Case #11: Medical Prognosis & Withdrawing Life Sustaining Procedures
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
In Scenario 1:
A 20-year old man, Billy White, took an overdose of sleeping pills one month ago in a suicide attempt. He was discovered by his roommate and brought to the hospital unconscious and nearly dead. Mr. White suffered moderately severe brain damage and remains in the ICU on ventilator support. There are apparently no close living relatives and the patient has left no instructions for his care. His roommate does not recall any discussions with Billy about death and dying. The neurologist finds evidence of permanent brain damage but leaves open the possibility of partial recovery. Based on interviews with Mr. White’s roommate, the psychiatrist believes the suicide attempt was due to a situational depression brought on by an argument with his girlfriend.
Mr. White does not have medical insurance. Hospital billing records reveal charges already in excess of $300,000. An attempt to transfer the patient to a long-term care facility failed when its staff refused to accept Mr. White, saying he was too sick for their facility. Because continuing care will be very expensive, the hospital administrator, chief of staff, and hospital attorney are searching for ways to move the patient out of the ICU and to have the ventilator turned off.
They ask the neurologist to review his original prognosis. The chaplain argues that turning off the ventilator would be murder and morally unacceptable should the patient die. The hospital administrator refers the case to the hospital ethics committee of which you are chairperson.
1. What would you recommend? Explain your rationale.
2. Should the committee recommend that all extraordinary care be ceased and the patient be allowed to die a natural death? Would the age, social status, or potential for making a contribution to society be a factor in your consideration?
3. Should the committee recommend that a second opinion be sought from another neurologist? Could the ventilator then be turned off if the second opinion concurs with the first? Is there a critical question you would like the neurologist to attempt to answer? If so, what is it and how will that answer drive your recommendation?
4. If the patient were in fact trying to die, would it be morally wrong to allow his wishes to be carried out? Might a psychiatric consult be advisable to help the committee understand the situational factors that may have motivated Mr. White?
Let us assume that the hospital ethics committee recommended that the life support be continued for the present time to allow for the possibility that the patient may regain consciousness. Meanwhile the life support care for the patient is continued at the cost of $8,000 per day, (in 2013 the cost of daily life support ranged from $2,000 to over $10,000/day depending on hospital location and medical conditions) an additional cost to the hospital of $56,000 per week. The hospital administration has agreed to refer the matter to the courts for appointment of a guardian ad litem who can make decisions for a patient unable to make decisions for himself or herself.
The hospital administration also begins negotiations with the local tax- supported hospital for transfer and care. Its administrator points out that if the hospital takes Mr. White as a charity patient, it will have to cut some educational and clinical services for the low-income families and persons who have no health insurance. You are the chairperson of the ethics committee of the tax-supported hospital. In committee deliberations, what would be your position and recommendation? Explain your rationale.
Mr. White’s case has been referred to the court for an appointment of a guardian. However, since the patient is found to be an undocumented, unfunded worker (under an assumed name) living in this country, the court would not appoint a guardian. Mr. White is not eligible for Medicaid. Therefore, the hospital which originally admitted the patient is faced with the dilemma of whether to continue life support while faced with a weekly cost of $56,000 ($2,920,000 annually) or remove the life support and possibly have him die. What will be your recommendation and explanation in discussions with the hospital ethics committee? If in your discussion, a member of the ethics committee reminds the group that even in warfare, enemy military when captured are to be provided medical treatment equivalent to that provided our own military, what would be your response? Is it “wrong” to consider the economic impact of decisions when life and death issues are involved?
8/10/04: H. Bell; 2/27/09 revised by M. Witmer, & H. Radest; 9-15-10; revised by David Quast, 8/7/19
Physician-assisted suicide is legal in nine U.S. states (California, Colorado, Hawaii, Maine, Montana, New Jersey, Oregon, Vermont and Washington) and the District of Columbia. It is also legal in several countries, including Canada. Since 2016 about 30 euthanasia patients in Canada have donated organs after death. In the New England Journal of Medicine, two Canadian researchers and a Harvard bioethicist argue that in order to improve the quality of donated organs, euthanasia patients should have the option to elect to have their organs removed while alive. In other words, the euthanasia patient would be killed by removing his/her organs in order to improve the quality of the organs to be transplanted. On June 3, 2019, the Canadian Medical Association issued guidelines for organ donation by euthanasia patients, stating that organ removal should not begin until the patient is medically deceased and the heart has stopped beating. It did; however, permit doctors to raise the question of organ donation with euthanasia patients.
You are a member of a state legislature that has not approved physician-assisted suicide that is to vote on a bill to permit it in your state. How will you vote? What ethical principles do you use? If you vote to approve physician assisted suicide would you permit doctors to suggest that patients consider organ donation? Would you permit organs to be donated prior to the point when the heart ceases to beat?
8/7/19: David Quast