Welcome to Ethics Consult -- an opportunity to discuss, debate (respectfully), and learn together. We select an ethical dilemma from a true, but anonymized, patient care case, and then we provide an expert's commentary.
Last week, you voted on if it was ethical to withdraw life-saving treatment if siblings can't agree.
If the siblings cannot agree on what to do, should the doctors continue with the aggressive antibiotic treatment or stop it and let Clarence die?
Continue treatment: 70%
Stop treatment: 21%
Other: 9%
And now, bioethicist Jacob M. Appel, MD, JD, weighs in with an excerpt adapted from his book, .
Questions surrounding when to halt aggressive care and to remove life support did not surface frequently in medicine until the 1970s, when new technologies -- from ventilators and dialysis machines, to more powerful antihypotensive agents and antibiotics -- made it possible to prolong the lives of the critically ill as never before. Right-to-die cases that entered the public discourse, such as those of Karen Ann Quinlan (1954-1985) and Nancy Cruzan (1957-1990), resulted as much from improved medical care as from any change in ethical norms.
Clarence's case raises two distinct issues that often arise in contemporary medical ethics: how to weigh "sanctity of life" against "quality of life" and what to do when an incapacitated patient's wishes are unclear and family members cannot agree.
Advocates for upholding the sanctity of life believe that human life has intrinsic value and should be preserved at all costs. Historically, many religious conservatives have adopted this position. In contrast, critics of this standard argue that, under some circumstances, the quality of a person's life drops so low that aggressive care or life support no longer makes sense. At their extremes, both positions prove highly controversial.
Utilitarian philosopher Peter Singer, a strong champion of the quality-of-life position, has used it to justify euthanasia for disabled infants. The entire nation saw the extremes that sanctity-of-life advocates adopted to keep Terri Schiavo alive in 2005 over the objections of her husband and her own reported wishes.
One should note that under ordinary circumstances, these two values are not in conflict: doctors are usually laboring both to prolong a patient's life and to improve its quality. Ethicist Dan Callahan has noted that there is an imbalance between these two standards: "sanctity of life" leads to minimal ambiguity, while the minimum quality of life one might be willing to tolerate varies greatly from person to person.
Advance directives, such as living wills and healthcare proxies, which spell out one's wishes long in advance of illness, are designed to address this subjectivity. Yet such documents raise the question of whether a healthy person can predict with accuracy what he or she would want if one became critically ill, without having already experienced such an illness. Patients are frequently known to "bargain down": to adjust their standards to accept a lower quality of life than they would have when healthy, once they actually find themselves in a more impaired condition.
The purpose of appointing a healthcare proxy is to empower an agent to act on one's behalf if a person can no longer make medical decisions. Healthy people are advised to discuss their end-of-life wishes with their proxies. In the absence of a proxy, nearly every state enables a so-called "surrogate," often a closely related family member, to make decisions for the patient. State laws provide for hierarchies of surrogates: usually, spouses take precedence over adult children, followed by parents, siblings, collateral relatives, and sometimes even close friends.
When two or more surrogates of equal rank cannot agree -- as with Clarence's sisters -- states vary widely in how to resolve the disagreement. Some, like New York and Maryland, refer the case to a committee of experts to address the matter, which may ultimately end up decided in court, while West Virginia lets the doctors choose which surrogate has the stronger claim based on such factors as perceived knowledge of the patient and degree of concern. In cases with an odd number of potential decision-makers, some states allow for a majority vote.
The challenge of cases like Clarence's is that nobody can predict whether he will thrive or suffer in his new condition. A closely related set of cases involve patients who wake up on ventilators after enduring C2 level spinal cord injuries that render them lifelong quadriplegics who will remain permanently dependent on machines to breathe. When these patients awake from medically induced comas or sedation, they often demand (via computerized eye trackers) that their ventilators be shut off, insisting they would rather die than live in their impaired conditions.
In these cases, the patient is expressing a clear wish -- but one that may be compromised by shock or depression. One of the most contentious disagreements in many hospitals surrounds how long such patients should be compelled to remain on life support over their objections, often suffering existentially during this time, while psychiatrists and therapists attempt to help them adjust to their new lives.
Jacob M. Appel, MD, JD, is director of ethics education in psychiatry and a member of the institutional review board at the Icahn School of Medicine at Mount Sinai in New York City. He holds an MD from Columbia University, a JD from Harvard Law School, and a bioethics MA from Albany Medical College.
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