Epidural analgesia in labor.

acting unethically: they describe a typical case in which elective ventilation might be considered-a patient with a clearly diagnosed fatal cerebral injury who undergoes respiratory arrest. They write, "Deliberately prolonging a patient's dying is unacceptable for any reason." But such patients die when breathing ceases; elective ventilation does not prolong the act of dying, for one is ventilating a corpse. If that is wrong, let them tell us why, rather than differentiate between dead bodies on the basis of whether a diagnosis was made before or after death, or whether the patient stops breathing in the accident and emergency department rather than a medical ward. We were taxed by ethical issues when we set up the elective ventilation protocol: ethics may be defined as what is right, and in turn that can be regarded as behaviour that causes no distress, offence, or indignity in the context of current societal values. To act ethically, firstly, we must respect the wishes of the dead and dying; secondly, we must cause no unnecessary distress to relatives; and, lastly, we must cause no emotional crisis for the staff of intensive care units. We know from many surveys of public opinion that over 70% of the public would wish their organs to be used for transplantation after death. In our unit one of the goals of elective ventilation is the respecting of these wishes. It seemed to us illogical that patients who stop breathing before irreversible brain injury is diagnosed can become organ donors, whereas clinically identical patients who become apnoeic after diagnosis cannot. Such patients often differ only in the time taken to reach hospital, and to claim that they differ in any more fundamental way is pure sophistry. It is hard to see how the denial of a patient's right to be an organ donor after death is ethical behaviour. The relatives of our electively ventilated organ donors do not feel that we act improperly; rather, they all consider that the process of organ donation allows them to make some sense ofan otherwise inexplicable loss.3 It is sad that Park and colleagues have not understood the logical and moral basis of elective ventilation. We welcome this opportunity to restate our position and encourage other units to follow our lead.