Bioethics Discussion Blog: Role Playing Exercise: A Case of Killing vs Letting Die

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Saturday, October 14, 2006

Role Playing Exercise: A Case of Killing vs Letting Die

What does one do when a patient who has the mental capacity to make medical decision requests a physician to turn off a life-supportive treatment knowing that the act will lead to the patient’s death. One of the ethical issues is whether that act represents intentional killing of the patient or not killing but simply allowing the patient to die from the underlying illness. In this case example of the issue, you will be role-playing the physician. ..Maurice.



Mr. G. is a 34 year old unmarried man who has been a quadriplegic (unable to breathe without the respirator and unable to move his arms or legs) for the past 4 years since he was injured in a motorcycle accident. You, as the newly appointed physical therapy physician in a neurologic rehabilitation hospital have met and examined Mr. G. for the first time. He can talk during the respirator phase when he is exhaling and tells you his history. For most of the 4 years, the patient lives alone at home except for a full-time male aide who attends to his comfort, nursing care and feeding. During this time he was hospitalized about 5 times, twice for pneumonia and a few times for severe urinary tract infections which led to infection in the blood stream and required intensive intravenous antibiotics. This admission was a few days before you arrived and was for another urinary tract infection, now being treated and his fever is abated.

Mr. G. states that he was a city motorcycle officer for 8 years prior to his accident and had a girl friend whom he was hoping to marry living with him for the year before the accident. He speaks sadly about the fact that his girl friend left him shortly after he became quadriplegic and has not returned. Though at first he had understood he had a slim chance for some recovery, he states after additional tests that doctors told him that his spinal cord was completely severed and there can be no return of function. He says he has been evaluated by physical therapists numerous times in the past and has had whatever support and encouragement that they could provide but he has continued in an immobile state, spending most of his life of a quadriplegic in bed. The few hours the aide gets him up in a chair causes him to be exhausted easily. He finds his quality of life so poor that in the past year, he has decided that he no longer wants to live. He knows that if he could turn off the respirator, he would die fairly quickly but he is physically unable to perform the act himself. He has asked his aide to turn off the respirator so he could die. The aide refused. On two previous hospital admissions, he had asked the physicians in the hospital to turn off the respirator, but they too refused. He has been given anti-depressants in the past but they have not changed his demands to end his life.

Mr. G. now turns to you, as his new physician, and after relating his life story, he requests that you turn off the respirator and let his underlying illness cause him to die. As you talk to Mr. G., you evaluate his mental state you find that he is mentally clear and his understanding of the medical facts of his illness and the consequences of his request is excellent. You understand that every patient has the autonomous right to refuse unwanted treatment and to force treatment on a patient who has capacity to make medical decisions may even represent legal battery.

Mr. G. says to you “Doctor, I no longer want to live the way I have been living these past 4 years so now I want you to turn off the ventilator and allow me to die a natural death.” OK.. now you as Mr. G.’s physician must decide what to do next. …. Well, Mr. G. is waiting for your response. You can write the response in the Comment section of this posting.


(For your information, this has been a altered description of a real case. Some of the facts may be a bit different but the issue and ethical challenge is the same as the original case.)

12 Comments:

At Sunday, October 15, 2006 3:58:00 PM, Anonymous Moof said...

My response, by way of "role playing":

---

Mr. G. you know that what you're asking me is putting me, as your new physician, in a very difficult position. If I refuse, then I know that you will continue to live a life which you find burdensome ... while if I agree, I could well be throwing my own life away, since if I were tried for your death, I could lose my profession, and in turn, my own family, and everything which is dear to me.

Since I'm personally not in favor of euthanasia, I'm already not disposed to helping you in that manner. I would, however, like to discuss possible ways that we could improve your quality of life for you once you're feeling well enough to go home. I'm not at all surprised that you're depressed. That is something we may be able to do something about, however.

If, after trying to improve your life, you still insist on ending it, I will reluctantly bring your case to an ethics committee. Perhaps they will be able to find options that I haven't thought of - or a physician who would be willing to carry out your request.

I do want to remind you though ... our ways of seeing our own lives are firmly wrapped around our daily living experience. If that experience is painful, burdensome, even the best of us come to a point of wanting it to end - by whatever means. However, that doesn't necessarily mean that we want to die, but rather that we want the pain to stop, even if that means dying. Your life doesn't need to be as lonesome and "unproductive" as it appears to be at the moment. Even in your condition, there are ways to give you a fuller experience of living. Let us try to explore those avenues before you give up on life altogether.

---

I'm not very good at role playing, and I do not have the training that a physician has - so I don't see things the way a physician would.

As myself, with my own understanding, if I were a physician, I would want to try to give the patient a reason to want to continue, because with today's technology, there are ways to do so.

The person who gives the patient this wish is in far more danger of being tried for his death than he his for being tried for battery if he refuses.

Difficult stuff ...

How about about sharing how you would handle it, Dr. Bernstein?

 
At Sunday, October 15, 2006 5:15:00 PM, Blogger Maurice Bernstein, M.D. said...

Moof, thanks for a fine example of the approach one may take. By the way, you don't have to be a physician to role-play this scenario.. you just need to be human.. a thoughtful, caring human being is all that is necessary.

I should disclose that at least in the United States, if not elsewhere (folks from outside of U.S. let me know), not starting or discontinuing any treatment including life-supporting treatment on the request of a patient who has the mental capacity to make medical decisions and who has been fully informed and aware of the potential consequences to the patient's life and health by carrying out the request, does not carry any possibility of punishment for the consequences or death if it should occur. The classic example of this would be the physician following the request of the Jehovah’s Witness patient not to be transfused with blood even if hemorrhaging to death. Under this legal permission, even if one looked at the act of turning off the ventilator on Mr.G. or the act of not transfusing a JW patient at the patients request as a killing act and not one of dying from the underlying disease, the act would not be treated as a homicide. However, if a person did the same act without the explicit request of the informed patient, the act could be interpreted as a homicidal act.
For example, if somebody with malice entered a room of a patient who was being maintained on a ventilator and simply pulled the electric plug out of the wall, the act would not be considered as the patiet dying from the consequences of his or her underlying disease. It is all in the intent of the actor. ..Maurice.

 
At Monday, October 16, 2006 4:28:00 PM, Anonymous Lisa said...

I have been thinking about this one for 24 hours off and on. I am not a physician, but I am in healthcare and acquainted with bioethics. However, before my occupation, I am a spiritual seeker. And here is what I came up with based on that.
The first knee-jerk reaction would be to support euthanasia and try to think up some way Mr G could pull his own plug. Or help him to die.
But that is the easy way out. The Buddha, Christ and all great spiritual teachers say the same thing: "Do not kill." They do not say: "except when...." Therefore the most compassionate and ethical thing an individual could do would be to fire oneself as the physician, and become a friend. A friend who visits once a week and really listens and talks. A friend who enlists other visitors from social service agencies or temples and churches to do the same. A friend who does everything in her power to get this man the human and spiritual support that made Christopher Reeves decide not to suicide.
To evolve into this friend and show human compassion to this individual would be a lot more time-consuming and selfless than to pull the plug. Of course I would educate the man about the fact he doesnt have to treat the next UTI or pneumonia. By being this companion and helping the guy make more friends and get more stimulation while he is "doing time" in that body therefore is the most ethical and compassionate thing I can think of. But, as stated, not the easiest.
What do you think?

 
At Monday, October 16, 2006 5:31:00 PM, Blogger Maurice Bernstein, M.D. said...

Lisa's comment raises some interesting points for discussion. First, the concept of a empathetic physician to terminate his/her doctor-patient relationship with the patient (presumably also arranging for another physician to take over care to avoid claim of professional abandonment) and then become a friend who provides the patient presumably a kind or degree of emotional and spiritual support the physician would be unable to provide as the patient's physician. What do my visitors think about this interesting approach to the personal moral dilemma the physician may be facing?

Another issue I see raised by Lisa is when she writes:"Of course I would educate the man about the fact he doesn't have to treat the next UTI or pneumonia." Is there a difference between the refusal of possibly life-sustaining treatment for urinary tract infection or pneumonia and the patient's current refusal to continue life-sustaining ventilatory treatment? If both would lead to the desired death by the patient, would the difference be simply that the physician might consider his/her hands "would not be covered with blood" so to speak? What do you think? ..Maurice.

 
At Tuesday, October 17, 2006 7:26:00 AM, Anonymous bob koepp said...

First, Maurice is correct about competent patients having the right, both moral and legal, to make an informed refusal of any and all unwanted medical interventions. This means that in most circumstances, a physician who refuses to halt an unwanted treatment is violating the patient's right to self-determination.

That said, although I believe that choosing death can be rationally and morally justified, I also think that it rarely is so. It is my impression that many (perhaps most) of those patients who request help in dying do so because they fear that the events unfolding around them will deprive them of any control over their own destinies. Such patients might not want to die so much as to assert their control in circumstances where what is left of their lives seems to be spinning out of their control. I think that's why many of the patients who obtain prescriptions for lethal drugs ultimately die of their diseases with the drugs ready to hand, but unused.

I also think that in order to learn whether a patient is "really" seeking death, one needs to befriend that patient, to get past all the baggage of roles and expectations and engage on the deepest of personal levels. There are certainly obstacles to such humane communication that are "built into" the physician's professional role, but I don't think one actually needs to withdraw as a physician in order to overcome those obstacles. One can, I hope, be a good physician and a good friend at the same time. But I also think that if patients felt truly befriended, felt that someone else valued them and would suffer a loss when they exited this vale of tears, they would be less inclined to want to hasten the time of that exit.

 
At Saturday, October 21, 2006 12:07:00 PM, Blogger Bardiac said...

The person has made the same request multiple times, and been turned down? (I wonder if he was even given the option not to be treated for the current infection?)

Here's what I'd do. Document the request, making sure that he isn't being coerced by anyone. (The scenario already documents that he has an excellent understanding of his medical situation and that he'll die if his ventilator is shut off.)

Offer whatever palliative drugs etc. are appropriate to the situation. Offer to have a chaplain or other person(s) present if he wishes.

Turn off the ventilator. Be there respectfully while he dies.

 
At Sunday, November 05, 2006 8:36:00 AM, Blogger BuddhistValkyrie said...

Is Mr.G a candidate for any of the current, FDA-approved trials of brain-computer interfaces, external or internal (such as Cyberkinetics BrainGate)? Some of his issues of helplessness and not wanting to live seem like they're predicated upon his utter lack of control of his life - to be able to use email, change the remote control of the telly on his own, and so forth, might enhance his quality of life to the point that he would no longer wish to end it.

In addition to helping himself, one presumes that his previous life of service as a police officer would incline him towards helping others, and as a participant in a research trial, he could be bringing hope and help to a large number of people in positions similar to his own.

That said, if he's not a candidate for trial, or not inclined towards it, the physician should bring in the ethics committee in a CYA move. I suspect, though, that the committee would find Mr. G of a clear mind and having sound decision-making capacity, and advise withdrawing treatment as requested. (And were I on the committee, I would support that choice - we should not force capable adults through any medical treatment, as that way lie bad things.)

 
At Sunday, March 17, 2013 6:32:00 PM, Anonymous Anonymous said...

It sounds like Mr. G is depressed and is having difficulty adjusting to his new life. Being in that state only 4 years would tell me he is still grieving the loss of who he once was. I would also question why he is spending most his time in bed, does he not have a power chair? I think I would arrange a power chair for him, counseling and introduce him to people through (websites, groups etc.) in similar situation who lead full lives. It sounds to me like Mr. G needs to learn how to live not be helped do die.
-Lily

 
At Sunday, March 17, 2013 8:26:00 PM, Blogger Maurice Bernstein, M.D. said...

Lily, you write "Mr G needs to learn how to live not be helped to die". But "to live" is much more than "to exist". So far, he has existed. What teachings would you suggest, based on his physical condition, which educate him about him "living"? ..Maurice.

 
At Sunday, March 17, 2013 9:12:00 PM, Anonymous Anonymous said...

Well for one I would suggest he be out of bed, many quads go out on their own with a power chair and staying home in bed would be lonely for most people. I think he might want to try socializing, go see a movie, a play I know there are groups and social events for people with disabilities, online communities and there are many people who still value his life and company. I think he needs to learn that life is more than a persons abilities. Since he likes helping people he could join a cause of interest to him, he could do fundraising, he could visit with disabled children be an inspiration for them. Many people struggle with grief and depression when faced with disability, it can take years to overcome. I think he needs help to grieve and help to see he is valuable not for his "abilities" but for who he is.
-Lily

 
At Thursday, December 19, 2013 12:15:00 PM, Anonymous Anonymous said...

Lily suggests that he should follow her lead, damned his want, need, and desires.

No Lily. You're projecting. It's not your life, it's not your decision.

 
At Thursday, December 19, 2013 12:18:00 PM, Anonymous Anonymous said...

Please reference the film of a few years back, "Who's Life is it Anyway?" starring Richard Dryfess. (I don't know how to spell it.)

He portrayed the role so well, I find it hard to watch him in any other role since then.

 

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