Bioethics Discussion Blog: "Million Dollar" Ethical Lapse of Reality

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Saturday, February 26, 2005

"Million Dollar" Ethical Lapse of Reality

I received the following e-mail from a physician, whom I don't know, but he appears to be very concerned about the ending of "Million Dollar Baby" and the ethical misinformation the public is receiving and wants everyone involved in ethics to spread his word. Since what he writes actually mirrors my own evalution of the movie which I saw, I thought it would be appropriate to put up on my blog virtually his entire e-mail communication for my visitors to read and be educated.


To all persons involved in ethics,

I hope you will help to correct a very unfortunate mistake that is
being made in the media. I hope there is time. The public's views on
end of life issues is harmed, with needless suffering for patients.

This was not a case in which euthanasia or assisted suicide had any
role whatever!

Crucial point of "Baby" missed: the patient has the right to refuse therapy!

The nation is buzzing with news about "Baby", but somehow the most
important point has been missed. Since the patient had the right to
refuse therapy, the dilemma of this movie could not happen. All
commentators are letting this simple fact fly by them.

Please, someone needs to set the record straight. Patients have a
right to refuse therapy! This movie's dilemma is not real in any
sense. The religious activists are wrong. The disability debate is
wrong. The commentators are completely wrong.

Swank's doctor should have removed the ventilator when she refused
therapy. Do you know anyone who would print my op-ed?

The public is poorly served by this very unfortunate distortion. All
persons have to live through the deaths of their loved ones, and we
all face dilemmas at the end of life. Unless the perceptions
generated by this movie are corrected quickly, the suffering of dying
patients and their loved ones will become much more difficult to bear.

I hope you can get this out to the public. Good luck!

This movie also distorts Catholic values terribly. Pope Pius XII
settled this question back in 1952.


+++++++++++++++++++++++++++++++++++++++++++++++++++++


Movie-Inspired Debate Over "Euthanasia" Is Absurd
"Million Dollar Baby" Deserves An Oscar -
But The Medical Ethics Debate Has Gone Off The Track


By James J Murtagh, M.D.

[... Note:James Murtagh has spent 20 years as Intensive Care
Unit physician at a major Southeast hospital.]

When they open the envelope for "Best Picture" at the Oscars next
week, I'll be rooting hard for Million Dollar Baby - the dazzling new
Clint Eastwood film about a woman left paralyzed after sustaining a
neck injury during a boxing match.

Because I like the movie so much, it's no fun to
report that both the film and its critics have made a major mistake:
they forgot that it's illegal for doctors to treat alert, rational
patients against their will. Somehow, the film distorts the medical
aspects of end-of-life decision-making almost beyond recognition.

Indeed, the movie's depiction of Hilary Swank's
character (the Baby) as paralyzed on a ventilator and begging a
friend to "pull the plug"- by sneaking into the hospital, turning off
her respirator and giving her a shot of adrenaline - completely
ignores the reality of routine medical ethics. Where was the
patient's doctor? That doctor had a moral, legal and religious duty
to honor the patient's wishes!

No one has to guess what Swank wants. She's not
unconscious, she's not a vegetable, she's not depressed. She's
depicted as completely rational. Which means that her wishes must be
obeyed. As a matter of fact, failing to honor a patient's
instructions for these end-of-life procedures is actually illegal -
and theoretically could result in criminal prosecution of any doctor
who insisted on keeping a patient alive artificially against the
patient's will.

Unfortunately, the medical premise of Million Dollar Baby is
dead wrong, because Baby could have refused the ventilator without a
quibble, merely by asking. Since the famous Karen Quinlan case 30
years ago, U.S. doctors have been totally prohibited from insisting
on unwanted therapy against a patient's wishes.

Pope Pius XII, himself, understood as much in 1952, when he
condemned "extraordinary means" to maintain life against the will of
patients. The major religions are in agreement. I have worked with
chaplains and rabbis of all faiths to help patients make these
decisions - and most of the priests I work with have written advanced
directives to ensure they are never placed on a ventilator against
their will.

Gray areas do arise when a patient is unconscious, however.
Difficult ethical cases come up all the time. But a rational, talking
patient could have refused the ventilator, the IV fluids, medicines,
surgery - or a dozen other treatments needed to stay alive. Is the
film really suggesting the doctors took the patient to surgery to
remove a leg, in order to save her life without her consent? Had Baby
refused the operation, she would have died from infection, and she
would have spared the Eastwood character his torment, and her own
attempt to end her life by biting her tongue.

Apparently unaware of this medical reality, the creators of
Baby came up with a thoroughly Orwellian and barbaric plot twist in
order to solve a non-existent problem - by having Eastwood sneak into
Baby's hospital room to pull the plug.

But if the movie's depiction of a typical ventilator scenario
was absurdly unrealistic, the talk-show and op-ed page debates that
have followed it seem even more ludicrous. While conservatives Rush
Limbaugh and Michael Medved huff and puff about "the sacred right to
preserve life" and disability activists protest the depiction of
Baby, nobody seems to have grasped a key fact: This is a total
non-issue in American hospitals today!

Like most ICU doctors, I learned a great deal about
end-of-life decisions during 20 years of caring for people. I do my
best to treat pain and depression in these patients, while also doing
everything I can to show them that life can be worth living. More
than once over the years, I found myself referring to the inspiring
example set by paralyzed actor Christopher Reeve, who lived a rich
and creative life on a ventilator, while also becoming a hero to
millions. Like Reeve, severely disabled scientist Stephen Hawking
and scores of other disabled Americans are honored precisely because
they've made the decision to soldier on, despite pain and obstacles.

Nonetheless, disabled patients - like all other
patients - enjoy the right to refuse therapy. Jehovah's Witnesses are
permitted to refuse life-saving blood, and all patients are free to
refuse life-saving surgery. To insist otherwise would be to
transform the ICU unit into Orwell's "Big Brother" - a tyrant who
would ride roughshod over a patient's innate right to allow nature to
take its course, and to die in dignity.

Like most people, I sometimes found myself wondering
during my earlier years: What would happen if I became severely
disabled? Would I choose to turn the ventilator off? And then it
actually did happen, several years ago. Suddenly I faced the same
questions that had confronted Reeve and many other disabled patients.
Fortunately, I recovered, but I will never forget walking in the
shoes of a critically ill patient.

Anyone walking in the shoes of severely disabled
patients would find it truly terrifying. Some states of life are
worse than death. I applaud Reeves and others who continue
life-sustaining therapy - but if any person had decided otherwise, I
certainly wouldn't have wanted medical staffers forcing tubes down
throats and keeping person's alive against their will.

As a medical doctor and a patient, I've been given a
rare glimpse into both sides of this important public issue. And
that experience has taught me a crucial lesson: We need to focus on
real problems at the end of life-and not on the boogey man!

I am very afraid that patients seeing this film will be
misled on their real options, and will wind up fearing Frankenstein
ventilators run amok.

As both doctor and patient, I urge all of us to ignore the
medical distortions contained in this film - and to treat it as an
opportunity to explore the deep and searching questions that will
face us at the end of life.


Maurice's Comments: I fully agree Where was the patients physician? Where was the ethics committee to help educate the patient and physician (and, by the way, the viewing public) on the well established ethics and law? Where was the advocate of the disabled, the rehabilitation therapist to provide the patient with factual information of what could yet be done to help her live maybe a worthwhile life if she elected not to turn off the ventilator? Where was the chaplain to support her spiritually during this difficult decision-making time and perhaps get an understanding of her religious motivations? It certainly didn't require a friend to facilitate her death if this was not a lapse of reality. ..Maurice.

7 Comments:

At Saturday, February 26, 2005 8:33:00 PM, Blogger Bioethics Dude said...

I could not agree more with the anonymous doctor's opinion, as well as the host of this blog. A book that was written about 12 years ago that also speaks to this end is First, Do No Harm by Belkin -I have no interest in the book:-) Although it discusses end of life decisions faced by both doctors, patients, and the family without getting into the ethics per se, it is easy for the reader to ponder the ethical dilemma. Million $ Baby is similar, up to the point of going of an a tangent in order to make a theatrical point. -bioethicsdude@blogspot.com

 
At Saturday, February 26, 2005 9:15:00 PM, Blogger Maurice Bernstein, M.D. said...

Bioethics Dude and my other visitors:
I don't know much about the production end of movies but it would seem to me that for the rather realistic boxing scenes, someone with teaching skills in professional boxing must have been in attendance before and during the filming to provide education to the actors. In the same vein, one would assume that there should have been a physician in attendance for technical advice regarding the medical aspects of the movie. I don't recall the scrolling credits to document this. However, if there was a physician present, I can't imagine he or she would not inform the director about the ethical standards and law associated with termination of life support. Sooo..Dude, what I am wondering, if the distorted ending was not to make a "theatrical point" but instead to make a political point. But why would that have been necessary? Can anyone suppose an explanation? ..Maurice.

 
At Sunday, February 27, 2005 12:54:00 PM, Blogger Dave Schuler said...

This comment has been removed by a blog administrator.

 
At Sunday, February 27, 2005 1:37:00 PM, Blogger Maurice Bernstein, M.D. said...

The deleted post was not a narrative but an indication that Dave linked to my blog from the Glittering Eye. You may want to take a wink at http://www.theglitteringeye.com

..Maurice.

 
At Sunday, February 27, 2005 5:12:00 PM, Blogger Jeremy said...

First, Do No Harm is an excellent book.

And I pondered the ethics of this movie while watching. I suppose I knew it couldn't happen...but darn it's a good movie.

 
At Sunday, February 27, 2005 10:00:00 PM, Blogger Maurice Bernstein, M.D. said...

First I would like to congratulate Clint on the Oscar winnings of his picture tonight. I think it was a very good movie.. but you know.. it could have been excellent and contributed constructively to the ethical education of the public and avoided the bad press of the "right to lifers" if the last part of the movie was handled differently.

Clint, may I talk to you directly here? I have thought of the best ending for your movie which would have kept the quality of the ending in keeping with the great quality of the first parts.
Keep the traumatic quadriplegia in the scenario. I think it is a realistic and emotionally important contrast to all the previous progressively upbeat winning. But.. first do away with the need for amputation without disclosing the patient's truely informed consent. Also the pictured lesion looked trivial and didn't appear, as I recall, in an anatomic area subjected to pressure.
More importantly, change the ending to a detailing of a conflict in decision-making by the patient herself.
Have her discuss the issue with her doctor. Have him be supportive and talk to her about the ethics of autonomous request for termination of life support but not directing her one way or another. Or maybe have him express to others how he feels about the position he is in... possibly having to turn off the ventilator. Have a physical rehabilitation representative present to give the patient the rehab view of the situation. Clint, you can give her loving support but you are uncertain whether she should leave you. Are you sure what is in her best interest? And how would your own interest enter into how you would talk to her about her decision? And then end the film with all the uncertainty of what she will finally decide and let the audience think it over as they leave the theater. This kind of indecisive ending might be the best mental exercise for the audience to think about the ethics and I don't think would impair the uplifting story preceeding it.

I leave it to my visitors to suggest their own endings. ..Maurice.

 
At Monday, February 28, 2005 2:05:00 PM, Blogger Bioethics Dude said...

Maurice said: "if the distorted ending was not to make a theatrical point' but instead to make a political point", I can certainly see that and agree with it. What I wonder about now if and if so, how much, of the issue of came about as a result of Clint's own meditations on end of life issues. But Bioethics Dude has a difficult time wtih ascertaining other folks's psyches.

Btw, Maurice, you can find the full credits to the move online at:

IMDB-Million $ Baby. I did't see any doctors, but then i'm note sure if this is includes acknowledgments, etc., that would be in the film.

 

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