Who gets to make end of life decisions?

This is currently being debated by our neighbors to the north, where a situation is unfolding involving the family of an 84 year old man on a ventilator and the hospital/medical staff currently treating him.

Background:

Samuel Golubchuk is an 84 year old Orthodox Jew who suffered brain injury and multi-organ failure, and was at some point admitted to the hospital and hooked up to a ventilator. Many times when we imagine a brain-injured person hooked up to such a machine, we (as a lay person) assume that they can’t breathe on their own – note that this is certainly not always the case, and that mechanical ventilation is often provided to people who are merely having difficulty breathing and need some assistance until they get better. Sometimes people can be removed from ventilators, and sometimes they are so sick that it is one of the only things keeping them alive. Before the advent of mechanical ventilators, death was usually based upon the heart – when your heart stopped beating, you were dead. But now we have so many ways of keeping the body alive, that death (from a medical point of view) is based upon brain function – you are dead when you no longer have meaningful brain activity. It all gets confusing when you add the various terminology including vegetative state, persistent vegetative state, etc where a person’s body appears alive, but clinically/medically they are defined as “dead.” For simplification, it is enough to know that Mr. Golubchuk is not (based on what I’ve read) clinically brain dead – he is merely very sick, and at the age of 84 this is never a good sign. He may not die immediately, but certainly the odds are not in favor of his living for much longer.

Now, enter into this picture the Canadian health system, and the doctors it employs. The hospital treating Mr. Golubchuk, having decided the prognosis is not favorable, wants to remove his ventilator and “hasten his death.” Though not stated directly, we must look at this as a case of resource rationing – the system only has so many ventilators available, and it would be a more efficient use of resources to give the ventilator to someone who has better odds of surviving (e.g. a younger patient).

Enter Mr. Golubchuk’s family – they argue that his condition has been improving, and that he has even regained consciousness. As Orthodox Jews, it is against their religious beliefs to remove the ventilator – plus the patient had signed an advance directive specifically saying that he wants to be kept alive. Says Prof. Shimon Glick, a leading Israeli medical ethics expert:

“From a halachic point of view, removing a feeding tube from a patient who has any brain function is active euthanasia, equivalent to murder… But here, in addition, unless the patient has specifically indicated by advance directive that such is his desire, one has a violation of the patient’s autonomy, as well.”

Alright, so enough background – what do you think should be done in this situation? If you were paying taxes to support such a system, is it fair for your money to be spent on someone who has a small chance of recovery at the expense of other people who might benefit more? If you were in that situation, would it be fair to have your beliefs and specific wishes (as indicated on a legal document) trumped by a physician who has decided the plug should be pulled?

There is no easy answer in this case, given the public funding of the health care system. Many people (in the US at least) seem to think that a national health care system would solve all of our problems, but it really should be seen as a trade-off. Some people gain access into a system that was previously unaffordable, but in the process you lose a (significant) degree of liberty. For me, a libertarian, this is unacceptable. I do not want a doctor, hospital, or government official dictating my health care choices. I don’t want to be “rationed” according to someone else’s belief system. In fact, this quote from Dr. Jeff Blackmer (executive director, office of ethics, for the Canadian Medical Association) scares the bejeezus out of me:

“Our viewpoint is that we want to make sure that clinical decisions are left to physicians and not judges…These decisions are not made lightly and they’re not made in haste, and they’re not made with anything except the best interest of that individual patient at heart.”

The only person who has the patient’s best interests at heart is the patient! And if the patient is incapacitated, as in the case of Mr. Golubchuk, it should defer to his legal wishes or immediate family.  From the standpoint of an American hospital, this situation is baffling. Certainly we have end-of-life issues as well, but rarely of this sort. From the perspective of the Canadian health system, however, the case may be rare but is unlikely to be unique (particularly when you consider our rapidly aging population). How many times each day must difficult decisions be made within such a system as to who gets what test/procedure/equipment, and who doesn’t? I’m not saying the US system is perfect (far from it!), but our way of”rationing” is very different. Americans who favor a single-payer national health system need to think carefully about situations such as these. How much of your individual decision-making abilities are you willing to hand over to a stranger? It will be interesting to see what the Canadian judge decides in this case (I believe it is scheduled for sometime this week).

~Lily

Sources:

Insure Blog – “A troubling conundrum

Jewish Post (1/7/07) – “Canadian judge to rule on Jew facing euthanasia

Retuers (UK – 12/14/07) – “Canadian life-support case pits religion vs. science

2 Comments

  1. Jamelle said,

    January 10, 2008 at 3:15 pm

    I do not want a doctor, hospital, or government official dictating my health care choices. I don’t want to be “rationed” according to someone else’s belief system.

    I don’t have much of an opinion on this yet, but it is worth nothing that in the United States, you will be “rationed according to someone else’s belief system” except that instead of it being done by bureaucrats, it’ll be by “market forces.” The trade-off isn’t between rationing and freedom, it’s between the type of rationing and the degree of fairness.

    And by the way,

    Good to hear from you! It’s been awhile since you’ve posted.

  2. Lily said,

    January 10, 2008 at 3:31 pm

    Thanks for the comment! I was on winter break, so spent much of it traveling and away from a computer and internet access…nice to know I was missed. 🙂

    And I agree with your statement – certainly we have “rationing” in the US, but it is done by a person’s ability to pay rather than the ethical views of a stranger (which I suppose would be a better choice of words on my part than “belief”). I wouldn’t say one is inherently more “fair” than the other, but just that they are based upon different moral frameworks. Some people value collectivism more than individualism or vice versa, and I think different health care systems reflect these views in varying degrees.


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