Artificial Nutrition and Hydration and the Permanently Unconscious Patient: The Catholic Debate

20. The Clarence Herbert Case: Was Withdrawal of Treatment Justified?

฀ 257 20 The฀Clarence฀Herbert฀Case:฀฀ Was฀Withdrawal฀of฀Treatment฀Justified? John฀R.฀Connery,฀SJ Clarence฀Herbert,฀age฀fifty-five,฀was฀admitted฀to฀the฀Kaiser฀Permanente฀Hospital ฀in฀Harbor฀City,฀California,฀on฀Aug.฀25,฀1981,฀for฀routine฀closure฀of฀an฀ ileostomy.฀In฀the฀recovery฀room฀after฀the฀surgery฀on฀August฀26฀he฀suffered฀ respiratory฀collapse,฀which฀one฀doctor฀believed฀was฀caused฀by฀cardiac฀arrest.฀It฀ is฀not฀clear฀how฀much฀time฀elapsed฀before฀respiration฀was฀restored฀artificially฀ through฀a฀respirator,฀but฀the฀anoxia฀resulted฀in฀severe฀brain฀damage.฀According฀ to฀the฀testimony฀of฀the฀nurses฀and฀the฀medical฀board,฀the฀patient฀was฀in฀severe฀ or฀deep—perhaps฀irreversible—coma. The฀Wayne฀County฀medical฀examiner฀testified฀to฀the฀brain฀damage฀but฀said฀ that฀such฀damage฀was฀consistent฀with฀a฀speculative฀prognosis฀that฀the฀patient฀ could฀recover฀but฀probably฀not฀beyond฀a฀vegetative฀state.฀A฀neurologist฀testi- fied฀that฀in฀his฀belief฀the฀patient฀had฀a฀good฀chance฀of฀recovery.฀It฀is฀not฀clear฀ what฀he฀meant฀by฀“recovery.”฀My฀interpretation฀is฀that฀neither฀thought฀that฀the฀ patient฀was฀going฀to฀die,฀but฀at฀the฀same฀time฀they฀did฀not฀think฀that฀he฀would฀ recover฀consciousness. On฀August฀29฀Mrs.฀Herbert฀signed฀a฀consent฀form฀indicating฀that฀the฀family฀ wanted฀all฀life-sustaining฀machines฀removed.฀At฀this฀point฀the฀patient฀was฀taken฀ off฀the฀respirator.฀Shortly฀after,฀all฀blood฀tests฀and฀all฀intravenous฀(IV)฀fluids฀ were฀terminated.฀Then฀the฀nasogastric฀feeding฀tube฀was฀ordered฀removed.฀As฀of฀ August฀31,฀the฀patient฀received฀no฀further฀nutrition,฀hydration,฀or฀medication.฀ He฀was฀given฀other฀care฀(e.g.,฀he฀was฀turned฀to฀avoid฀bed฀sores,฀to฀keep฀him฀ comfortable,฀and฀to฀relieve฀other฀needs),฀but฀no฀life-sustaining฀measures฀were฀ used.฀The฀patient฀died฀on฀September฀6,฀twelve฀days฀after฀admission฀to฀the฀hospital ฀and฀six฀days฀after฀termination฀of฀life-sustaining฀treatment. The฀district฀attorney฀entered฀a฀case฀against฀the฀two฀attending฀physicians.฀ The฀charge฀was฀murder฀by฀deprivation฀of฀medical฀treatment.฀After฀studying฀the฀ case฀in฀a฀preliminary฀hearing,฀the฀magistrate฀of฀the฀Municipal฀Court฀dismissed฀ the฀complaint฀alleging฀murder฀and฀conspiracy฀to฀commit฀murder฀by฀the฀doctors .฀He฀declared฀further฀that฀there฀was฀no฀evidence฀of฀unlawful฀conduct฀or฀ of฀malice฀aforethought฀on฀the฀part฀of฀the฀physicians.฀This฀judgment฀was฀overruled ,฀and฀the฀case฀was฀entered฀in฀the฀California฀Court฀of฀Appeals.฀This฀court,฀ which฀filed฀its฀decision฀on฀Oct.฀12,฀1983,฀confirmed฀the฀magistrate’s฀judgment;฀ it฀found฀that฀the฀ “omission฀to฀continue฀treatment฀under฀the฀circumstances,฀ though฀intentional฀and฀with฀knowledge฀that฀the฀patient฀would฀die,฀was฀not฀an฀ unlawful฀failure฀to฀perform฀a฀legal฀duty.”฀We฀are฀concerned฀here฀only฀with฀the฀ moral฀aspect฀of฀the฀case.฀Our฀question฀is,฀Can฀the฀withdrawal฀of฀treatment฀in฀ this฀case฀be฀morally฀justified? The฀first฀comment฀that฀must฀be฀made฀is฀that฀the฀court฀accounts฀are฀in฀many฀ places฀unclear.฀In฀fact,฀the฀absence฀of฀much฀key฀information฀makes฀it฀impossible ฀to฀give฀any฀categorical฀response฀to฀the฀actual฀case.฀We฀can฀only฀conjure฀up฀ possible฀alternatives฀in฀the฀case฀and฀respond฀to฀them. The฀first฀question฀that฀arises฀concerns฀the฀removal฀of฀the฀respirator.฀It฀is฀not฀ clear฀why฀this฀was฀done฀so฀precipitously.฀According฀to฀the฀account฀(Magistrate’s฀ Findings),฀the฀internist฀removed฀the฀patient฀from฀the฀respirator฀two฀days฀after฀ he฀had฀been฀put฀on฀it.฀The฀account฀calls฀this฀“an฀unusual฀procedure”฀but฀indicates ฀that฀the฀internist฀ordered฀it฀after฀consulting฀with฀the฀neurologist.฀It฀adds฀ that฀the฀prognosis฀at฀the฀time฀was฀“not฀absolutely฀clear”฀from฀the฀record.฀The฀ patient฀was฀clearly฀in฀a฀coma,฀which฀may฀have฀been฀irreversible.฀The฀neurologists ฀consulted฀in฀the฀case฀disagreed฀about฀the฀possibility฀and฀extent฀of฀recovery฀ in฀such฀cases,฀although฀the฀weight฀of฀opinion฀seemed฀to฀be฀against฀a฀possible฀ return฀to฀consciousness. The฀magistrate’s฀findings฀do฀not฀indicate฀whether฀it฀was฀thought฀that฀the฀ patient฀could฀survive฀without฀the฀respirator.฀The฀account฀refers฀to฀the฀removal฀ of฀the฀respirator฀as฀an฀unusual฀procedure฀but฀does฀not฀elucidate฀further.฀Yet฀this฀ is฀relevant฀to฀the฀first฀moral฀issue.฀If฀it฀was฀thought฀that฀the฀patient฀would฀die฀ shortly฀whether฀on฀or฀off฀the฀respirator,฀it฀would฀have฀been฀morally฀permissible฀ to฀remove฀the฀respirator฀as฀a฀useless฀means.฀If฀it฀was฀thought฀that฀the฀patient฀ 258฀ ฀ ฀฀฀฀ might฀survive฀indefinitely฀on฀the฀respirator,฀removing฀it฀would฀have฀been฀wrong...