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Refusing Life-Sustaining Treatment after Catastrophic Injury: Ethical Implications

Published online by Cambridge University Press:  01 January 2021

Tia Powell  and
Bruce Lowenstein
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Extract

In theory, a competent patient may refuse any and all treatments, even those that sustain life. The problem with this theory, confidently and frequently asserted, is that the circumstances of real patients may so confound us with their complexity as to shake our confident assumptions to their core.

For instance, it is not the case that one may always and easily know which patients are competent. Indeed, evaluation of decision-making capacity is notoriously difficult. Not only may reasonable and experienced evaluators, say a judge and a psychiatrist, disagree, but also a person's capacity may change from hour to hour and may extend to some decisions yet not to others. And yet it is on this subtle art of capacity evaluation that life and death decisions often turn, especially when patients decline life-sustaining treatment.

An evaluation of capacity may consider the impact of serious medical or psychiatric illness, as well as the patient's life circumstances.

Type
Article
Information
Journal of Law, Medicine & Ethics , Volume 24 , Issue 1 , Spring 1996 , pp. 54 - 61
Copyright
Copyright © American Society of Law, Medicine and Ethics 1996

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References

Quill, T.E., “Death and Dignity—A Case of Individualized Decision Making,” N. Engl. J. Med., 324 (1991): 691–94; Block, S. Billings, A., “Patient Requests for Euthanasia and Assisted Suicide in Terminal Illness,” Psychosomatics, 36 (1995): 445–57; Chochinov, H.M. et al. , “Desire for Death in the Terminally Ill,” American Journal of Psychiatry, 152 (1995): 1185–91; and Sullivan, M. Youngner, S., “Depression, Competence, and the Right to Refuse Lifesaving Treatment,” American Journal of Psychiatry, 151 (1994): 971–78.CrossRefGoogle Scholar
Shapiro, J., “No Less Worthy a Life,” in Shapiro, J., No Pity: People with Disabilities Forging a New Civil Rights Movement (New York: Times Books, 1993): Ch. 9; Michel, V., “Suicide by Persons with Disabilities Disguised as the Refusal of Life-Sustaining Treatment,” HEC Forum, 7 (1995): 122–31; and Ridley, B., “Tom's Story: A Quadriplegic Who Refused Rehabilitation,” Rehabilitation Nursing, 14 (1989): 250–53.Google Scholar
Patterson, D. et al. , “When Life Support is Questioned Early in the Care of Patients with Cervical-Level Quadriplegia,” N. Engl. J. Med., 238 (1993): 506–09.CrossRefGoogle Scholar
For further discussion of Bouvia, see: Annas, G., “When Suicide Prevention Becomes Brutality: The Case of Elizabeth Bouvia,” Hastings Center Report, 14, no. 2 (1984): 20–21; Annas, G., “Elizabeth Bouvia: Whose Space is this Anyway?,” Hastings Center Report, 16, no. 2 (1986): 24–25; and Kane, F., “Keeping Elizabeth Bouvia Alive for the Public Good,” Hastings Center Report, 15, no. 6 (1985): 5–8.Google Scholar
Cruzan v. Director, Missouri Dep't of Health, 497 U.S. 261 (1990).Google Scholar
Satz v. Perlmutter, 362 So. 2d 160 (Fla. App. Ct. 1978), aff'd, 379 So. 2d 359 (Fla. 1980); and In re Requena, No. P-326-86E (N.J. Super. Ct. Ch. Div. Sept. 24. 1986), aff'd per curiam, No. A-442-86T5 (N.J. Super. Ct. App. Div. Oct. 6, 1986). For amyotrophic lateral sclerosis, see In re Farrell, 108 N.J. 335, 529 A.2d 404 (N.J. 1987). For locked in syndrome, see In re Rodas, No. 86PR139 (Colo. Dist. Ct. Jan. 22, 1987), modified, (Colo. Dist. Ct. Apr. 3. 1987). All above cases are cited in Bernat, J. et al. , “Competent Patients with Advanced States of Permanent Paralysis Have the Right to Forgo Life-Sustaining Therapy,” Neurology, 43 (1993): 224–25.CrossRefGoogle Scholar
Maynard, F. Muth, A., “The Choice to End Life as a Ventilator-Dependent Quadriplegic,” Archives of Physical Medicine and Rehabilitation, 68 (1987): 862–64.Google Scholar
Id. A C1 lesion is an injury sustained to the upper part of the spinal cord. The injury results in quadriplegia and ventilatory dependence.Google Scholar
Ridley, , supra note 2.Google Scholar
Thobaben, J.R., “The Case of Mr. Sims,” HEC Forum, 7 (1995): 94–109.CrossRefGoogle Scholar
Report of the Ethics and Humanities Subcommittee of the American Academy of Neurology, “Position Statement: Certain Aspects of the Care and Management of Profoundly and Irreversibly Paralyzed Patients with Retained Consciousness and Cognition,” Neurology, 43 (1993): 222–23.Google Scholar
Caplan, A. Callahan, D. Haas, J., “Ethical and Policy Issues in Rehabilitation Medicine,” Hastings Center Report, 17, no. 4 (1987): S1–S20.CrossRefGoogle Scholar
Id. at 12.Google Scholar
See, for instance, Kliever, L., ed., Dax's Case: Essays in Medical Ethics and Human Meaning (Dallas: Southern Methodist University Press, 1989).Google Scholar
Rosenberg, E. Karides, D., “An Interview with Dax Cowart,” JAMA, 272 (1994): 744–45.Google Scholar
Charlifue, S. Gerhart, K., “Behavioral and Demographic Predictors of Suicide after Traumatic Spinal Cord Injury,” Archives of Physical Medicine and Rehabilitation, 72 (1991): 488–92.Google Scholar
Statistics cited from Blumenthal, S., “Suicide: A Guide to Risk Factors, Assessment, and Treatment of Suicidal Patients,” Medical Clinics of North America, 72 (1988): 937–71.CrossRefGoogle Scholar
Lee, M. Ganzini, L., “Depression in the Elderly: Effect on Patient Attitudes Toward Life-Sustaining Therapy,” Journal of American Geriatric Society, 40 (1992): 983–88.CrossRefGoogle Scholar
Sullivan, Youngner, , supra note 1.Google Scholar
Quill, T. Cassell, C. Meier, D., “Care of the Hopelessly Ill: Potential Clinical Criteria for Physician Assisted Suicide,” New Engl. J. Med., 327 (1992): 1380–84; and Powell, T. Kornfeld, D., “On Promoting Rational Treatment, Not Rational Suicide,” Journal of Clinical Ethics, 4 (1993): 334–35.Google Scholar
Patterson, et al. , supra note 3.Google Scholar
Hopkins, M., “Patterns of Self-Destruction among the Orthopedically Disabled,” Rehabilitation Research and Practice Review, 3 (1971): 5–16.Google Scholar
Anon, “Behind a Boy's Decision to Forgo Treatment,” New York Times, June 13, 1994, at A12.Google Scholar
Stone, A., “Psychiatry's Undiscovered Country,” American Journal of Psychiatry, 151 (1994): 953–55.Google Scholar
Bowe, F., Handicapping America (New York: Harper and Row, 1978), as quoted in Longmore, P., “Elizabeth Bouvia, Assisted Suicide and Social Prejudice,” Issues in Law and Medicine, 3 (1987): 141–68.Google Scholar
Gardner, B.P. et al. , “Ventilation of Dignified Death for Patients with High Tetraplegia,” British Medical Journal, 291 (1985): 1620–22.CrossRefGoogle Scholar
Humphrey, D. Wicket, A., The Right to Die: Understanding Euthanasia (New York: Harper and Row, 1986).Google Scholar
Pence, G., “Elizabeth Bouvia and Voluntary Death,” in Classic Cases in Medical Ethics (New York: McGraw-Hill, 1990): Ch. 2.Google Scholar
Coles, R., The Moral Life of Children (Boston: Houghton Mifflin, 1986).Google Scholar