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Do hospitals give up on severely impaired patients too soon?
By Sandy Caspersen And Nancy Valko
Editor's note: Following an operation in March 2000 to relieve pressure on the brain brought on by a cyst, Steven G. Becker, 28, of suburban St. Louis, was diagnosed as being in a "persistent vegetative state". In late May, Becker's wife, the attending physician, and St. John's Mercy Medical Center decided to end assisted nutrition and hydration (administration of food and water by feeding tube). Becker's mother sued to stay that decision and to require continued health care. A hearing on the matter is scheduled in mid-September.
Nancy Valko, R.N., was contacted by Sandy Caspersen, the aunt of Steven Becker, and together they wrote the editorial below which appeared in the St. Louis Post-Dispatch. At the demand of the Commentary Page editor, they deleted all references to Catholicism ("too narrow"). The Post-Dispatch "balanced" this pro-life editorial by another by Father Kevin O'Rourke, an influential St. Louis ethicist who gained national prominence in the Nancy Cruzan case, in support of her parents who wanted their daughter's food and water discontinued. Father O'Rourke opposes continuing nutrition and hydration for disabled patients who seem unlikely to recover full "cognitive function". In his view, food and water delivered by feeding tube is not "ordinary care" that we are obliged to give every disabled patient, even if full recovery seems dim.
THERE are many ways to kill a sick or disabled person. Removing food and water is only one.
Since Steven Becker's March operation to relieve pressure on his brain, discussion has revolved around eliminating food and water, provided through a tube into his digestive tract. This medically assisted food and water was correctly called "comfort care" in records at St. John's Mercy Medical Center before the decision was made to end his life. Now the hospital -- as well as the media -- calls it "life support".
But St. John's and its ethics committee have also decreed that other treatments -- antibiotics, other beneficial medications, physical therapy and a possible operation to correct his now-infected brain shunt -- can also be denied to Becker even though the legal process is still proceeding.
Becker has been deemed by his doctors to be in a "permanent vegetative state", defined as "awake but (assumed) unaware". That diagnosis is disputed by at least one other doctor. But pain medications and muscle relaxants, which can cause sedation, are among the few treatments that may be provided. Why would a supposedly unresponsive person even need pain medication?
With the kind of "death ethics" mentality promulgated by the hospital's ethics committee, it isn't surprising that even Becker's hygiene has suffered. When family members have offered to help by bathing him themselves during their visits, their requests for washcloths were unmet, and family members now bring their own.
It is outrageous that St. John's ethics committee can sanction the denial of beneficial treatment, which had helped Becker progress and fight infection, while continuing Becker's feedings until a September hearing only because of a court order.
Is this where the "right to die" has brought us?
Becker's case must be setting a speed record for such public cases, but this ignores the studies and news reports showing that many severely brain-injured people eventually recover -- sometimes even fully recover -- with time and treatment.
Some members of the family asked for this time for Becker. However, the ethics committee decided that he would not make a good enough recovery. Becker's wife, Christie, has accepted its recommendations to end his life. Other family members were then offered similar counseling to induce them to accept the recommendations and thus avoid controversy, but they resisted. Now Becker's fate will be decided by a judge.
Becker never chose this situation. He had taken courses toward a possible career as a nurse. The court-appointed guardian's report stated that because he was medically sophisticated enough to understand ethical dilemmas and had allegedly made comments that he wouldn't want to live like people in other public "right to die" cases, this constituted "clear and convincing" evidence that he would rather die than potentially live with severe disabilities. However, some members of his family say that, even after he had consulted with a neurosurgeon and knew brain surgery was being considered, he adamantly refused to sign a living will or other advance directive. If he had signed such a directive, this would have made his wishes known about refusing treatment if he were unable to speak for himself.
Becker's wife supposedly disputes this incident now, but the fact remains (and the hospital record proves) that he did not sign an advance directive, which the law required he be offered. This should confirm that he did not choose to refuse treatment even though he was aware of the possibilities. This refusal is his last known health-care decision, so why should alleged comments from years ago be considered more persuasive?
What does it take to refuse the "right to die"? We all should be asking this question.
With the push to contain costs, coupled with multi-million-dollar malpractice suits when a person survives but is disabled, we must also be alert to an inherent conflict of interest when a hospital's ethics committee urges withdrawing or limiting necessary care. Also, doctors and nurses have the right and the responsibility to resist a "death ethics" mentality and protect their most vulnerable patients who cannot defend themselves due to age, disability or mental impairment.
Steven Becker isn't the first person to face death by denial of basic care -- despite refusing to sign a living will or other advance directive.
But, please, let him be the last.
Editor's note: for a follow-up on Steven Becker's story, click here.
Nancy Valko is president of Missouri Nurses for Life, and writes "Bioethics Watch" for Women for Faith & Family. (The above editorial is reprinted with the permission of the author.)
Taking a stand against causing death, March 2,2005
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