Aiding and Abetting a Suicide?
OK..as a segue from my last posting and as a followup on a topic I have mentioned on this blog previously, here is a real case with which I had experience.
A lady in her 30s, in jail for a prostitution charge, hung herself in the jail cell. She was brought to the hospital still alive but with severe brain damage due to the prolonged lack of oxygen to the brain before she was found (anoxic encephalopathy). The patient, of course, was comatose and couldn’t communicate and was kept alive by breathing by means of the ventilator and blood pressure sustained by IV medications. When the family arrived at the hospital the neurologist told them that the prognosis was grim and if the patient survived at all she would be severely handicapped. The family decided to have the physicians stop the life support and allow her to die. The hospital, however, was concerned that by turning off the life support, the act might be interpreted as aiding and abetting a suicide, an action which was against the hospital’s religious directives. So.. if you were the ethicist called in for consultation, what would you have advised the hospital? ..Maurice.
posted by Maurice Bernstein, M.D. @ 9:07:00 AM
10 comments
10 Comments:
Dr. Bernstein, this isn't quite the same thing as your previous post, I don't think.
"The patient [...] was kept alive by breathing by means of the ventilator and blood pressure sustained by IV medications [...] the family decided to have the physicians stop the life support and allow her to die."
At this point, I don't think the cause behind how she came to be in that state matters. What were they going to do, keep her body alive artificially until ... ?
The family made the decision, I assume it was done with no outliers, and that was a legal absolution for the hospital removing the life support.
I honestly don't see what their concern was - they weren't abetting anything. The deed was already accomplished. The family, who had a legal right to make a decision, had done so. I believe that whoever had religious qualms about it was failing to see that they were already well beyond the point of the hospital itself having any way to influence the outcome.
However - I'm aware that I'm ony seeing an outline of the issue.
Moof, I intentionally posted this case to contrast it against the simulated case I posted previously. In the current case, there was no past history for the patient. Unlike the previous case, the patient was unable to make her wishes known except that by hanging herself she demonstrated that she intended to kill herself. In the previous case, taking of pills in a place where the victim could be found and rescued may represent and attraction getting act. Finally, the patient in this present case was no longer in the emergency room where intention to treat is the main and default action. The patient was now hospitalized in the intensive care unit on the ventilator and instead of the physician having the sole moral decision to make, it was now the hospital who had to defend their religious directives. The hospital's first concern was that, if they stopped resusitative treatment, they would be allowing the original act of attempt suicide to continue to it's conclusion whereas if they continued energetic treatment the patient might not die, therefore caring for the patient but without aiding or abetting the original act. ..Maurice.
Dr. Bernstein, I'm afraid that I must confess to feeling like a dull student. There is a connection which I feel I must be overlooking.
What I don't understand is why the hospital felt that way in view of her condition (severe brain damage) and the decision of her family (stop the life support and allow her to die.)
Wasn't it really, as we've discussed in other venues, the family's decision at this point?
Moof, it was the hospital's concern that the religious directive against aiding and abetting a suicide was not to be violated. I am not sure that simply arguing that it would be acceptable for the patient's "severe brain damage" to trump a clear religious directive against assisting a suicide would be a satisfactory response. One would have to present a case or explanation, beyond reminding the hospital about the clincal state or a family directive, to overcome the concern. In other words, specifically why, if the patient dies as the immediate result of terminating life-support treatment, would this not qualify as actually assisting the original attempted act by the patient? There is a better logical and ethical argument that can be given and indeed was given to the hospital which settled the issue. I wanted to see if my visitors could come up with that argument. Any takers? ..Maurice.
I don't see how actions undertaken in the hospital could be construed as "of a piece" with this woman's attempt to kill herself -- anymore than saving the life of somebody who then goes out and commits a murder would make hospital staff complicit in murder. Actions are usually individuated by their intent, and allowing somebody to die is hardly the same as intending to hasten their death.
Bob, yes I think you are using the right word to establish whether the hospital is aiding and abetting: "intent". There was no intent on the hospital's part to involve itself in supporting a suicide attempt. But there was an even more significant argument that was part of the resolution of the hospital's concerns. And that was to establish when the act of attempted suicide was completed. The ethical argument presented to the hospital was that the act itself ended in the jail cell. By the time the patient was found, transported to the hospital, with life support treatment continued was after the act of an attempted suicide was already completed (the act was then over)and the hospital's actions were providing the established and expected standards of medical care including continuing resusitation. When the family, after consultation with the neurologist, requested the life-support to be discontinued because of the unhopeful prognosis, the request was considered medically appropriate because it was consistent with the medical opinion that further energetic treatment would not lead to restoration and rehabilitation. Her subsequent death would be part of an establish legal and ethical removal of life support. It was explained to the hospital an example of how the hospital would be aiding and abetting an attempted suicide: by having placed that chair, the patient may have used in her attempt, in the empty jail cell. ..Maurice.
The hospital's responsibility is a medical one. This questions would not have come up if instead of hanging herself, the patient was in her condition due to some accidental reason. It is the prognosis of severe brain damaged that is guiding the process, not the method by which she reached her current state.
I think that it is tempting to use periphreal information to influence our advice and decision making. While additional information about a person's past can be very useful and informative, it can be very dangerous. The fact the the woman attempted suicide does not seem relevant in light of her current circumstance. It is not her past, but her potential future that is of interest in this decision making process.
Alyssa, I agree with your first paragraph. While, in the second paragraph, I might challenge your view that in this attempt suicide patient her past history "does not seem relevant". When a patient with no capacity to make a decision has no advance directive to guide in end-of-life medical decision making, then any information about the patient's past may be important to consider. Thus, one may interpret her suicide attempt as an indication of what she considered as her quality of life at the time and perhaps in the future. Now, of course, it also could be that her act tells nothing of her view of her future quality of life, but was mainly due to a significant psychiatric depression or some sudden irrational self-destructive motivation. However, since understanding what the patient might accept as a quality of life as part of others making her medical cecision, then looking at what has transpired in the past can be relevant. ..Maurice.
Dr, Mo~
Well put.
I didn't think that her condition was completely irrelevant, but rather, not the lynch pin in whether or not the hospital removed treatment. It seems that the hospital in question was prepared to continue treatment in accordance with its own interests, rather than the overall picture of the patient. The patient's suicidality is a factor in her case, but is by no means the only factor.
Alyssa, the hospital was in a dilemma.. and that is why they involved the ethics committee. The dilemma was either to follow the religious directives as the hospital understood them and as they were morally compelled to do, vs following a decision based on the clinical prognosis for the patient, supported by the family. It was a conflict of these two interests. ..Maurice.
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