Introduction

Decisions about life-sustaining treatment are among the most difficult in medical ethics. Advances in technology have made it possible to keep patients alive for extended periods, but at enormous financial, emotional, and moral cost. When a patient cannot express their wishes, healthcare providers, families, and institutions are left to wrestle with questions of autonomy, beneficence, justice, and the economic burden of care.

The following scenarios center on a single patient, Billy White, and highlight the ethical, legal, and financial complexities involved in determining whether and when to withdraw life-sustaining treatment.

Scenario 1: Initial Prognosis and the Ethics Committee

Billy White, a 20-year-old man, attempted suicide by overdosing on sleeping pills. His roommate found him unconscious and rushed him to the hospital. Although doctors saved his life, Mr. White sustained moderately severe brain damage and remains in the ICU on ventilator support. He left no advance directives, has no close relatives, and his roommate recalls no discussions about end-of-life preferences.

The neurologist’s prognosis suggests permanent brain damage but allows for the possibility of partial recovery. The psychiatrist believes the attempt stemmed from situational depression triggered by a fight with his girlfriend. Meanwhile, medical bills already exceed $300,000, and long-term care facilities refuse to accept him.

The hospital administrator, chief of staff, and attorney question whether to withdraw ventilator support. The chaplain argues this would constitute murder. The case is referred to the hospital ethics committee, with you serving as chair.

Questions for Discussion

1. What would you recommend, and why?

2. Should extraordinary care be ceased so the patient can die naturally? Do age, social status, or future potential matter in such decisions?

3. Should a second neurological opinion be sought? What key questions should be asked to guide the decision?

4. If Mr. White’s suicide attempt reflected his true wishes, is it wrong to let them stand? Should a psychiatric consultation be pursued to understand his motives more fully?

Scenario 2: Costs and Transfer to a Public Hospital

The ethics committee recommends continuing life support for now. Daily ICU costs average $8,000, adding $56,000 per week to the hospital’s financial burden. The administration seeks to appoint a guardian ad litem through the courts, but in the meantime, negotiates with a tax-supported hospital to accept Mr. White as a charity case.

The administrator of the public hospital notes that accepting Mr. White would force reductions in education and clinical services for uninsured, low-income patients. As chair of that hospital’s ethics committee, you must weigh in.

Questions for Discussions

1. What is your position and recommendation regarding transfer?

2. How should competing obligations to one patient versus many vulnerable patients shape the decision?

Scenario 3: Legal Status and Economic Burden

The court refuses to appoint a guardian after learning that Mr. White is an undocumented, unfunded worker living under an assumed name. He is ineligible for Medicaid. The original hospital must decide whether to continue his $56,000-per-week life support indefinitely (roughly $2.9 million annually) or withdraw care.

Questions for Discussions

1. What would you recommend to the ethics committee?

2. How would you respond to the argument that, even in war, captured enemy soldiers are entitled to medical care equivalent to our own troops?

3. Is it ethically acceptable to factor economic impact into life-and-death decisions?

Scenario 4: Physician-Assisted Suicide and Organ Donation

Physician-assisted suicide is legal in nine U.S. states and the District of Columbia, as well as in several countries, including Canada. Since 2016, some euthanasia patients in Canada have donated organs after death. Recent debate has focused on whether organ quality would improve if removal occurred while patients were still alive.

The Canadian Medical Association’s 2019 guidelines permit physicians to discuss organ donation with euthanasia patients but prohibit organ removal before the heart has stopped.

As a legislator in a state considering legalization, you must decide how to vote.

Questions for Discussions

1. Will you vote to legalize physician-assisted suicide? What ethical principles guide your decision?
2. If legalized, should physicians be allowed to raise the option of organ donation?
3. Should organ removal be permitted before the heart ceases beating to improve organ viability?

Closing Reflections

“When discussing issues in medical ethics, it is routine to mention that some particular action is wrong because it ignores someone’s rights. Or that some other action is obligatory because someone has a right to be treated in a certain way. We often become so engaged in the practical discussion that we take ‘rights talk’ for granted, without ever wondering what ‘rights’ are, where they come from, or even if they actually exist.” — Michael A. Gillette

“It [one’s decision] is not to decide simply between right and wrong and between good and evil, but between right and right and between wrong and wrong.” — Dietrich Bonhoeffer