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 whether doctors should take the wife of a stroke patient to court over continuing life support.
Should the doctors go to court to overrule the wife’s decision?
And now, bioethicist Jacob M. Appel, MD, JD, weighs in:
From the 1970s to the 1990s, most end-of-life conflicts between families and hospitals involved cases where the family wanted to withdraw life support and the medical facility objected. These families often fought public battles through the court system in the hopes of letting their loved ones die “naturally.”
Over the past two decades, the disagreements between families and providers have increasingly been reversed: in a series of high-profile disputes, hospitals have sought to withdraw life support in cases of supposed medical futility, while families have fought to keep their loved ones on ventilators. Among the earliest and best-known of these cases was that of Helga Wanglie, an 86-year-old Minnesota woman in a persistent vegetative state whose doctors wanted to withdraw care over her husband’s objections. (A court ultimately ruled for her family, but she died anyway 2 days later.)
In 2005, ethicist Lachlan Forrow, MD, of Boston’s Beth Israel Deaconess Medical Center told the New York Times: “About 15 years ago, at least 80% of the cases were right-to-die kinds of cases. Today, it’s more like at least 80% of the cases are the other direction: family members who are pushing for continued or more aggressive life support and doctors and nurses who think that that’s wrong.”
These cases can prove extremely costly for the healthcare system. Helga Wanglie’s final years of medical care, for instance, reportedly carried a price tag of $800,000 in 1991 — or about $1.5 million today.
The motives for keeping patients on life support past the point of “futility” vary greatly. Some families hold out hope, often irrationally, that their relatives will recover.
Yet the media intermittently reports precisely those sorts of miraculous tales: On the day that the family of 56-year-old Nebraska mother Teri Roberts planned to turn off her ventilator in 2015, the toxic shock syndrome patient awoke from her “irreversible” coma. Car crash victim Terry Wallis woke up in 2003 after nearly two decades. Canadian woman Annie Shapiro fell into a coma on the day John F. Kennedy was assassinated in 1963 — and woke up suddenly in 1992!
Other families recognize that their relatives will not improve but have religious or cultural reasons for refusing to terminate care, as in Alexander’s case; his prognosis for recovery is not relevant to his wife’s decision-making process.
State laws vary on whether hospitals can ever overrule families in these cases. Texas affords providers the greatest power in the area. Under the Texas Advance Directives Act (better known as the Texas Futile Care Law), hospitals can withdraw life support from patients when such care is deemed “futile,” once certain procedural safeguards are met. Among the first patients affected by the law were infant Sun Hudson and terminal cancer patient Tirhas Habtegiris.
Scenarios like the conflict between Alexander’s wife and his physicians can often be prevented. Had the hospital’s medical team discussed with the couple in advance the precise circumstances under which life support would be withdrawn, and emphasized the societal costs of keeping patients with no prognosis of recovery on life support, it is always possible that Alexander might have accepted these terms; alternatively, the hospital might not have offered him the biventricular assist device at all. Like many cases in medical ethics, these issues are best addressed before the fact — rather than after tragedy strikes.
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.
Check out some of our past Ethics Consult cases:
Potentially Hasten Baby’s Death to Ease Suffering?
Genetic Testing for Potential Employees?
Add Lithium to Town’s Drinking Water?