Is This Nurse a Killer? Examining the Ethics of Withdrawing Life-Sustaining Treatment

The case of Mary, a nurse charged with murder for disconnecting a ventilator

Is This Nurse a Killer? Mary a nurse at a city hospital was charged with murder for disconnecting the ventilator of a comatose patient. The patient was a 48 year old man. We will call him Henry Gift. Mr. Gift was a former cab driver who had been hospitalized with bladder cancer, cirrhosis of the liver and pneumonia. He had suffered heart failure while in hospital and had stopped breathing. It was claimed during the nurses trial that he would have died in any case within hours. When she was asked during the trial if she disconnected the ventilator she stated, “Yes, after I felt he had no pulse and no blood pressure”. Later when asked again why she did it, she stated “I was trying to act in the best interest of the patient. I felt helpless. I don’t know exactly why I did it”. At another point she was quoted as saying, “I only do it to GORK’s (Patients for whom God only really knows whether they are alive)”. Others commenting on Mary’s actions observed that if they were in the place of Mr. Gift who had a terrible array of fatal conditions they would not have wanted further life sustaining treatment. They would have wanted their venitlators turned off. One critic of the Mary stated, “she was not willing to just wait for him to die, she had to kill him. She murdered him”. Testimony was introduced during the trial that Mary had spoken in favour of mercy killing in cases of comatose patients who had little or no hope of recovery. Was disconnecting the machine a “mercy killing?” Was it morally different from simply failing to resuscitate Mr. Gift when he had his next ventilatory arrest? Commentary Something seems very wrong with Mary’s action. Was the problem here that Mary had crossed the line between the decision to let the patient die and active killing? We have seen that even for reasons of mercy, active killing is illegal. It is morally condemned by many, but not all. She disconnected a ventilator, the result of which was the death of her patient. Should that be classified as active killing? Traditionally, many clinicians have thought of withdrawing treatment as a kind of action. If the withdrawal resulted in the death of the patient, it would then be considered active killing. Withdrawal of treatment requires an action. Switches must be thrown; tubes must be removed. Psychologically, the nurse or physician engaging in the withdrawal of an ongoing medical treatment might feel like he or she is taking an action. On the other hand, those outside the clinical setting have tended to classify withdrawing treatment as more akin to not starting treatment in the first place. Part of this argument is pragmatic. Ongoing treatments can be viewed as the continual repetition or administration of individual units of treatment. An indwelling IV supplying continuous medication is akin to repeated injections. A ventilator is akin to continual compressions supplying air. Stopping a treatment is like deciding not to supply the next dose. Moreover, almost any ongoing intervention is stopped from time to time—to place a new line or to clear an airway, for example. If it is deemed unacceptable to stop a treatment in order to let the patient die but acceptable not to start it again once it has been stopped, we could simply wait until that moment when the intervention has been discontinued and then exercise the option of not restarting. There seems to be no significant moral reason to go through that fiction. Moreover, if it is policy that treatments can be omitted, but once begun, they must be continued, there would be a strong incentive to refuse to start procedures. This would be true even if, as in Mr. Gift’s case, when they were begun it would have been imprudent to have omitted them. Some of those who favor classifying withdrawing treatment as more akin to not starting it ask that we examine the moral basis of the right of refusal of treatment. It rests, in part, on the principle of autonomy, which gives people the right to consent or refuse to consent to treatment. The decision to forgo treatment follows from the right of persons to be left alone. The person with authority for Mr. Gift’s care would have the right to refuse treatment when that judgment is plausibly in Mr. Gift’s best interest. The authority to make that judgment, however, does not imply the right to have Mr. Gift killed. The principle of autonomy could never be used as the basis for authorizing someone else to actively kill another person. Some people have concluded that if there is a moral principle of the sanctity of human life, it does not extend to all decisions to omit life-prolonging treatments. They are not considered active killings, which can remain morally prohibited. The President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research reached a similar conclusion. It says, “Neither law nor public policy should mark a difference in moral seriousness between stopping and not starting treatment” (2010). Still, it appears that Mary did something wrong. If she did not engage in an action that can be thought of as being the same as actively killing Mr. Gift, then has she committed no moral offense? One possible response is that, even though she withdrew a ventilator and that withdrawal is morally akin to omitting, there are circumstances when it is morally wrong either to withhold or withdraw treatment. In some cases, forgoing treatment can even be the equivalent of murder. Withholding or withdrawing food from a starving, but otherwise healthy child for whom one is responsible would be an example. If Mr. Gift’s case were such a circumstance, Mary might be guilty of murder by forgoing treatment. It is clearly wrong for health professionals (nurses or physicians) to forgo treatment when there is a presumption in favor of treatment and the patient or agent for the patient has not decided to refuse treatment. The presumption in favor of treatment is present in Mr. Gift’s case. There is no evidence that he had refused the ventilator nor that he had a relative or anyone else speaking for him who had refused the treatment. Had he offered such a refusal, forgoing treatment would have been plausible, but without it there is an abandonment. In this case, it was an abandonment that resulted in death. Those who follow this line of argument might conclude that even though withdrawing a ventilator is morally like an omission and, therefore, is as morally acceptable as omissions, it is wrong to forgo life-prolonging treatment when the patient or agent for the patient has not refused the treatment. The alternative way of accounting for our intuition that Mary did wrong is simply to classify what she did as an active killing. That would mean, however, that withdrawals of treatment even upon the refusal of the patient would also be so classified. QUESTIONS: 1. Do you think Mary is guilty of Murder? Why or Why not? Support with literature. 2. Would you have viewed Mary’s actions differently with Mr. Gift had asked to be disconnected from his ventilator in advanced directives? Why or Why not? Support with literature.