The Growing Trend Toward Involuntary Euthanasia

By Jenny Nolan, Legislative Assistant
NRLC Department of Medical Ethics

On January 12, 2001, an elderly California man with Alzheimer's disease fell in his home and broke his hip. He was taken to a nearby hospital, St. John's Health Center, where doctors determined that he would need surgery to insert a pin, a plate, and screws to repair the injury in a procedure that would take little more than an hour.

Four years earlier, the Alexian Brothers Hospital in San Jose, California, had issued its policy on "non-beneficial treatment." Under the guidelines any treatment or testing other than comfort care would be denied to patients like this elderly man, who suffered from "terminal illness with neurological ... or other devastating disease." Further, cardiopulmonary resuscitation (CPR) was strictly forbidden for patients with severe, irreversible dementia.

Fortunately, this particular elderly man was Ronald Reagan and he was taken to St. John's Health Center, where surgeons were more than willing to treat him. On January 20, 2001, Mr. Reagan went home, seven days after his successful hip surgery. His doctors reported that his recovery was quick and his appetite hearty.

One wonders what might have happened to Mr. Reagan had he been brought to the Alexian Brothers Hospital instead. Would the hospital have denied Reagan's hip surgery based on his "terminal" Alzheimer's diagnosis?

[Clinically, Alzheimer's is defined as a terminal disease, although patients can and do live with it for many years.]

If the surgery had been agreed to, but followed by complications, would the hospital have refused at that point to provide CPR?

Since its inception, the pro-life movement has been strongly committed to protecting the lives of vulnerable older people and people with disabilities from euthanasia. Policies like the one described above, which deliberately deny lifesaving medical treatment to patients because of their disabilities, amount to involuntary euthanasia. Doctors make these life-and-death decisions based on their own personal views about a good "quality of life," but they are sometimes in direct opposition to what the patient and family want.

Sadly, such policies are becoming more prevalent year by year, fueled in no small part by advocacy articles published in prestigious medical journals. Much of the most damaging discussion revolves around an increasingly elastic definition of medical "futility."

For example, one definition is that care is futile if it does not offer sufficient likelihood of producing a "meaningful" existence. The danger arises when it is the physician who decides what constitutes a "meaningful" existence for that individual.

Just this past fall, the Cambridge Quarterly of Healthcare Ethics reported on a 1998 conference in San Diego that drew 74 doctors, judges, clergy, and other community representatives. The participants met to critique the "futility" policies of 26 California hospitals and to discuss conflicts in end-of-life treatment, namely cases in which patients and families desired life-sustaining care that health care professionals wanted to refuse.

The authors of the article, Lawrence J. Schneiderman and Alexander Morgan Capron, strongly asserted that the medical profession should have this right of refusal in some circumstances, and sought to minimize judicial interference. In these situations of conflict the authors advised that doctors would "get better legal results when they refuse to provide nonbeneficial treatment and then defend their decisions as consistent with professional standards than when they seek advance permission to withhold care."

The policies of the hospitals studied at the conference demonstrate that many health care facilities have already adopted this attitude. Twenty-two of the 24 futility documents specifically defined circumstances in which treatments should be considered nonobligatory, even if requested by the patient or the patient's representative.

Fourteen hospitals described conditions that would not warrant life support on the grounds that the patient was not aware enough to appreciate the benefit. One can't help going back to the former president and wondering whether he would be considered aware enough to qualify for treatment to continue to live his life or not.

The issue is not requiring doctors and nurses to provide physiologically futile treatment: treatment that, in reasonable medical judgment, cannot preserve a patient's life. Health care professionals, not patients and families, have the necessary training, experience, and knowledge to make technical medical judgments concerning what treatments are or are not likely to be life-sustaining.

However, what makes the California policies so alarming is that they cover a much broader range of circumstances than physiological futility. Indeed, their point is to draw a line between patients who should and should not live, based largely on intellectual capacity, though all of them can live. In the cases discussed at the 1998 conference, the medical treatment in question was likely to preserve the patient's life. The root of contention was that the health care providers did not deem the quality of that life to be worth living.

Schneiderman and Capron explained, "[A] judge who orders that a severely disabled child be kept alive rarely sees firsthand the long-term consequences of that decision, which remain a continuing vivid experience for the health professionals who must provide care for the child."

This is a value judgment, not a medical judgment, and it clearly ignores the fact that the child who seeks to live and the child's family members who seek to defend their child's right to life will experience a far more first-hand impact of a decision for the child's life or death than will the health care personnel. A medical degree does not convey a right superior to that of a patient or family to decide whether someone who can live should be allowed to continue doing so.

The authors' perspective is also inconsistent with the 1991 statement of the American Medical Association's Council on Ethical and Judicial Affairs: "These determinations, which attempt to define...the qualities of existence that constitute a benefit for the patient, undermine patient autonomy because they are based on the value judgments of someone other than the patient. [They] are appropriate only if the patient is the one to determine what is or is not of benefit, in keeping with his or her personal values and priorities."

The California policies are by no means the first attempts to deny life-sustaining measures to patients and families who request and would benefit from them. After a 1996 medical journal article revealed that Houston-area hospitals were implementing policies allowing for the refusal of lifesaving treatment in spite of the patients' or families' wishes, then- Governor George W. Bush vetoed a bill that would have had the effect of ensuring legal protection for such policies.

As a result of his strong stand on the 1997 bill, Texas Right to Life was invited by a number of Texas medical groups to participate in a series of negotiations beginning in 1998 to develop a new version of the legislation, negotiations in which now-President Bush's staff played an important role. These negotiations resulted in a Texas law Bush signed in 1999.

This measure required that a health care facility must provide lifesaving treatment until a realistic opportunity has been afforded for transferring the patient to another physician or health care facility willing to comply with the choice for life. Furthermore, laws and policies that deny medically effective treatment desired by the patient or family on the basis of a health care facility's negative view of the patient's "quality of life" discriminate against people with disabilities and therefore violate the Americans with Disabilities Act and other federal law.

It is vitally important that we in the pro-life movement determine whether our local hospitals have such "futility" policies, and if so, demand that they be modified. No policy should attempt to authorize what is illegal and discriminatory denial of lifesaving medical treatment based on a person's " quality of life" or disability.