Public Health Law Map - Beta 5 - Medical and Public Health Law Site

Few termination of life-support cases present irreconcilable ethical problems.
[Weir RF, Gostin L. Decisions to abate life-sustaining treatment for
nonautonomous patients: ethical standards and legal liability for physicians after
Cruzan. JAMA. 1990;264:1846–1853.] Most of the patients involved are going to
die relatively quickly, irrespective of treatment. All but a few of the rest will be
condemned to a persistent vegetative state, which they have previously rejected as
unacceptable. Family members may have personal psychological reasons to resist
the termination of life support. These are not compelling, however, because of the
patient’s inability to contribute either personally or financially to family life.
Unlike refusal of curative therapy, there is no compelling ethical basis for a
physician or hospital to resist the termination of essentially futile treatment. Once
treatment becomes both ineffective and unacceptable to the patient, society’s
interest is to preserve its resources for other patients. [Callahan D. Setting limits:
Medical goals in an aging society. Washington, DC: Georgetown University Press;
1995.]
This leaves a residuum of hard cases, cases such as that of Hector Rodas. Rodas
suffered an accidental brain injury that left him mentally competent but otherwise
totally dependent on life-support technology. He could neither speak nor swallow.
He could respond to yes or no questions by nodding his head, which allowed him
to spell out messages with the help of a therapist pointing to letters on a board. By
this means, Rodas requested that he no longer be fed or hydrated. The hospital
required Rodas, through his lawyer, to seek a court order discontinuing life
support. The court ultimately ruled that Rodas could refuse nutrition and hydration
while remaining in the hospital. [Miller DH. Right to die damage actions. Denver
Law Rev. 1988; 65:184.]
The physicians and the hospital in this case were reluctant to terminate treatment
without a court order, but it is difficult to imagine a court refusing Rodas’s request
to be allowed to die. According to Mishkin, [Mishkin DB. You don’t need a judge
to terminate treatment. J Intensive Care Med. 1990;5:5201–5204.] allowing Rodas
to die without a court order is certainly legally proper. Considering the
prolongation of Rodas’s suffering caused by the court action and his extremely
limited prognosis, it may be more than merely legal. In cases such as this one,
where none of the stakeholders other than the patient has a compelling interest, the
delays and suffering inherent in judicial process make such a course of action
ethically questionable.
5. Living Wills in the Emergency Room
A patient who presents in an emergency room is presumed to be there for all
necessary medical care. Patients who are conscious and able to make their wishes
known may refuse unwanted medical care. But a living will should not be taken to
forbid resuscitation efforts in the emergency room. Without knowledge about the
patient, the physician should not assume that the document belongs to that patient or
that it reflects the patient’s wishes in that situation. However, at the same time that
the resuscitation is being attempted, someone should try to clarify the status of
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