Ethicist, finding herself in the oft-decried quandary where no
ethicist likes to dwell, has borrowed a tip from the playbook of a
fellow journal editor: reader empowerment! Facts, background, and
opinion galore follow on a distressing case. Then over to you for
the tough part: deciding on the matter.
Robert Wendland, now 49, was
severely injured in 1993 in a car accident .
For 16 months after the accident, he was in a coma. He is no
longer comatose, nor in a persistent vegetative state, but is
“minimally conscious,” in the words of Ronald Cranford, MD, a
professor of neurology affiliated with the Center for Bioethics at
the University of Minnesota. Wendland is incapable of
communicating, remains hospitalized in California, and receives
artificial nutrition through a feeding tube. Doctors believe he
has no hope of further recovery.
Once, after Wendland pulled out
his feeding tube, his wife, Rose, who is his conservator, and
children decided not to replace the tube if it became dislodged
again, and thus to let him die. They reached this decision, with
the approval of the hospital ethics committee, based in part on a
conversation Rose and Robert had had about disconnecting Rose’s
father from life support. Robert, according to his wife, expressed
a wish never to be kept alive on tubes.
California law allows a
conservator to decide whether to withhold treatment, based on
clinical advice and consideration of the patient's previously
expressed wishes. But when Robert's mother learned of Rose's
decision, through an anonymous tip from someone at the hospital,
she went to a court, which blocked the removal of the feeding
tube. The judge ruled that Rose had not provided “clear and
convincing evidence” that Robert wanted to die. Rose's lawyers
have argued that this standard is too high, and that the state
requires only that the conservator be acting in good faith, based
on medical advice.
The case turns on the questions of
whether Robert Wendland should be considered truly conscious, and
what his wishes would be were he able to express them. Legal
decisions until now have allowed termination of nutrition and
hydration only in cases in which the patient was terminally ill or
unconscious; Wendland is neither. He did not have an advance
directive, so the only “proof” of his wishes is his wife's
recollection of their conversation. The case has now gone to the
California Supreme Court.
Lined up on Rose’s side of the
case are the American
Civil Liberties Union, the California
Medical Association, and some 40-odd bioethicists. On the
other side are Florence Wendland, Robert’s mother, and his
sisters; advocates for the disabled, the elderly, and people with
Alzheimer’s disease; and abortion opponents. Florence
Wendland’s supporters see this case as a watershed, and fear
that a decision to stop nutrition and hydration for Robert will
open the floodgates to withdrawing treatment in other conscious
but disabled patients.
Before you reach your own decision
about what should be done in this case, a few more considerations
may muddy the waters. The standard in law and ethics over the past
few decades has been that competent adults have the right to
determine what happens to their own bodies, including the right to
refuse treatment. Robert isn't competent, so that doesn't help.
Right-to-life groups have argued that nutrition and hydration
aren't “treatment,” and that withdrawing them is different
from withdrawing artificial respiration or intravenous medication.
Ethicists have consistently rejected this argument, but there is
little question that the provision of food and water has an
emotional charge greater than any other “treatment.”
In the best of all possible
worlds, Robert would have had an advance directive that clarified
his wishes, and failing that measure, that his family would have
been able to agree among themselves on his best interests. But as
my old undergraduate philosophy professor used to say, “Sadly,
this is not the best of all possible worlds.”
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