“Million Dollar Baby”: A Physician’s Ethical and Legal Analysis

Definitions are important if the terms are going to be used in a rational argument about an issue. I bring this up because I have seen the misuse of the terms “euthanasia” and “assisted suicide” with regard to the controversy about the ending of “Million Dollar Baby”. I would like to explain the words as physicians and lawyers and ethicists use them today.

Euthanasia means essentially a easy, good and painless death. The way this term is used in modern practice is that as a beneficent action to a acutely or chronically ill patient, a person, most likely a physician, hopefully on the request of a patient who has the mental capacity to make a life and death decision, will administer a lethal chemical, for example, into the patients body and cause the death. I would like to stress two points. One is why I wrote “hopefully”. Euthanasia is unlawful in the United States. Euthanasia as performed in the Netherlands is legally tolerated but only on the request of the patient. However, there are many reports from that country suggesting that this procedure is being carried out on incompetent adults and children. The other point is that the death which occurs with euthanasia is not caused by the patient’s underlying illness but by the action of the person administering the chemical. If any person attempts euthanasia in the United States, as I understand it, the act may represent a homicide regardless whether the patient approved the act. As an example, March 26, 1999, a jury in Michigan found Dr. Kevorkian guilty of second-degree murder and delivery of a controlled substance, for administering a lethal injection to a Thomas Youk, an ALS sufferer.

Assisted Suicide term as used in the United States is a death by the administration of a lethal dose of barbiturates, for example, by the patient themselves. The act that makes the suicide assisted is that the prescription for the lethal dose was written by a physician. The patients themselves decide when or even whether to take the pills and the physician is usually not with the patient when the patient takes the pills. Assisted Suicide is illegal in every state of the United States except the state of Oregon. There, the physician has to meet a set of criteria to issue such a prescription to a patient requesting to die. The assistance is in the form I noted above and not by providing the patient with a gun or other means to self-inflict death. I am not sure if there is the same uniform penalty in all states regarding a physician who is found to have assisted a suicide in the states other than Oregon. Perhaps some lawyer visitors here can answer that.

In the case of “Million Dollar Baby” what Clint Eastwood’s character did was to personally, as a non-physician, facilitate the death of a patient who requested death but was physically unable to perform the act. Unfortunately an explanation of exactly what he did is complicated by the fact that Clint's character first turned off the ventilator and though he was doing this at the request of the patient, the order for the ventilator was written by a physician and a physician must write an order to discontinue the unwanted treatment. If Clint’s character or any family member went into an ICU and pulled the plug of the ventilator out of the wall on their own, this might well represent manslaughter or a homicide. In addition, Clint’s character did not perform the termination of ventilator life-support as per the standard of medical practice which is to provide sedation by barbiturate or tranquilizer or narcotic just prior to removal to reduce the chance that the conscious patient would suffer the terrible discomfort of suffocation caused by the rapid accumulation of carbon dioxide in a person who is not breathing and before death occurs because of lack of oxygen. Now if a patient dies when, in clinical practice, the life-support is removed, the death can be ethically and legally considered as the patient dying from the underlying disease that led to the life-support. If the death is accelerated by the administration of the sedation medication, it is ethically accepted as the “double effect” principle (See the ADDENDUM below for criteria) since the intent of the administration of the medication was to relieve suffering from the suffocation with a drug known to relieve suffering and the acceleration was possibly expected but NOT intended. However, Clint’s character administered a dose of adrenalin which pharmacologically would not be expected to sedate but to accelerate or cause death and if the intent was to accelerate death or cause death to prevent suffering then the “double effect” principle would not pertain and the patient’s death might not have been due primarily to shutting off the ventilator.(Read the ADDENDUM below and decide for yourself if all the criteria for "double effect" were met.) Was this act euthanasia? Possibly. Would it be legal in the U.S.? No. Homicide in the U.S.? Possibly. Was the act assisted suicide? Not by definition. Unfortunately there was no legal determination since Clint’s character just walked out of the room and left the hospital and the story with no communication to the nurses on duty or the doctor. An unethical and unlawful ending to a tragic story that could have been made simpler, ethical and lawful by the carrying out of medicine’s long established and standard operating procedures for termination of unwanted life-support treatment. ..Maurice.

ADDENDUM: What are the criteria for "Double Effect"? All the following 5 conditions must apply to the act:
1) The Act is GOOD or MORALLY NEUTRAL
2) Only the GOOD effect is intended
3) The GOOD effect is NOT achieved through the BAD effect
4) There is NO ALTERNATIVE way to achieve the GOOD effect
5) There is a PROPORTIONALLY GOOD reason for running the risk