.
I am not just saying the original claim wasn’t universal, I’m saying it’s at most a tiny minority opinion (because it’s so extreme, taken literally).
“You should put your wishes in an advanced directive so you don’t suffer in the ICU in ~hopeless situations” (true) and “there are a non-negligible number of cases where the suffering in the ICU is not worth the modest life extension according the patient’s own values” (also true) and “the balance between life extension and quality of life errs, on average, too much toward the former” (plausibly true) are nothing like “the ICU is worse than death for most people”.
“You should put your wishes in an advanced directive so you don’t suffer in the ICU in ~hopeless situations” (true) and “there are a non-negligible number of cases where the suffering in the ICU is not worth the modest life extension according the patient’s own values” (also true) and “the balance between life extension and quality of life errs, on average, too much toward the former” (plausibly true) are nothing like “the ICU is worse than death for most people”.
It helped some COVID patients to survive. Great technology.
This is common conversation doctors have amongst themselves and with patient’s family. In cases of premature births with complications, often doctors suggest not having the child on ECMO unless the chances of survival are really high.
ECMO saved my granddaughter’s life 12 years ago at John Hopkins. She was born on Christmas Eve and weighed over 8lbs but turned “blue” within 30 mins of birth. She was immediately put on ventilator- dx with pediatric pulmonary hypertension. Later placed on ECMO when condition deteriorated and it saved her life. She spent months in hospital but is now a very active 12 y/o with no cognitive deficits. She is now on only one heart medication and recent heart catheter showed slight improvements. It’s my understanding she will always be on a heart medication. She came home from the hospital with a j-tube and was quite a struggle to get her to eat food or take a bottle as she never had a bottle or breast for months. It was amazing how articulate she was at a young age and how active as she had been in a induced comma for a long time.She will not be able to participate in competitive sports but can enjoy some sports for fun. She is on level at school. ECMO and the team including the surgeon who came in during the night to make the incision will never be forgotten. I still remember the team pushing the machine down the hall towards her room as a doctor carefully explained the ECMO. Not everyone is as fortunate as our “Warrior Princess” as she was in the right place at right time where the ECMO was readily available in Baltimore's John Hopkins.Margaret Evans
ECMO is also a cause of death, when the patient's lung problems are worsened by hyperoxia [0].
[0] "Supplementary oxygen administration is widely used in emergency and intensive care medicine and can be life-saving in critical conditions, but too much can be harmful and affects a variety of pathophysiological processes. Reactive oxygen species are known problematic by-products of hyperoxia which have an important role in cell signaling pathways. There are a wide range of effects, but when the homeostatic balance is disturbed, reactive oxygen species tend to cause a cycle of tissue injury, with inflammation, cell damage, and cell death.[2]" - https://en.wikipedia.org/wiki/Hyperoxia
The Boeing whistleblower just got finished off with ECMO, according to the recent submission [1]. I think the progression of his illness must have been "poor oxygen saturation treated with O2" -> intubation -> ECMO -> death.
[1] https://news.ycombinator.com/item?id=40230790
[0] "Supplementary oxygen administration is widely used in emergency and intensive care medicine and can be life-saving in critical conditions, but too much can be harmful and affects a variety of pathophysiological processes. Reactive oxygen species are known problematic by-products of hyperoxia which have an important role in cell signaling pathways. There are a wide range of effects, but when the homeostatic balance is disturbed, reactive oxygen species tend to cause a cycle of tissue injury, with inflammation, cell damage, and cell death.[2]" - https://en.wikipedia.org/wiki/Hyperoxia
The Boeing whistleblower just got finished off with ECMO, according to the recent submission [1]. I think the progression of his illness must have been "poor oxygen saturation treated with O2" -> intubation -> ECMO -> death.
[1] https://news.ycombinator.com/item?id=40230790
I fail to see how this is, as one specialist puts it, a “profound ethical dilemma," and not simply a temporary and embarrassing misalignment of resources. If you can prevent people from dying—and enable them to live meaningful, sentient lives despite being tethered to a device—then the solution is clear: scale up production while making the devices smaller and cheaper, and in the meantime seek out alternative long-term facilities for palliative care to avoid occupying hospital beds.
The fact that the article frames the problem as "we have this fear of letting people die"—instead of a difficult but solvable problem of research, economy, logistics—seems to me emblematic of a certain dead-end, anti-growth mindset that pervades much of supposedly humanistic writing from the NYer.
So what if this is "a bridge to nowhere?" So is life! And in the end, we are all, in our own ways, waiting for time to run out, tethered to something immovable.
The fact that the article frames the problem as "we have this fear of letting people die"—instead of a difficult but solvable problem of research, economy, logistics—seems to me emblematic of a certain dead-end, anti-growth mindset that pervades much of supposedly humanistic writing from the NYer.
So what if this is "a bridge to nowhere?" So is life! And in the end, we are all, in our own ways, waiting for time to run out, tethered to something immovable.
> scale up production while making the devices smaller and cheaper, and in the meantime seek out alternative long-term facilities for palliative care to avoid occupying hospital beds.
I feel like you're just hand-waving away the issue. If they could move them out of the ICU they would have, the issue is they require constant care while on the ECMO machine.
Additionally, while the "smaller, cheaper, no care required" devices may appear in the future (the article talks about this very thing), they're not here _right now_. There's currently a limited number of machines and people who can maintain them in the hospital, and hence an immediate problem that they have to deal with when there's more people who can benefit from them than machines they have.
I feel like you're just hand-waving away the issue. If they could move them out of the ICU they would have, the issue is they require constant care while on the ECMO machine.
Additionally, while the "smaller, cheaper, no care required" devices may appear in the future (the article talks about this very thing), they're not here _right now_. There's currently a limited number of machines and people who can maintain them in the hospital, and hence an immediate problem that they have to deal with when there's more people who can benefit from them than machines they have.
I'm not hand-waving the issue; as I said, it's clearly a very difficult problem. But it is not an ethical dilemma; it is a resource-allocation problem. In the United States, we are historically good at solving those, when properly motivated.
Why can't more machines be made? Why are there a limited number of people who can maintain them and perform care on a long-term basis? These are questions that lie downstream of many long-standing institutional problems with the practice of medicine in the US, and framing them as ethical "maybe-some-people-should-just-die" questions is missing the broader story.
Why can't more machines be made? Why are there a limited number of people who can maintain them and perform care on a long-term basis? These are questions that lie downstream of many long-standing institutional problems with the practice of medicine in the US, and framing them as ethical "maybe-some-people-should-just-die" questions is missing the broader story.
> But it is not an ethical dilemma; it is a resource-allocation problem.
Sure, it's a resource-allocation problem, but _right now_ it is an ethical dilemma. None of what you're suggesting will suddenly make the problem gone in a year, hence why I called it hand-waving.
> Why are there a limited number of people who can maintain them and perform care on a long-term basis?
You're just asking the question "why aren't there more people working in the ICU?". Somehow I don't think this is a problem that would be solved in a year if someone just 'finally sat down and worked on it'.
As the the article points out, people are _already_ working on the issues you came up with, it just turns out they're actually hard problems to solve.
Sure, it's a resource-allocation problem, but _right now_ it is an ethical dilemma. None of what you're suggesting will suddenly make the problem gone in a year, hence why I called it hand-waving.
> Why are there a limited number of people who can maintain them and perform care on a long-term basis?
You're just asking the question "why aren't there more people working in the ICU?". Somehow I don't think this is a problem that would be solved in a year if someone just 'finally sat down and worked on it'.
As the the article points out, people are _already_ working on the issues you came up with, it just turns out they're actually hard problems to solve.
Well, no, the article doesn't address any of those issues. In the case of the teenager apparently allowed to die through refusal-of-service, the logic of the situation as presented by the hospital—either the child dies, or others die—is not interrogated with regard to possible alternatives. Vastly increasing ICU capacity nation-wide in a single year might be tough (although I don't agree with your framing of its impossibility) but why could it not be done in this particular, local case? It seems obvious that hospitals have a strong incentives to present cost-minimization as "profound ethical dilemmas."
The future work briefly touched on at the end—focusing on organ transplants and miniaturization, and framed by a professional arguing that "the overarching problem here is that we have this fear of letting people die"—does not cover any of the obvious but difficult ways of dealing with individual situations in the near-to-medium term (bottlenecks in production, personnel, etc.).
The future work briefly touched on at the end—focusing on organ transplants and miniaturization, and framed by a professional arguing that "the overarching problem here is that we have this fear of letting people die"—does not cover any of the obvious but difficult ways of dealing with individual situations in the near-to-medium term (bottlenecks in production, personnel, etc.).
It absolutely boggles my mind that this is such a controversial viewpoint. We're talking about a machine that can keep people not just alive, but awake, talking, and riding an exercise bike, without working lungs or a heart. It's an insane, miraculous treatment, and extremely strong evidence that death is something we can conquer. And people come along and just downvote comments like yours, with no explanation at all, because it's so deeply engrained in their brains they they and everyone they love simply must die, and everyone who believes otherwise must be naive and stupid. Because death is this magical, spiritual, special problem unlike any other problem humanity has ever faced: the one thing we will never be able to solve?
It absolutely is a dead-end, anti-growth mindset, and I don't understand it. Why is everyone so in love with death?
It absolutely is a dead-end, anti-growth mindset, and I don't understand it. Why is everyone so in love with death?
It’s not a particularly fair accounting of the framing of the article, which also profiles people who are working precisely on making the technology more practical and portable and ends on a hopeful note. For the time being it’s a high maintenance way to keep people alive, though, so the ethical dilemmas of resource allocation are real.
This framing is a false dilemma. All resource allocation decisions are also ethical choices.
No—not necessarily. In the case of, say, a hypothetical plane crash in a desert, with two thirsty survivors and one cup of water, resource allocation may also be a profound ethical dilemma. The article’s author (and hospital administrators) encourage us to see the situation in this light.
But in our vastly wealthy, highly-productive 21st-century society, this situation need not be not zero-sum; production can be scaled up on demand, priorities can be shifted, costs can be absorbed. What’s constrained in this case is not supply of the life-saving resource, but political and economic will over inertia.
In this case, calling this an “ethical dilemma” stretches both the definitions of “ethics” and “dilemma” to the breaking point. There is a clear right answer here—but the insistence on choosing the wrong answer over and over, to keep costs down and avoid long-delayed reforms to medical staffing and supply chains, leads to tragic outcomes in which a patient’s survival is determined by institutional bureaucracy. That would be a much more useful framing!
But in our vastly wealthy, highly-productive 21st-century society, this situation need not be not zero-sum; production can be scaled up on demand, priorities can be shifted, costs can be absorbed. What’s constrained in this case is not supply of the life-saving resource, but political and economic will over inertia.
In this case, calling this an “ethical dilemma” stretches both the definitions of “ethics” and “dilemma” to the breaking point. There is a clear right answer here—but the insistence on choosing the wrong answer over and over, to keep costs down and avoid long-delayed reforms to medical staffing and supply chains, leads to tragic outcomes in which a patient’s survival is determined by institutional bureaucracy. That would be a much more useful framing!
Last I checked we are not post scarcity, so we still are those thirsty survivors vying over limited resources. There is only a clear "right" answer provided we first agree on ethics.
Whether you propose an industry subsidy, or campaign for regulatory reform, or initiate a cabal of technocrats to accelerate progress, every dollar towards this cause is a dollar not spent elsewhere. Strongly asserting that you have the one right answer doesn't make opportunity costs disappear.
Whether you propose an industry subsidy, or campaign for regulatory reform, or initiate a cabal of technocrats to accelerate progress, every dollar towards this cause is a dollar not spent elsewhere. Strongly asserting that you have the one right answer doesn't make opportunity costs disappear.
ECMO is a miracle, but can also lead to some of the saddest situations imaginable:
"Without ECMO, she would die. But owing to the complexity of the machine and its attendant risks—catastrophic bleeding, stroke, infection, malfunction—she couldn’t leave [the ICU]. She was waiting, stuck in a kind of limbo between life and death."
"Without ECMO, she would die. But owing to the complexity of the machine and its attendant risks—catastrophic bleeding, stroke, infection, malfunction—she couldn’t leave [the ICU]. She was waiting, stuck in a kind of limbo between life and death."
To be fair that pretty much describes all patient visits to the ICU. You're not there because things are fine and you'll be going home soon, you're there because you're on death's door and the hospital folks want to keep you on this side of it.
The difference is that most other ICU patients are there with an (albeit slim) chance of recovery. Their body just needs time to heal, and the ICU provides the support necessary to do that. 75% of ICU patients are discharged from the hospital alive, and those who die often do so within the first few weeks.
On the other hand, it seems some ECMO patients have zero chance of recovery. Their own organs have failed and aren't coming back, and a transplant doesn't seem to be an option. Sooner or later they will die in that room, most likely due to complications.
On the other hand, it seems some ECMO patients have zero chance of recovery. Their own organs have failed and aren't coming back, and a transplant doesn't seem to be an option. Sooner or later they will die in that room, most likely due to complications.
It really seems similar to dialysis, except more expensive. As technology develops and cheaper devices can be made we can democratize access to these lifesaving devices.
It's in the interests of both you and I to democratize access to technologies like ECMO.
It's in the interests of both you and I to democratize access to technologies like ECMO.
I'm not convinced that is in my interest. Personally if I'm in a condition where I need ECMO and don't have a good chance to recover with a high quality of life then I'd rather just check out. (My preference only, not a choice that I want to impose on other patients.)
While this technology is amazing, at a societal level I am skeptical whether widespread use is the right way to expend our limited resources. In the USA we could save a lot more life years by diverting some funding away from advanced life support and towards fixing our appalling maternal mortality rate.
https://www.cdc.gov/nchs/data/hestat/maternal-mortality/2021...
While this technology is amazing, at a societal level I am skeptical whether widespread use is the right way to expend our limited resources. In the USA we could save a lot more life years by diverting some funding away from advanced life support and towards fixing our appalling maternal mortality rate.
https://www.cdc.gov/nchs/data/hestat/maternal-mortality/2021...
This is definitely in the “nice problems to have” ethics pile.
What? In the sense that better to have that problem than just already dead because ECMO doesn't exist, you mean?
Otherwise I can't think of any way it's at all nice, and that applies to any dilemma - you can always say 'oh well nice to have the option, better than only the bad lemma'!
Otherwise I can't think of any way it's at all nice, and that applies to any dilemma - you can always say 'oh well nice to have the option, better than only the bad lemma'!
I mean that countless people going forward will be saved by this. Some people will become ICU bound walking corpses. It’s an incredible technology that will have profound benefits for humanity.
"The overarching problem here is that we have this fear of letting people die"
This feels like a crazy thing to hear a physician say. Our acceptance of death as inevitable is a learned helplessness. Modern medicine is not even 100 years old by some accounts, and every new decade brings new "miraculous" treatments that naysayers called completely unrealistic before. There's no reason to believe that humanity will need to accept death as inevitable forever. Any theory of medicine that is based on accepting that people die is dooming itself to a primitive, barbaric existence.
The ethical dilemma goes away if these machines become more portable and 100x cheaper, a transformation we've seen many times. From keeping a cat alive for 30 minutes in 1934 to humans in 1952 to days in 1971 to months/years in the 2010s-2020s to ... what, decades? Centuries? These people are having conversations and we're saying "well we should let them die because death is a part of life" -- no, it clearly doesn't have to be. Yes, there are cost concerns, triage concerns and quality of life concerns, but those are engineering problems that we know we could dramatically improve if we actually invested significantly in this technology. I do not accept that we should not be afraid of "letting people die" -- let's be fucking terrified of it and do everything we can to stop it, please. Because everything we've seen from medicine over the last 100 years indicates that we can.
And to those who say that death must be a part of life or (insert societal problem with shaky justification here) will happen, I ask: what if the situation were reversed? What if everyone lived forever and we were facing overcrowding or whatever -- would your solution be to kill everyone nearing 100 years of age?
This feels like a crazy thing to hear a physician say. Our acceptance of death as inevitable is a learned helplessness. Modern medicine is not even 100 years old by some accounts, and every new decade brings new "miraculous" treatments that naysayers called completely unrealistic before. There's no reason to believe that humanity will need to accept death as inevitable forever. Any theory of medicine that is based on accepting that people die is dooming itself to a primitive, barbaric existence.
The ethical dilemma goes away if these machines become more portable and 100x cheaper, a transformation we've seen many times. From keeping a cat alive for 30 minutes in 1934 to humans in 1952 to days in 1971 to months/years in the 2010s-2020s to ... what, decades? Centuries? These people are having conversations and we're saying "well we should let them die because death is a part of life" -- no, it clearly doesn't have to be. Yes, there are cost concerns, triage concerns and quality of life concerns, but those are engineering problems that we know we could dramatically improve if we actually invested significantly in this technology. I do not accept that we should not be afraid of "letting people die" -- let's be fucking terrified of it and do everything we can to stop it, please. Because everything we've seen from medicine over the last 100 years indicates that we can.
And to those who say that death must be a part of life or (insert societal problem with shaky justification here) will happen, I ask: what if the situation were reversed? What if everyone lived forever and we were facing overcrowding or whatever -- would your solution be to kill everyone nearing 100 years of age?
For a contrasting viewpoint, you might consider this New Yorker article from a practicing physician ("The Hidden Harms of CPR"): https://www.newyorker.com/news/the-weekend-essay/the-hidden-...
Death is a necessary consideration, but so is prolonged suffering.
Death is a necessary consideration, but so is prolonged suffering.
I don't think it's so much that we kill people. It's that we let them die. If we are truly, brutally honest with ourselves (and overcoming denial, social, religious, whatever conditioning here is a huge struggle), much of the time, the efforts we put in to keeping loved ones alive is really often more about us than it is about them.
The elderly (and I'm generalizing, I realize) are far more accepting of death. It's easier to accept that when you feel you have lived a full and happy life. Contrarily, that full and happy life often involves having the presence of loved ones, who are NOT ready to accept that their life will be - or rather, will feel - less full and happy without that person.
Even just simple denial is a huge thing. One of my first experiences in emergency medicine was an older gentleman, family patriarch. The rest of his extended family had been able to gather at the hospital while he was in and out of arrest.
A provider and support person went to talk to the extended family, who was adamant about following his son, the 'number two patriarch', and his steadfast insistence, "He is a good strong Christian man, and he is going to be okay." (I say this not to mock Christians, to be clear, and also to be clear, he didn't mean in the "eternal life" sense, he and the family truly believed almost that divine intervention was going to take care of things).
After some discussion on this, a decision was made to bring the son into the ER where we were working on his father. Seeing the hopelessness and futility, seeing his father the shadow of the man he knew, and all of that assorted detail was no doubt traumatic, but it also made it viscerally real to his son. No matter the concerted efforts of nearly 10 medical professionals, drugs, defibrillation, ventilation, we were not going to be able to keep his father alive, and there was not going to be any divine intervention. He watched this silently for a few moments, and then asked us to discontinue CPR and if his father's organs were suitable for donation.
My heart broke for him. But this is a struggle we have not figured out, recently. We had it figured out, historically, by necessity, but we are complacent now.
Leaving aside the separate issue of healthcare costs, you can still look at the ratios:
In the US, on average we spend more on healthcare keeping someone alive for the last year of their life than we do on the previous decade. And we spend more on that decade than we do on the rest of their life. Some of which seems obvious, given youth, but nonetheless.
The elderly (and I'm generalizing, I realize) are far more accepting of death. It's easier to accept that when you feel you have lived a full and happy life. Contrarily, that full and happy life often involves having the presence of loved ones, who are NOT ready to accept that their life will be - or rather, will feel - less full and happy without that person.
Even just simple denial is a huge thing. One of my first experiences in emergency medicine was an older gentleman, family patriarch. The rest of his extended family had been able to gather at the hospital while he was in and out of arrest.
A provider and support person went to talk to the extended family, who was adamant about following his son, the 'number two patriarch', and his steadfast insistence, "He is a good strong Christian man, and he is going to be okay." (I say this not to mock Christians, to be clear, and also to be clear, he didn't mean in the "eternal life" sense, he and the family truly believed almost that divine intervention was going to take care of things).
After some discussion on this, a decision was made to bring the son into the ER where we were working on his father. Seeing the hopelessness and futility, seeing his father the shadow of the man he knew, and all of that assorted detail was no doubt traumatic, but it also made it viscerally real to his son. No matter the concerted efforts of nearly 10 medical professionals, drugs, defibrillation, ventilation, we were not going to be able to keep his father alive, and there was not going to be any divine intervention. He watched this silently for a few moments, and then asked us to discontinue CPR and if his father's organs were suitable for donation.
My heart broke for him. But this is a struggle we have not figured out, recently. We had it figured out, historically, by necessity, but we are complacent now.
Leaving aside the separate issue of healthcare costs, you can still look at the ratios:
In the US, on average we spend more on healthcare keeping someone alive for the last year of their life than we do on the previous decade. And we spend more on that decade than we do on the rest of their life. Some of which seems obvious, given youth, but nonetheless.
It's a powerful story, but it's simply not relevant to my argument, and I suspect the reason you think it is relevant is because you've deeply internalized the inevitability of death. Of course you, and we all, have: it's been inevitable for the entirety of human existence. But humans were never able to fly across the ocean for the vast majority of our existence either, nor were we able to orbit the Earth or communicate at near light speed with the other side of the Earth. People who say death is inevitable are putting it in a special category: it's the one thing humanity will never be able to solve with technology? We can colonize other planets, split the atom, develop computers and AI, but keeping oxygen flowing to the cells is just forever beyond our reach? No.
Your story is about a man's denial that his father, currently in critical condition, would die. Yes, the probability that humanity would solve death in the hour of life his father had remaining was low. I'm talking about humanity's denial that death is just a giant bag of problems that we can, eventually, solve one by one. The probability that humanity will solve death in the next thousand years is nearly 100%; the probability that it will be solved in our lifetimes may be low, but it's not 0. (Keep in mind, 1000 years is ten times the lifespan of an exponentially accelerating medical field, not simply 1% of the whole human history in which basically no progress was made.)
If we had a simple, maintainable, cheap machine that could keep people alive for 100 years without a working heart or lungs, there is no ethical dilemma, and the line between "killing them" and "letting them die" becomes pretty blurry.
The reason this matters is that once we actually start to realize that death is a problem that we can actually solve, then we can get the fuck to work on it! We could be investing so much more than we are in treatments like ECMO. There should be a national moon-landing-level initiative to make these machines available to everyone. But the longer we mope around with our learned helplessness, calling people like me naive and in denial, the more people will die needlessly.
Your story is about a man's denial that his father, currently in critical condition, would die. Yes, the probability that humanity would solve death in the hour of life his father had remaining was low. I'm talking about humanity's denial that death is just a giant bag of problems that we can, eventually, solve one by one. The probability that humanity will solve death in the next thousand years is nearly 100%; the probability that it will be solved in our lifetimes may be low, but it's not 0. (Keep in mind, 1000 years is ten times the lifespan of an exponentially accelerating medical field, not simply 1% of the whole human history in which basically no progress was made.)
If we had a simple, maintainable, cheap machine that could keep people alive for 100 years without a working heart or lungs, there is no ethical dilemma, and the line between "killing them" and "letting them die" becomes pretty blurry.
The reason this matters is that once we actually start to realize that death is a problem that we can actually solve, then we can get the fuck to work on it! We could be investing so much more than we are in treatments like ECMO. There should be a national moon-landing-level initiative to make these machines available to everyone. But the longer we mope around with our learned helplessness, calling people like me naive and in denial, the more people will die needlessly.
> There should be a national moon-landing-level initiative to make these machines available to everyone
You are doing a logical jump here. You argue, quite convincingly that “solving death” is a problem worth pursuing, and we should prioritise it higher than we are already do. We are on the same page about that.
Then you posit that we should pour huge amount of money into development of ECMO. But you don’t say why? Why do you think pouring all those resources in particular to ECMO research is the best way towards “solving death”?
ECMO even in the best possible dream circumstances will always remain a shitty, painfull and risky procedure which can only help a few. On the other hand senescence will affect every one of us who is lucky enough to live long enough. For some reason, most likely for a bunch of reasons, our bodies start to fall apart as we age. Understanding how exactly that happens and what can be done about it should be a higher priority. The national moon-landing-level initiative monies you plan to pour into ECMO research and development should be spent on senescence research and anti-senescence development.
Which future do you want to live in? One where masses are kept kinda-sorta alive by machines, always on the knife edge of dying from a bleed, or a blood clot, or an infection? Or one where 150 year olds go rock climbing and windsurfing because through medical and technological advancements we figured out how to keep their bodies younger longer?
You are doing a logical jump here. You argue, quite convincingly that “solving death” is a problem worth pursuing, and we should prioritise it higher than we are already do. We are on the same page about that.
Then you posit that we should pour huge amount of money into development of ECMO. But you don’t say why? Why do you think pouring all those resources in particular to ECMO research is the best way towards “solving death”?
ECMO even in the best possible dream circumstances will always remain a shitty, painfull and risky procedure which can only help a few. On the other hand senescence will affect every one of us who is lucky enough to live long enough. For some reason, most likely for a bunch of reasons, our bodies start to fall apart as we age. Understanding how exactly that happens and what can be done about it should be a higher priority. The national moon-landing-level initiative monies you plan to pour into ECMO research and development should be spent on senescence research and anti-senescence development.
Which future do you want to live in? One where masses are kept kinda-sorta alive by machines, always on the knife edge of dying from a bleed, or a blood clot, or an infection? Or one where 150 year olds go rock climbing and windsurfing because through medical and technological advancements we figured out how to keep their bodies younger longer?
ECMO is short term, and you're talking long term. We're not going to cure aging in 10 years. We probably could have an ECMO in every home in 10 years. Of course senescence research must be a part of it. And that research will benefit tremendously if cheap ECMO keeps a few veteran senescence researchers alive who otherwise would have died of heart attacks.
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I want to live in the real world where most people live a hopefully fulfilling natural life of 75-100 years and then "make room" for the next generation.
I want a world where geezers like Joe Biden and Donald Trump are not our choices for who will be running things. Imagine if they were 40 years older than they are.
People get old, and die. It's OK.
I want a world where geezers like Joe Biden and Donald Trump are not our choices for who will be running things. Imagine if they were 40 years older than they are.
People get old, and die. It's OK.
Then going to your point, there are many discussions around theoretical upper bounds for human life, even factoring in technology.
Studies look at blood cells and footsteps and establishing hard limits. One of the more recent ones suggests around 150 (today it's around 120).
> with things that usually kill us omitted, our body's capacity to restore equilibrium to its myriad structural and metabolic systems after disruptions still fades with time. And even if we make it through life with few stressors, this incremental decline sets the maximum life span for humans at somewhere between 120 and 150 years. In the end, if the obvious hazards do not take our lives, this fundamental loss of resilience will do so.
https://www.scientificamerican.com/article/humans-could-live...
Studies look at blood cells and footsteps and establishing hard limits. One of the more recent ones suggests around 150 (today it's around 120).
> with things that usually kill us omitted, our body's capacity to restore equilibrium to its myriad structural and metabolic systems after disruptions still fades with time. And even if we make it through life with few stressors, this incremental decline sets the maximum life span for humans at somewhere between 120 and 150 years. In the end, if the obvious hazards do not take our lives, this fundamental loss of resilience will do so.
https://www.scientificamerican.com/article/humans-could-live...
Ctrl+F > "telomere" -- 0 results
Weird to not mention telomeres in that article. It sounds like basically what they're talking about. We already know about Telomerase:
https://en.wikipedia.org/wiki/Telomerase
We are rapidly developing gene editing, e.g. with CRISPR:
https://en.wikipedia.org/wiki/CRISPR
Not to mention that we already know about "immortal" organisms that beat this "limit". There's no reason to think that "fundamental limit" is anything more than yet one more problem to solve.
Weird to not mention telomeres in that article. It sounds like basically what they're talking about. We already know about Telomerase:
https://en.wikipedia.org/wiki/Telomerase
We are rapidly developing gene editing, e.g. with CRISPR:
https://en.wikipedia.org/wiki/CRISPR
Not to mention that we already know about "immortal" organisms that beat this "limit". There's no reason to think that "fundamental limit" is anything more than yet one more problem to solve.
Leonardo da Vinci imagined flying machines. When most people may have believed it to be a priori impossible during his time, instead da Vinci probably believed it to be simply another (solvable) engineering problem.
That being said, even if da Vinci had absolute certainty that his viewpoint was correct, that heavier-than-air flying machines were a factual inevitability... what could da Vinci have done to capitalize on this knowledge? Other than draw some diagrams and hope future generations pick it up, but in his own contemporary timeframe, this knowledge of the inevitable future would still be generally useless to him. It would not affect his daily life, it likely would not change a single decision that he would make otherwise.
Likewise, let's say you're right, that conquering death is an inevitably solvable engineering problem. So what would you do with that knowledge, right now? Of the cases called out in the article, of people who could not live off of ECMO, how does having this knowledge of inevitable immortality that's coming 100s of years later, how would that change the decision-making rubric today for those patients or whether those ECMO machines are better used on someone else?
I venture to say that, even if you knew with absolute certainty that engineered-immortality would be achieved by a known future date, say 200 years from now (though it took ~400 years between da Vinci and heavier-than-air flight)... IMHO it shouldn't make any difference at all to the present-day decisions of how those ECMO patients should be treated today. Only if you knew the date of pending immortality was let's say, <10 years away, would you make some kind of drastic push to try and keep everyone alive barely long enough to benefit from that breakthrough.
... In fact, I vaguely remember reading a short story about this very conceit, of generations of humans in a fictional setting, working towards immortality, and how at a certain point, they reached a stage of awareness that, achieving immortality was likely going to happen soon in the next generation, so what would they do with that "last generation" of humans to ever need to face death? How would people feel, how would they react, if they knew that they were just a little bit too early to benefit from the breakthrough that might come 20 years from now? Sadly can't recall what that story was called or any more details that would make it easier to search for.
That being said, even if da Vinci had absolute certainty that his viewpoint was correct, that heavier-than-air flying machines were a factual inevitability... what could da Vinci have done to capitalize on this knowledge? Other than draw some diagrams and hope future generations pick it up, but in his own contemporary timeframe, this knowledge of the inevitable future would still be generally useless to him. It would not affect his daily life, it likely would not change a single decision that he would make otherwise.
Likewise, let's say you're right, that conquering death is an inevitably solvable engineering problem. So what would you do with that knowledge, right now? Of the cases called out in the article, of people who could not live off of ECMO, how does having this knowledge of inevitable immortality that's coming 100s of years later, how would that change the decision-making rubric today for those patients or whether those ECMO machines are better used on someone else?
I venture to say that, even if you knew with absolute certainty that engineered-immortality would be achieved by a known future date, say 200 years from now (though it took ~400 years between da Vinci and heavier-than-air flight)... IMHO it shouldn't make any difference at all to the present-day decisions of how those ECMO patients should be treated today. Only if you knew the date of pending immortality was let's say, <10 years away, would you make some kind of drastic push to try and keep everyone alive barely long enough to benefit from that breakthrough.
... In fact, I vaguely remember reading a short story about this very conceit, of generations of humans in a fictional setting, working towards immortality, and how at a certain point, they reached a stage of awareness that, achieving immortality was likely going to happen soon in the next generation, so what would they do with that "last generation" of humans to ever need to face death? How would people feel, how would they react, if they knew that they were just a little bit too early to benefit from the breakthrough that might come 20 years from now? Sadly can't recall what that story was called or any more details that would make it easier to search for.
For your analogy to hold, let's assume that everyone on Earth in 1500 A.D. had a strongly vested interested in heavier-than-air flight (as they do with not dying today), and Leonardo da Vinci was completely convinced it was possible. You assert it wouldn't have made a difference. I assert it could have changed the course of human history.
Leonardo would have done what everyone like him did around that time: convinced a wealthy patron to fund his experiments. If he had gotten many very rich nobles convinced as well, he may have gotten tons of money to hire lots of people to build and test various designs. We might have had heavier-than-air flight 400 years earlier. Of course, without powered engines, they wouldn't have had nearly the success they have today, but one can imagine some pretty elaborate gliders, or possibly hot air balloons, showing up hundreds of years earlier than they actually did.
So I absolutely reject your notion of "it would never have made any difference." The fallacy that history must always have gone exactly as it did is a common one, but it is a fallacy nonetheless.
> Likewise, let's say you're right, that conquering death is an inevitably solvable engineering problem. So what would you do with that knowledge, right now?
I already told you: organize a nation-wide (or international) Moon-landing level effort to make ECMO machines 100x cheaper, more portable, and more widely available by the end of the decade. Spend 4% of GDP on it. Keep spending 4% of GDP on similar research.
> Only if you knew the date of pending immortality was let's say, <10 years away, would you make some kind of drastic push to try and keep everyone alive barely long enough to benefit from that breakthrough.
It's not one date. It's a long path with many problems to solve along the way. It may indeed take hundreds of years to achieve complete agelessness. But every year that we wait to start (and we are waiting, because of our belief that it's not possible), is another year that people are needlessly dying. Every problem solved along the way is a few more years for many more people.
> I vaguely remember reading a short story about this very conceit,
Yes, bad sci-fi has used the inevitability of death as a plot element for a long time, along with the silly argument "do we really want to live forever!? BUT EVIL!!" It's never really held up to scrutiny.
Leonardo would have done what everyone like him did around that time: convinced a wealthy patron to fund his experiments. If he had gotten many very rich nobles convinced as well, he may have gotten tons of money to hire lots of people to build and test various designs. We might have had heavier-than-air flight 400 years earlier. Of course, without powered engines, they wouldn't have had nearly the success they have today, but one can imagine some pretty elaborate gliders, or possibly hot air balloons, showing up hundreds of years earlier than they actually did.
So I absolutely reject your notion of "it would never have made any difference." The fallacy that history must always have gone exactly as it did is a common one, but it is a fallacy nonetheless.
> Likewise, let's say you're right, that conquering death is an inevitably solvable engineering problem. So what would you do with that knowledge, right now?
I already told you: organize a nation-wide (or international) Moon-landing level effort to make ECMO machines 100x cheaper, more portable, and more widely available by the end of the decade. Spend 4% of GDP on it. Keep spending 4% of GDP on similar research.
> Only if you knew the date of pending immortality was let's say, <10 years away, would you make some kind of drastic push to try and keep everyone alive barely long enough to benefit from that breakthrough.
It's not one date. It's a long path with many problems to solve along the way. It may indeed take hundreds of years to achieve complete agelessness. But every year that we wait to start (and we are waiting, because of our belief that it's not possible), is another year that people are needlessly dying. Every problem solved along the way is a few more years for many more people.
> I vaguely remember reading a short story about this very conceit,
Yes, bad sci-fi has used the inevitability of death as a plot element for a long time, along with the silly argument "do we really want to live forever!? BUT EVIL!!" It's never really held up to scrutiny.
> complete agelessness
I'm still puzzled why you think an ECMO machine of all things is related to this at all. It's no more sensible than thinking a tourniquet has anything to do with prolonging lifespan. They both might save your/a life in the moment, but people still age, they get old, and no one basically even knows where to begin on that one even if they agree with you that it may be possible. I would go even further that those that sincerely imagine it is possible in the foreseeable future have no specialized knowledge of how it would actually work or be done (people like 4000 supplements and alkaline water Ray Kurzweil only prove out this point). You don't even know what you don't know.
And even if possible there is no sane reason to think that ECMO has any role in prolonging lifespan any more so than a ventilator or dialysis, you've completely lost the plot on that one.
> But every year that we wait to start (and we are waiting, because of our belief that it's not possible), is another year that people are needlessly dying.
Amusing that when dealing with eternity, what difference does it make if its 100 years, 400 years or 1000 years. Unless you have a better prediction than 1. build a better heart-lung machine 2. ??? 3. eternal life, chances are it's not going to be in your lifetime, so it really is of no consequence to you or your peers. And I'll guess you have little practical or actionable to add to this body of "research".
I'm still puzzled why you think an ECMO machine of all things is related to this at all. It's no more sensible than thinking a tourniquet has anything to do with prolonging lifespan. They both might save your/a life in the moment, but people still age, they get old, and no one basically even knows where to begin on that one even if they agree with you that it may be possible. I would go even further that those that sincerely imagine it is possible in the foreseeable future have no specialized knowledge of how it would actually work or be done (people like 4000 supplements and alkaline water Ray Kurzweil only prove out this point). You don't even know what you don't know.
And even if possible there is no sane reason to think that ECMO has any role in prolonging lifespan any more so than a ventilator or dialysis, you've completely lost the plot on that one.
> But every year that we wait to start (and we are waiting, because of our belief that it's not possible), is another year that people are needlessly dying.
Amusing that when dealing with eternity, what difference does it make if its 100 years, 400 years or 1000 years. Unless you have a better prediction than 1. build a better heart-lung machine 2. ??? 3. eternal life, chances are it's not going to be in your lifetime, so it really is of no consequence to you or your peers. And I'll guess you have little practical or actionable to add to this body of "research".
You get very close to the real issue here:
The important part of a flying machine wasn’t the machine itself, but the engine to run the machine itself. We’ve had flying machine designs for centuries but it only took 27 years after the Otto engine was invented to put one in the air.
ECMO is the flying machine design
The important part of a flying machine wasn’t the machine itself, but the engine to run the machine itself. We’ve had flying machine designs for centuries but it only took 27 years after the Otto engine was invented to put one in the air.
ECMO is the flying machine design
What is the engine we are missing?
Excuse me, but I do want to live in a world where death is inevitable and will choose that option at any time. It has nothing to do with helplessness, it's pure reason and engineering considerations.
The current system with auto-refreshing humans has got us very far and obviously it works really well. Not only it solves biological problems like cancer (which you can argue eternal humans will solve themselves) but most importantly it solves scientific, engineering and social problems.
It avoids dead-ends, it can't get stuck, it iterates relentlessly over infinity of alternatives to find the one that brings us further. A mistaken scientist dies and so does his theory. A tyrant dies and so does his regime. A liar dies and no one maintains his lies.
Starting life afresh, without decades of mental baggage is a blessing. Carrying it with you forever is hell for you and for others who will have to endure your presence.
The current system with auto-refreshing humans has got us very far and obviously it works really well. Not only it solves biological problems like cancer (which you can argue eternal humans will solve themselves) but most importantly it solves scientific, engineering and social problems.
It avoids dead-ends, it can't get stuck, it iterates relentlessly over infinity of alternatives to find the one that brings us further. A mistaken scientist dies and so does his theory. A tyrant dies and so does his regime. A liar dies and no one maintains his lies.
Starting life afresh, without decades of mental baggage is a blessing. Carrying it with you forever is hell for you and for others who will have to endure your presence.
> Excuse me, but I do want to live in a world where death is inevitable and will choose that option at any time.
This feels a little like saying "I like death, therefore everyone else must die too." Besides, you'd always be able to choose that option at any time. I'm not talking about some cursed-monkey-paw version of immortality.
> the current system with auto-refreshing humans has got us very far
The system of hunter-gathering got us pretty far too, and switching over to agriculture was indeed not 100% positive at first. The system of feudal/clan-based government and labor-and-wood-based energy economy got us very far, too, and switching to the industrial revolution also had its early downsides. Just because systems are working doesn't mean they can't be improved.
> importantly [Senescence] solves scientific, engineering and social problems.
Again I ask: if we already lived forever, and we were running into those scientific, engineering, and social problems that death supposedly "solves", then would your solution be to start killing everyone approaching 100 years old? Another solution to all our problems is that the sun goes supernova and the Earth is completely annihilated. That's along the same line of "solution" as yours.
Besides, I haven't seen any convincing argument that such problems would necessarily occur, or at least be insurmountable.
> A mistaken scientist dies and so does his theory. A tyrant dies and so does his regime. A liar dies and no one maintains his lies.
This is unfortunately quite accurate for the time being. But death is a rather blunt solution to these problems, and I believe there are better ones. I also believe people would be more interested in ousting tyrants if they didn't think they just need to wait for them to die.
This feels a little like saying "I like death, therefore everyone else must die too." Besides, you'd always be able to choose that option at any time. I'm not talking about some cursed-monkey-paw version of immortality.
> the current system with auto-refreshing humans has got us very far
The system of hunter-gathering got us pretty far too, and switching over to agriculture was indeed not 100% positive at first. The system of feudal/clan-based government and labor-and-wood-based energy economy got us very far, too, and switching to the industrial revolution also had its early downsides. Just because systems are working doesn't mean they can't be improved.
> importantly [Senescence] solves scientific, engineering and social problems.
Again I ask: if we already lived forever, and we were running into those scientific, engineering, and social problems that death supposedly "solves", then would your solution be to start killing everyone approaching 100 years old? Another solution to all our problems is that the sun goes supernova and the Earth is completely annihilated. That's along the same line of "solution" as yours.
Besides, I haven't seen any convincing argument that such problems would necessarily occur, or at least be insurmountable.
> A mistaken scientist dies and so does his theory. A tyrant dies and so does his regime. A liar dies and no one maintains his lies.
This is unfortunately quite accurate for the time being. But death is a rather blunt solution to these problems, and I believe there are better ones. I also believe people would be more interested in ousting tyrants if they didn't think they just need to wait for them to die.
> This feels a little like saying "I like death, therefore everyone else must die too."
Well you sound like "I'm so scared of death that I'm ready to pay for immortality with eternal suffering for the rest of humanity".
I don't like death in particular but I can admit I enjoy being born in the XX century and not being a slave in the mines of Ramses II. And I'm not too bothered by death because I'm already immortal in a sense. My kids are literally a piece of me that keep on living, I see no reason to worry much about the meatbag I currently reside in.
> Again I ask: if we already lived forever, and we were running into those scientific, engineering, and social problems that death supposedly "solves", then would your solution be to start killing everyone approaching 100 years old?
You ask it like some smart theoretical brain teaser whereas it's simple reality. Your gametes don't age and it cost nothing to nature, however the rest of you do age. Ever think why is that? That is THE solution found by natural selection, literally kill everyone nearing 100 years old. And no, reset of body and consciousness to a clean state is not the same as end of life by supernova, it's the opposite. It's a way to ensure continuation of life.
> This is unfortunately quite accurate for the time being. But death is a rather blunt solution to these problems, and I believe there are better ones
The problem is I don't see another solution for corruption of humans. If humans are the ones who are responsible of implementing the solution then they'll just corrupt it too. It's like trying to reason your way out of insanity, doesn't work because your reasoning mechanism is affected. Solution has to be outside of our control like death is now. Conquering death would be a mistake even though I don't really see a way to prevent it long term.
Well you sound like "I'm so scared of death that I'm ready to pay for immortality with eternal suffering for the rest of humanity".
I don't like death in particular but I can admit I enjoy being born in the XX century and not being a slave in the mines of Ramses II. And I'm not too bothered by death because I'm already immortal in a sense. My kids are literally a piece of me that keep on living, I see no reason to worry much about the meatbag I currently reside in.
> Again I ask: if we already lived forever, and we were running into those scientific, engineering, and social problems that death supposedly "solves", then would your solution be to start killing everyone approaching 100 years old?
You ask it like some smart theoretical brain teaser whereas it's simple reality. Your gametes don't age and it cost nothing to nature, however the rest of you do age. Ever think why is that? That is THE solution found by natural selection, literally kill everyone nearing 100 years old. And no, reset of body and consciousness to a clean state is not the same as end of life by supernova, it's the opposite. It's a way to ensure continuation of life.
> This is unfortunately quite accurate for the time being. But death is a rather blunt solution to these problems, and I believe there are better ones
The problem is I don't see another solution for corruption of humans. If humans are the ones who are responsible of implementing the solution then they'll just corrupt it too. It's like trying to reason your way out of insanity, doesn't work because your reasoning mechanism is affected. Solution has to be outside of our control like death is now. Conquering death would be a mistake even though I don't really see a way to prevent it long term.
I can 100% promise that death will be a regular part of life not just 1000 years, but 100,000 years from now as well. Even if we solve senescence and we get 1,000,000 times better at emergency medicine, transplants etc. There are numerous ways to almost entirely destroy the brain in fractions of a second, or in hopelessly irreversible ways, or in covert ways that are slow but only get discovered too late. And, as long as such accidents are possible, if your life is otherwise endless, then they are in fact inevitable, no matter how unlikely they appear.
There will always be some probability of dying in a given year. Let's say our futuristic society has solved aging/senescence, and is able to reduce the rate of "random death" by about 1% per year, through technology, medicine, brain-redundancy, whatever. So if you have a 1 in 1,000 chance of randomly dying this year, next year it will be about 1 in 1,010.
The area under an infinite exponential decay curve is finite. In the scenario above, you have a finite probability of dying, ever. And it's not 100%, either. It could even be quite low. With the numbers above, it's about 10% chance to die, and 90% chance to never die. I know that's counter-intuitive, and it may be that maintaining 1% reduction in random death every year is impossible, but it's not a foregone conclusion that everyone must die.
Of course the heat death of the universe presents a problem. That's a good problem to have.
The area under an infinite exponential decay curve is finite. In the scenario above, you have a finite probability of dying, ever. And it's not 100%, either. It could even be quite low. With the numbers above, it's about 10% chance to die, and 90% chance to never die. I know that's counter-intuitive, and it may be that maintaining 1% reduction in random death every year is impossible, but it's not a foregone conclusion that everyone must die.
Of course the heat death of the universe presents a problem. That's a good problem to have.
Death is not a problem that needs to be eliminated. It's fine that people eventually die. We are all expendable.
The goal of medical care should be to extend healthspan, not lifespan. Minimize the burden of diseases and injuries.
Despite the claims from charlatans and grifters like David Sinclair, there is no scientific evidence that significantly extending human lifespans is even possible. If we were making progress then we would expect to see a few outliers living to 125+. But instead the record remains at 122, and that was set in 1997. It's time to put aside pointless fantasies and focus on achievable goals.
The goal of medical care should be to extend healthspan, not lifespan. Minimize the burden of diseases and injuries.
Despite the claims from charlatans and grifters like David Sinclair, there is no scientific evidence that significantly extending human lifespans is even possible. If we were making progress then we would expect to see a few outliers living to 125+. But instead the record remains at 122, and that was set in 1997. It's time to put aside pointless fantasies and focus on achievable goals.
A patient whose heart has stopped could potentially live on the machine for months, awake, able to walk and read the newspaper. But he might never leave the I.C.U. “It’s a trap,” Zitter said.
Holy shit. I think we should keep people alive as long as possible, as long as they want to be kept alive. This is awesome. Hopefully in future the cost can be decreased and the safety increased. The pessimistic take is that meaningful improvements in the tech are impossible. I think that's not true.
As an aside I think we need to really rethink circulatory system health -- seems a lot of death causes arise from circulatory system: ischemic heart attack, stroke, even kidney related diseases. If we can enhance the reliability / health of circulatory system it should have big effects.
Holy shit. I think we should keep people alive as long as possible, as long as they want to be kept alive. This is awesome. Hopefully in future the cost can be decreased and the safety increased. The pessimistic take is that meaningful improvements in the tech are impossible. I think that's not true.
As an aside I think we need to really rethink circulatory system health -- seems a lot of death causes arise from circulatory system: ischemic heart attack, stroke, even kidney related diseases. If we can enhance the reliability / health of circulatory system it should have big effects.
ECMO is often a "Hail Mary" that rarely includes a favorable outcome.
OTOH, perfusion is an under-staffed specialty offering a good career without as much academic investment as an MD. The downsides are the possibility of being on-call and sometimes having to be the one who pulls the plug.
OTOH, perfusion is an under-staffed specialty offering a good career without as much academic investment as an MD. The downsides are the possibility of being on-call and sometimes having to be the one who pulls the plug.
Having been the recipient of a double "Hail Mary" (extreme rare case - and luxury - of having two ECMO's used to sustain my life for 19-days after full organ failure post-pneumonia + severe allergic reaction to piperacillin/tazobactam) in 2014, and having a close colleague last month also receive ECMO care post-cardiac incident, I'm happy to say that we're both currently looking at 100% return-to-normal with no side-effects. I know there's a large spread of cases where the outcome is not as favourable as ours, but I'm not sure of the statistical curve justifying 'rarely'.
> “This is a big problem already,” Prager told me.
My boss was fond of saying "We don't have problems, we have challenges and opportunities!"
My boss was fond of saying "We don't have problems, we have challenges and opportunities!"
Great article, did New Yorker abandon its rambling house style?
Disclaimer: I have no medical training. But I have had two loved ones in ECMO in my life.
An adult age 48 and a premature infant that weighed a little over 600 grams at birth.
The adult died after a very successful month in ECMO during routine change of tubes. Bled to death after a ruptured artery.
The infant survived and is thriving today.
ECMO is highly specialised, very expensive, incredibly intrusive and also requires large amounts of blood plasma. Blood plasma is not an abundant resource.
Just the cost is almost twice that of a standard, expensive cancer treatment.
"The mean estimated total hospital costs, including pre- and post-ECMO procedures, was 213,246 USD". https://pubmed.ncbi.nlm.nih.gov/19699650/#:~:text=Results%3A...).
Cancer treatment cost example
https://www.asbestos.com/featured-stories/high-cost-of-cance....
So adding to the dangers of using ECMO it is also very very costly.
It doesn't make a lot of sense to promote ECMO as casually as this article does.