WASHINGTON: After the recent death of Robert Tools, the first recipient of the AbioCor artifical heart, and the death Wednesday of a 74-year-old man who was the third recipient of the device to die, it has become apparent that the patients in this ongoing medical trial are gambling for a slim chance of survival.

These are patients who are near death and who may feel that they have nothing to lose. This desperation has produced a vigorous debate about whether this sort of gamble is ethically permissible and whether informed consent is possible under these circumstances. The disagreement is deep-seated and shows no sign of a resolution.

One thing that everyone can agree on is that this study has taken the field of cardiac research, and research in general, into new and wholly uncharted territory. Patients who enrol agree to trade in their own hearts for an intricate contraption of plastic and metal that might work but which might not. Commentators - even the trial’s most vocal critics - all agree that this study pushes the boundary of what medicine can do.

But critics also argue that the trial places a weighty and perhaps unsupportable burden on the informed consent process and the choices that its subjects must make. Researchers, they say, are asking patients to step up to the gambling table and lay down their lives for science - and for a slim chance of a longer life.

It is true that as gambles go, the odds are long. Even in a scientific world whose headlines are fuelled almost entirely by serendipity and breakthroughs, the patients are playing at their own exclusive high-stakes table. The subjects who have enrolled in this trial have been told they had at least a 70-per cent chance of dying in the next 30 days.

Even now, experience with the artifical heart is far too limited to know anything about its effectiveness. The first few patients had even less information, forced to gamble on theory, intuition and trust. It’s also true that the stakes are high. Patients who enrol in this trial give up an uncomfortable but predictable existence, and a condition that is familiar to them, in exchange for the uncertainty of an entirely new technology. They may give up valuable time only to die in the operating room, alone and without his family.

So the AbioCor trial is a gamble. But is it a gamble that patients and their families es should be allowed to make? Or, if we told them they couldn’t, would we be trying to assume the role of parents for people who are old enough, and wise enough, to be parents to many of us? The question, in essence, is whether and when we should allow people near the end of life to throw everything they have down on the table, hoping and praying God and luck come through in time.

When is it foolish to gamble? This is the question at the heart of the discussion of the medical trial and one that has puzzled some of the best minds in law and bioethics. It is surprising, therefore, that the most cogent answer comes from an unlikely source.

In a country-and-western song, singer-songwriter Nanci Griffith promises that she will never be a fool, but that she will gamble foolishly. It is really a promise to herself, and it tells us a great deal about the choices that we make and those that we let others make.—Dawn/LAT-WP News Service (c) Newsday.