Commentary on Case of Mr. Smith John Z Sadler, M.D.
Professor of Psychiatry
Daniel W. Foster, M.D., Professorship in Medical Ethics
UT Southwestern Medical Center
Mr. Smith is a homeless man with severe alcoholic cirrhosis, no family, and no
financial resources. He is dying from his medical problems and is now in the
hospital requiring intensive treatment and multiple blood transfusions. The
medical and surgical treatments available now can only prolong his dying, not
save his life. The question is about what kind of humane dying process is ethical.
Sometimes, even often, medical ethics has to settle for not what is good, but
what is the least awful option. Mr. Smith’s case is one of these. A happy outcome
is not possible here. We have to find the most decent outcome.
There are three general options.
1) Continue to prolong Mr. Smith’s life, and dying, through the current program of
providing aggressive treatment including blood transfusions.
2) We could withdraw or withhold current life-sustaining treatments, and continue
to give Mr. Smith ‘comfort care,’ which is focused on keeping him comfortable
and respecting his dignity as a person as he passes.
3) Give Mr. Smith, some, but not all, life-sustaining treatments. Let’s consider
each in turn.
Continue current treatments (option 1). Given that the doctors, regardless of what
treatment they offer, cannot save Mr. Smith’s life, one might wonder what value
the current life-saving treatments offer to him. He’s going to die anyway, so
what’s the point?
However, every moment of life is precious, and so from that standpoint we might
want to continue his treatment. While we recognize that life is precious, in the
abstract, we have to ask ourselves is it likely that Mr. Smith is enjoying life in
some way, or any way, in his present, apparently miserable condition?
The answer here is almost certainly no, in that he is in a coma, one which he is
unlikely to recover from before he dies. So given the limited (at best) benefits of
treatment, we should see if the treatments provided to Mr. Smith somehow affect
other people, who may have a ‘stake’ in the issues.
It turns out that providing less-than-beneficial care to Mr. Smith might well have
an impact on others. For example, one of Mr. Smith’s problems requires frequent
blood transfusions.
Blood is always a scarce resource in the nation’s hospitals; it is routinely required
in scheduled surgery as well as in the treatment of accidents and other traumatic
injuries associated with blood loss. Mr. Smith’s need for blood has a potential,
and occasionally real, impact on the care of people whose transfusions could
save lives. Given the potential for blood to save the life of people who are not
dying, and who could receive great benefits from transfusion, it seems difficult to
justify giving repeated transfusions to Mr. Smith given that he will die soon
regardless.
The financial costs of treating Mr. Smith must be considered, however painful or
unfair it seems for us. Mr. Smith is likely cared for in a community hospital, like
Parkland in Dallas, where funding is limited. When you have many poor and
uninsured people to serve, it would be irresponsible to the community to not
consider the cost of care, because using limited resources wisely is a
requirement for making the best use of them, and helping the most people who
can benefit from those scarce resources.
In this regard, the need for a frankly scarce product like blood makes this case a
little easier, in that the need for limiting end-of-life care is explicit, so that blood
can be saved for use with other patients who can benefit much more.
For these reasons, I would favor withholding further transfusions and provide
comfort care to Mr. Smith (option 2), allowing his diseases to take their course,
and for Mr. Smith to have a more natural death.
The option (3) has not been considered yet. The difficulty with this option is
choosing which treatments to provide, and how to justify their value. As Mr. Smith
is slowly bleeding to death from untreatable causes, it’s unclear to me what
benefit other treatments would have, other than comfort care for him (pain
control, baths, dental care, spiritual care if the patient is responsive). Comfort
care would always be provided to him under option (2).
What is often as important, or even more important, than ‘what’ you do in similar
difficult end-of-life cases is ‘how’ you do it. American physicians are trained to
treat every human life as equally valuable - so with this ethic, whether Mr. Smith
is poor and homeless or Mr. Smith is the president of a major corporation should
make no difference in how his care is planned or regarded.
This is often difficult to do in the case of U.S. health care, where “health
disparities”-- unequal treatment-- is so common when we compare the insured
with the uninsured. I would want the discussion of withdrawing life-sustaining
treatment to be made with family, and with chaplain or religious support suitable
to the patient’s beliefs.
Moreover, serious decisions involving end-of-life care should always be medical
team discussions in concern with the patient and family - if possible. If the patient
is unable to participate, and no family is available, pastoral care services in
hospitals, as well as ethics consultation services can participate in these tough
decisions.
In cases like that of Mr. Smith, too often the soul of end-of-life care falls to the
nurses who will care for him in his dying hours, and I’ve been lucky to witness
extraordinary compassion on the part of nurses in caring for dying patients who
had literally no one else. So I’ll end this brief essay with a salute to nurses, who
are the heart and soul of medicine.