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Before he wakes.

Professor C, 85, is a retired English professor. He never married and now has few interests besides classical music and his beloved cat, Tosca. He has a friend in the English Department, Professor E, who visits at least once a week to make sure that he and Tosca are all right. He also has a brother, B, who lives in a nearby town, but he usually sees him only once a year, at Christmas.

In early May, Professor C has a heart attack and is admitted to the hospital, where Professor E joins him. The cardiologist, Dr. H, recommends a cardiac catheterization, a diagnostic surgical procedure that permits the physician to see exactly which blood vessels are blocked. Professor C agrees but worries about Tosca. He tells Professor E, "You'll think I'm a foolish old man, but you don't know how much that cat means to me. If I'm dying, don't let me die here. All I want is to go home and be with Tosca." During the catheterization, Professor C suffers another, more massive heart attack. The surgical team stops the procedure and, with Professor C's consent, performs a double bypass. He is then admitted to the Cardiac Intensive Care Unit (CICU) to recover.

Several years previously, Professor C signed a standardized form giving his brother durable power of attorney for his health care. The form says B is "to make care, custody, and medical treatment decisions for me in the event I become unable to participate in medical treatment decisions." It also directs that "my life not be prolonged by lifesaving measures if my condition is determined to be terminal and incurable or if I am diagnosed as being in a persistent vegetative state."

By mid-May Professor C's heart still performs well below its normal function. He drifts in and out of consciousness due to drugs he is taking. His condition puts great stress on his kidneys, which also begin to fail. Then, in the third week of May, just as his kidneys start responding to treatment, his lungs succumb to pneumonia. On June 1 he has serious difficulty breathing and is put on a respirator for a 72-hour period to be stabilized. At the end of that time he fails a lung function test.

On June 4 Professor E decides Professor C should be taken off the respirator and allowed to die. B is willing, and together they approach Dr. H. Dr. H disagrees, pointing out that Professor C isn't dying. His kidneys are doing much better--in fact, his urine output is back to normal. The pneumonia is clearing up, too, so there is no question of multiple organ failure. Besides, Professor C did consent to bypass surgery, which is a lifesaving measure, so he might want other lifesaving measures as well. Dr. H proposes a tracheotomy so that the breathing tube will be more comfortable and suggests inserting a PEG tube. He would also like to eliminate the drugs that keep Professor C in a stupor so that he can be awakened and asked what he would like the treatment team to do.

Professor E worries that if Professor C wakes up, he might consent to treatment because he is so sick, and that he would then improve just enough to have to end his days in a nursing home, unable to care for Tosca. To spare him that, Professor E wants to let him to die now, before he gets better.

What should be done for Professor C?


by Hilde Lindemann

As Professor E is Professor C's friend and the estranged B is willing to go along with what she decides, we need not let the fact that she has no legal standing as his proxy worry us unduly. What might worry us, though, is that it looks as if Professor E would rather let Professor C die than allow him to make what she regards as the wrong decision. By all that's bioethically orthodox, hers is the height of presumption. How does she know what Professor C would have chosen for himself?. Who is she to take away the chance that he might regain his autonomy?

To make Professor E's viewpoint morally intelligible, we must overthrow the belief that life is always better than death. In a culture of highly medicalized, drawn out end-of-life care, life can be an ordeal of suffering, invasive treatments, and loneliness, while death is a welcome respite. Professor C certainly seems to fear some ways of living more than he fears death.

As his proxy, Professor E is looking after what Ronald Dworkin would call Professor C's critical interests--interests that he, while competent, endorsed as worth pursuing because satisfying them was what made his life good. Guided by the advance directive that expresses those interests, and in the reasonable belief that although he isn't dying, he is "incurable," she requests that "extraordinary treatment or lifesaving measures" be stopped. Dr. H, on the other hand, champions Professor C'S occurrent, experiential interests, taking his patient's consent to lifesaving bypass surgery as an indication that he may have changed his mind about what he wants. From the narrative tissue that forms her sense of who he is, Professor E has not discarded the stories that depict her friend before he became ill, while Dr. H puts most of the narrative weight on the present moment.

The best way to resolve this disagreement would be for Professor C himself to tell us. If he woke and said he has changed his mind about the quality of life he's now prepared to tolerate, that would seem to settle the matter. After all, it's his life: he's the one who has to lead it or let it go. Shouldn't Professor E want to join Dr. H in giving him a chance to say what he'd rather do?

Not if she thought that simply waking him up wouldn't produce a trustworthy answer. It's true that on rare occasions, people radically depart from the stories that used to represent their lives, but when that happens (in a religious conversion, for example), friends, colleagues, and intimates who participated in the practices of narrative recognition keeping a person's identity in play will raise questions about the departure. They will wonder if he's lost his senses, knows what he's doing, is self-deceived or lacking proper self-awareness, or is simply mistaken. And if, as both B and Professor E seem to think, the identity-constituting stories consistently represented one sort of person for eighty-five years, an abrupt narrative shift under the duress of critical illness raises even greater skepticism about the trustworthiness of the new stories.

If the default presumption in favor of life no longer makes sense, then requests for life-sustaining treatments can raise the same kind of suspicion that refusals of such treatments routinely do. I argue that they do raise suspicion, especially if the patient made it very clear while of sound mind that this kind of treatment was not welcome. Isn't Professor C's possible change of mind far more likely to come from fear, the beating his body has taken, or the frozen thinking produced by his sudden loss of control, than from a settled conviction that all his life he's been mistaken about the things that matter most?

If what concerns Professor E is not that Professor C might say the wrong thing if he woke up, but rather that a change of mind is itself an indication that he is no longer capable of making his own decisions, then in allowing him to die she is faithfully fulfilling her responsibilities as his proxy.


by Daniel Callahan

One of the enduring and perhaps permanent puzzles in critical care medicine is when, exactly, a patient "dies." One might say that it is when one or more major life-sustaining organs fail, thus dooming the body as a whole. A century ago that might have been a workable definition--call it the ancient definition. Then along comes technology, complicating what had once been relatively simple. Now the question is not just what happens to major organs, but also what medical technology can do to arrest the body's decline.

In a study of attending physicians some years ago, the medical anthropologist Barbara Koenig and a colleague found that dying was, in effect, defined as that situation when available technology can no longer keep a patient alive. Death is not something going on in the body, but a function of whether technology can sustain it--call that the modern definition of dying. One might, in the same vein, define falling as a function not of gravity but of whether there is anything to stop the falling object.

Professor C had earlier said that he wanted no "lifesaving measures" if he is "determined to be terminal and incurable." Many diseases of aging, however, are "incurable"--most notably heart disease, which can be controlled but usually not eliminated. But the fact that a patient cannot be cured does not necessarily mean he is dying. Dr. H seems to believe that his patient can be cured, or at least that some of the conditions his patient suffers from can be. Implicitly, then, Dr. H also believes that his patient is not dying, clearly using the modern definition. He believes whatever bad things are happening to Professor C'S organs can either be cured (his pneumonia) or put on hold (his heart disease), at least enough to keep him alive. However, Dr. H doesn't mention whether he can be weaned from the breathing tube or the feeding tube. While Professor C may not be dying, he is obviously in bad shape. It is hard to imagine a long-term favorable prognosis, or that his chances of spending much time with his cat in the future are good. Nonetheless, he does not appear to have passed a point of no return.

I am inclined in this case to give the benefit of the doubt to Dr. H, allowing him to stop the heavy sedation, presumably bringing Professor C back to a state of competency so that he can make his own decision. But had he not already made a decision earlier? Is that not what an advance directive is all about? Yes--but it is not wholly evident that his present medical state quite fits his own earlier specifications (a common enough problem with advance directives). He is the only one who can decide whether they do, and he may be able to do so.

As for Professor E's concern that her friend might, once awake, consent to treatment "because he is so sick," two points can be made. One of them is simply to note that it is not unheard of for patients to consent to treatment when they are very sick, even if they had earlier thought they would not want to do so. The other is to say that Professor E's line of argument is close to that famous reasoning of children who refuse to eat their carrots: "No, I won't try the carrots. If I tried them, I might like them. But I don't like them."
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Title Annotation:case study
Author:Lindemann, Hilde; Callahan, Daniel
Publication:The Hastings Center Report
Geographic Code:1USA
Date:Jul 1, 2005
Previous Article:Realbioethik.
Next Article:Doctors of interrogation.

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