The reason for this urgency has mainly been brought about by advances in life support techniques which have gone hand in hand with advances in transplantation surgery, whereby the organs of one person living or recently dead can be surgically transplanted into a recipient. In technical and material terms, these were great advances, but they have brought in their wake a host of ethical and moral dilemmas which still have to be resolved if, indeed, they can be resolved at all. They also highlight the age-old philosophical question as to what constitutes right and wrong action, whether such a distinction is valid in any absolute rather than relative sense, and whether good results can ever follow wrong action, assuming that such a distinction as to 'right' and 'wrong' can be made at all.

Until relatively recently, death was diagnosed by the cessation of the rhythmic action of the heart and respiration and the failure of the peripheral circulation, disappearance of muscular tonus, loss of reaction to external stimuli, and neurological reflexes - particularly the pupillary reflexes - and dullness of the cornea. However, the need to harvest organs for transplantation heightened the awareness for more precision about the diagnosis of death which, in turn, led to the currently-used concept of "brain death" as demonstrated by cessation of electrical activity of the brain as measured by electroencephalogram (EEG). Although widely accepted as evidence of death, a question remains as to the extent to which apparent cessation of electrical activity can be taken as absolute proof of irreversible death of the brain and whether spontaneous recovery might occur, given sufficient time on suitable life support systems.

Another question is whether "life support system" is the correct term to use. Is it really life that is being supported? And, if so, the life of what - me total individual or the organs of mat individual?

Although current medical technical advances were made long after his death, Rudolf Steiner gave some valuable insights into these matters. Considered from a purely material aspect, the dilemmas appear insoluble. Seen from a spiritual scientific point of view, however, a different picture emerges. Rudolf Steiner drew the vital distinction between the death of an individual and the death of his or her organs.(1) He said:

You see, if we perceive the organs in the way that it is possible by taking the initiation path, the inner eye perceives not birth and death but something entirely different. When organs are truly perceived, birth and death actually lose their usual meaning/or, in fact, it is only the whole human being who can die, not the individual organ. The lung does not die, for instance. Modem science has got some notion of this, realizing that when the whole human being has died, individual organs can be vitalized on their own in a specific sense. Individual organs do not die, irrespective of whether the person is interred or cremated. Each individual organ finds its own way out into the cosmos according to its nature, even if the human body lies buried in the earth, with the soil covering it after burial, the organs find their way in the cosmos through air, water and heat. They dissolve but do not die; only the whole human being dies.

The ethics of prolongation of "life" by artificial means was brought sharply into focus by a case(2) which was managed at the Filderklinik, Stutt- gart, in 1991. The patient was a 33 year old woman who was 17 weeks preg- nant when she suddenly collapsed in a park in Stuttgart one day. A passing medical practitioner instituted cardiopulmonary resuscitation which was continued when the emergency medical services arrived and, in the course of which, she was defribillated twelve times. She was placed on life support systems at the hospital but never regained consciousness. On the 14fh day after admission, a 30-minute EEC showed no indication of any electrical activity in the brain. However, gynecological examination showed that her pregnancy was still proceeding apparently normally. The husband repeated his wish, expressed earlier, that her pregnancy should continue.

Thirty-five days after her initial collapse she was transferred to the Filderklinik where she had previously been booked for her confinement. Life support measures were continued, but as the pregnancy was progressing normally no further investigations were made to establish the cause of cerebral failure, and the aim of life support was now focused on the need to continue the pregnancy to the point where the unborn child became viable. On the 84th day of treatment, because of recurrent episodes of profound hypotension, a boy was delivered by caesarean section in the 29th week of pregnancy. After a stormy start to his life involving intensive care, he recovered and is now alive and well at the age of three years.

After the caesarean section, the mother's condition deteriorated, and thehusband eventually gave his permission for the life support systems to be discontinued. She died in asystole 86 days after her initial collapse.

Having to manage a case like this had a profound effect on all the medical and nursing staff who became a therapeutic community in the full sense of the word.(3) Central to their efforts was the attitude and deter- mination of the husband who, in spite of EEC evidence of brain death, was convinced that his wife was still in some way alive and "able to take care of our child in the spirit;" and it was largely due to this conviction that the decision was made to continue life support until the unborn child was viable. The same feeling pervaded the staff who had the strong feeling that she was somehow still present in spite of the technical evidence to the contrary.

The management of this case was, however, not without its critics, notably the authors of an article in Info 3(4) which, inter alia, described those responsible for the decision to continue life support "white-coated anthro- posophic demigods" and suggested the establishment of a hierarchy of responsibility and a protocol for the management of cases such as this one.

Debate will doubtless continue about this case and others like it, and the question of intent must surely be taken into consideration. In this case, the intent was to save the life of an unborn child by keeping the mother artificially "alive" - surely a morally good thing to do. Could the same judgment be made about a person kept artificially "alive" until a need arose for his or her organs for transplantation?

These are difficult questions. However, in the ultimate analysis, no matter what rules and regulations are made, decision-making ultimately, finally falls on the shoulders of the individual. Anthroposophical insights may well help the inner development of the individual to a point where those insights can form a firm basis for good decision making, but they never can make the decisions for him or her.

N.C.Lee,M.D. Flora House Queen's Road Simon's Town 7995 South Africa

References

1 Steiner R. Das einzelne Organ sttrbt nicht sondem es stirbt der ganze Mensch. Reproduced in DerMerkurstab 1994,47.465-467.

2 BavastroP.HimversagenbeieinerschwangerenPatientin. DerMerkurstab 1994.47.445. 3 Lamerdin M. Sterben und Geborenwerden im Uchte zweiter Welten. Der Merkurstab 47.452- 456. 4 Meyer F, Bruell R Info 3,1993,9. (sS.22/15)