We must face this issue both for practical and moral reasons. For one thing, if someone "dies" then their heirs can inherit their property. For another thing, the advances of medical science have given us the ability to transplant organs. When a person whose heart continues to beat is "dead", their heart and lungs and liver and kidneys and many other parts can be transplanted to others, and by so doing can save lives or restore normal living conditions to people who would otherwise live in terrible pain or would die soon.

So when is someone dead? When faced with a body lying in a bed which could be used for transplant donation, is it "murder" to take those organs to help others?

Medical ethics has tried to resolve this issue by changing the definition of "dead" from heart-dead to brain-dead. If measurements taken with the best instruments show that there is no brain activity and if the doctor's experience and knowledge indicates that there won't be any recovery of brain activity, then it doesn't matter whether the heart continues to beat. In most cases these days, such an individual is declared "dead" subject to approval by their relatives. This is a very tricky issue and doctors still tread very carefully around it. No such individual is ever used as an organ donor without direct permission from their relatives, because doctors know that it would only take one or two high profile scandals to do irreparable damage to organ donation as a medical procedure.

Even so, that particular issue is by no means finished, and we will need to revisit it again in coming years! We seem to have decided that the brain is the center of "life" rather than the heart.

There is experimental work being done now on taking cells from a person and cloning from them tissues or perhaps even whole organs, for transplant back into that person. This is an exciting prospect in many regards. The current approach to organ transplantation has two major flaws: organs are always in very short supply, and even after transplantation there is a high risk of rejection due to immune response. Anyone who gets a transplant must take an immune suppressant for the rest of their life.

But if the organ were derived from their own genes, there would be no rejection! And there would no longer be a shortage of organs!

What about brain tissue? Would it be immoral to clone and transplant brain tissue? If we've decided that brain activity indicates life, then is the in-vitro brain tissue culture a separate person? (This is something which may be promising as a treatment for Parkinson's disease.)

Setting that aside, though, it should be clear that the process being described is likely to be exceedingly expensive. Can we actually afford it?

This is not just a practical question, in my opinion. One of the ethical issues that we are beginning to deal with in the US, which the rest of the world will face sooner rather than later, is that of rationing of medical care. If we can't afford to treat everyone, how do we decide who we will not treat?

Suppose we have a medical procedure which has a good chance of saving a life, but which costs $1 million per patient. If only 5 people per year get the procedure, its impact on the economy is negligible and we don't have to concern ourselves with that. But if there are 500,000 eligible patients per year, what do we do?

Medical costs have to be paid for, one way or the other, by the economy as a whole. It's part of the goods and services, and economic resources put into medical costs are not available for other purposes. In countries with socialized medicine, medical costs are paid through taxation, with all that implies. In countries like the US where the majority of medical coverage is not socialized, it is primarily paid for through employer medical benefits. These costs are defrayed effectively as a surcharge per employee. As the cost per person in the populous of medical coverage rises, the surcharge rises and the cost of employing people rises, and this acts as a negative incentive to hiring.

At a certain point, runaway medical costs could ruin the economy. It is probable that the economy of the US could not support 25% of the GDP being spent on medicine, but what is scary is that we're not actually far below that. It's actually in the mid teens now.

500,000 patients per year needing $1 million per treatment is not farfetched when you consider organ transplants, bone marrow transplants, reconstructive surgery, and some of the other kinds of things current and upcoming.

There will come a point where it will be necessary for doctors to look patients straight in the eye and say "We have a procedure which will extend your life, but we're not going to do it on you." How do doctors make that decision?

So far, for the most part they don't. I watched this happen a few years back. A man I knew who was in his late 80's (and in poor health) developed an aortic aneurysm and was within days of death. For those who do not know, the aorta is the main blood artery which carries blood from the heart to every part of the body except the lungs. It has a thick wall lined with muscle, as do all arteries, and the muscle tone in one section of it had failed and it had blown up like a balloon. As such it was at serious risk of bursting. This happens to be a very rapid form of death when it does happen; the victim will be dead in seconds from internal bleeding.

It can be treated surgically, and his doctors elected to do so. So he spent another nine months before he died, flat on his back. He never left the hospital. He was never really totally himself again, in any case, because the blood flow to his body and brain never regained its former level. The expense was immense. At some times, he was in considerable pain. It devastated the savings of he and his wife. Though they had Medicare, it didn't cover everything. After he died, it was necessary for her to go onto public assistance in order to afford to pay her rent.

Who was served by this decision? He wasn't; he exchanged a quick and nearly painless death for a long and lingering one. His wife wasn't; she was nearly impoverished by it. (Certainly she didn't want him to die, but that wasn't a choice.) The taxpayers of the US weren't; they picked up most of the bill.

But the doctor's consciences were salved by it; it kept them from having to make a decision to not treat him even though they knew what to do.

There are things worse than death, and some deaths are preferable to others. Is a clean, fast, painless death sooner better than a slow painful lingering one which is delayed? I would say that it was.

I don't believe that either he or his wife were well served by the doctors. The doctors put their own interests ahead of this man's interests, for they did not want to make the decision that he should not be treated. My opinion is that he should not have been.

My own father died such a death, but in this case I believe the doctors served us well. My father died in 1972 of pancreal cancer which had spread to and destroyed his liver. Like as not it was elsewhere in his body too, but that was enough to condemn him to death.

Now the science of cancer treatment has come a long way since then, but a patient in the condition my father was in when he was diagnosed would still be certain of death today. But they did have radiation treatments and chemotherapy then.

Radiation and chemotherapy make a cancer patient absolutely miserable. Were it not for the fact that they do save lives, they would be unconscionable. My father's doctors presented him and my mother the following choice: they could aggressively treat his cancer with the best methods available to them at the time, and he would be miserable and would most likely die anyway, or they would not attempt to treat his cancer but would provide him with as much pain reliever (Demerol) as he needed to stay comfortable until he died naturally.

And he and my mother chose the second choice. And I am very glad that they did. To this day I believe this was the right answer, for him and for everyone else too. It should be pointed out that in our case, due to the kind of medical insurance we had, neither approach would have involved any expense on the part of our family.

For 1972, this was very forward thinking. But as the experience of my 88 year old friend shows, it's still not universal.

These are individual cases. We have to deal with the simple fact that we will not be able to afford to give every form of medical treatment we have available to us to every person who can utilize them. At a certain point, the collateral damage to the economy and the misery that would cause far outweigh any good which could come from this course.

So how do we make that decision? No-one has a good answer, but someone has tried.

The State of Oregon has tried to institute a rational way to make this kind of decision in its Medicaid program. Each year, a group of doctors and researchers make a list of various kinds of treatments and for each do their best to quantize three values: on an arbitrary scale the benefit the procedure gives per patient, the absolute number of patients on Medicaid which would be expected to need or want that procedure in the coming year, and how much it would cost per patient to provide it.

To take some examples: tattoo removal would be considered to have little benefit and is moderately expensive per patient, and there would be a moderate number of patients interested in it. Liver transplantation has a high benefit per patient, is hugely expensive, and a relatively small number of patients would need it. Childhood vaccination is very cheap per patient with a very high benefit, and nearly every child in Medicaid would be expected to use it.

Each procedure then has a cost-per-benefit ratio calculated, and they are ranked in linear order from low cost-per-benefit (e.g. vaccination) to mid cost-per-benefit (e.g. liver transplantation) to high cost-per-benefit (e.g. tattoo removal). For each entry the cost to fully fund that procedure is calculated by multiplying the cost per patient by the number of expected patients.

The state legislature, meanwhile, determines how much money it can afford to budget for Medicaid without destroying the State's economy. This money is then applied to the list I just described, going down step by step and fully funding each step until the money runs out. That dividing line then decides what will and will not be funded by Medicaid in the coming year. Anything above the line is funded for everyone who needs it (vaccination is certain to be funded every year), anything below the line is not (no-one is going to get public funding for tattoo removal) and those in the middle might or might not be depending on where the line is drawn. The decisions are not made on a patient-by-patient basis, but on a procedure-by-procedure basis.

This is an actuarial approach to the problem, and it may be the only defensible one we have. As can be seen, the idea is to try to get the best benefit for the most people out of the funds which can be afforded. Is it better to spend half a million dollars on one liver transplant, or to vaccinate fifty thousand kids with that same money?

"Do both" isn't an acceptable answer, unfortunately. Someday, it's going to be necessary to start saying "no" to people. I don't think that medical ethicists have yet dealt with this issue.

That's just one example of one current ethical problem we haven't solved. Based on my knowledge of Christian teachings, to take one example, I see no guideline for how to solve this. As I interpret Christian teachings we would all be expected to spend ourselves into poverty to provide complete medical care to everyone. But I can't accept this.

Looking down the pike towards the ethical future, we have coming towards us like a freight train the twin issues of computers and genetic engineering.

When does a computer stop being a machine and start being a slave? Alan Turing showed us the way on that one, with what is now known as the "Turing test". When we have computers which can pass the Turing test, will they be entitled to civil rights?

What will categorize as "murder" for such a device? Is it murder to turn one off? If we make a perfect copy of its storage but then junk the hardware, is it "dead"? Unlike humans, such a device could be duplicated. Is it two individuals or still only one? Can it/they own property? What do "life" and "death" mean when even the machine equivalent of "brain death" no longer means anything? I can turn a computer off and leave it off for a hundred years, and then turn it back on again. What was its legal status in the mean time?

Will such devices have the right to reproduce? Even in the most repressive country, there is implicitly a right to have children for most people.

Humans make their own offspring out of relatively simple materials (food and water) but have to purchase those materials. Sapient machines who wish to make offspring would need material far more complex and expensive. Would they have the right to get that material for lower prices?

Can a human adopt a computer? Can a computer adopt a human child?

And genetic engineering will face us with ethical and moral dilemmas which will make even these pale by comparison. What will we do with the ability to actually design our children instead of relying on pot luck?

I don't pretend to know the answers to all these questions. I just know that the human race is going to have to face them. And any ethical system which refuses to deal with them is useless.

Since the founders of any ethical system can never anticipate all the problems such an ethical system will need to handle, it must therefore be necessary for those ethical systems to be revised when new challenges come along.

And if you agree with me on that then you, too, are an "ethical cynic".

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