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Correction
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Patterson et al.,
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This approach represents a breach of respect for patients' autonomy. Patterson et al. reject the application of the principle of autonomy in the early phase because "the result may be the premature death of a person who could have lived a happy and productive life." The issue is not whether patients who would otherwise have died can be found to be leading productive or acceptably happy lives. Freedom, if it is to be taken seriously, must include the freedom to make good and bad decisions. As Engelhardt has stated, "It is not medicine's responsibility to prevent tragedies by denying freedom, for that would be the greater tragedy"2.
Physicians and their patients ought to pursue meaningful dialogue over a period of time. The period should be determined mutually. The dialogue should not be imposed by external sources. After that interval, a physician who overrides the patient's decision is disrespectful of the patient's autonomy. Meaningful dialogue may not be achievable in a period of days, but two years is obviously excessive. To breach patient autonomy until the patient "makes the right choice" is at best paternalistic, if not Orwellian.
Lainie Friedman Ross, M.D., M.Phil.
Yale University
New Haven, CT 06520
References
David H. Johnson, M.S., M.S.N.
University of New Mexico School of Law
David Bennahum, M.D.
University of New Mexico School of Medicine
Albuquerque, NM 87131
Lawrence B. Lehman, M.D.
Coney Island Hospital
Brooklyn, NY 11235
Although no one can assure new patients with quadriplegia that restorative therapies will become available in their lifetime, it is equally true that no one can honestly tell them that such therapies will not be developed.
Dundas I. Flaherty
3749 Malibu Vista Dr.
Malibu, CA 90265
Coincidentally, the article on early life-support decisions in the care of patients with cervical-level quadriplegia appeared in print the day before our class discussed these issues. In their otherwise excellent coverage of the topic, the authors appear to have incorrectly cited their eighth reference,2 which they include among citations of "published accounts of patients with high-level cervical injuries who have been granted permission by the courts to discontinue life support." In fact, this study does not deal with that important topic. Rather, the study by Gardner and colleagues explores subsequent attitudes among such patients and their caring relatives vis-a-vis the decisions that had been made to place the patients on a ventilator instead of allowing them to die. The fact that most patients and relatives indicated that they had subsequently been glad that health care providers had decided to provide temporary ventilatory support is most germane to the ethical and practical factors involved in this issue. We believe that this finding merited fuller acknowledgment and discussion by Patterson et al.
David E. Conwill, M.D., M.P.H.
William H. Sorey, M.D.
Vincent E. Herrin
and 72 Members of the Class of 1995
University of Mississippi Medical Center
Jackson, MS 39216
References
To the Editor: Ross appears to believe that we would never advocate allowing patients with quadriplegia to terminate life support early in their care. This is not the case. We recommend that health care professionals make decisions guided by beneficence and autonomy. Thus, a patient with fluctuating mental status who is overwhelmed by grief should be counseled to wait two years before discontinuing life support. Nevertheless, if a patient with intact sensorium and a full understanding of rehabilitation after quadriplegia consistently requests the cessation of ventilatory support, then he or she should be allowed to die. Under such circumstances, granting a patient's wishes would respect the principles of both autonomy and beneficence.
We argued that cost should not be a criterion for providing life support for patients with quadriplegia. The physician's primary moral duty in such cases is to serve the patient, not to act as a gatekeeper for society by making allocation decisions that deny life support to a particular group of patients already disadvantaged by spinal cord injury. We disagree with Lehman and are disturbed by the notion that an individual physician would decide unilaterally that the care of a person with quadriplegia is too expensive for society.
The points on biases in decision making raised by Johnson and Bennahum are appreciated. Their warning not to treat a rational request for the termination of life support as a psychiatric symptom is a welcome caveat.
Flaherty's point about the potential development of new treatments for quadriplegia is one that we believe should be included by health care professionals in discussions of life support with patients.
We are grateful that the scholarly acumen of the class at the University of Mississippi Medical Center brought an error in one of the references to our attention. The article by Gardner and colleagues supports our premise and is worthy of accurate citation.
Our article was generated by the alarming observation that some physicians allow patients with acute quadriplegic injuries to die without carefully considering important issues from a broader perspective. We do not recommend that the right to end life support be denied to patients with quadriplegia. Our objective is to argue that simply acquiescing in a devastated patient's wish to die is respectful neither of the patient nor of the subtleties of the principle of autonomy, particularly in a society with a pervasive negative bias about disability.
David R. Patterson, Ph.D.
Thomas R. McCormick, Ph.D.
Leonard D. Hudson, M.D.
University of Washington School of Medicine
Seattle, WA 98195
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