Imagine a hypothetical situation where a man name Jack slips on a tennis ball and becomes completely paralyzed. He is now only able to communicate through eye blinks and has repeatedly expressed his wish to die. Furthermore, let us suppose that prior to his accident he arranged an advance directive, which appoints his wife as his health care agent in the event that he cannot make decisions for himself. His wife, Ima Loire says that Jack had a very active lifestyle prior to his accident and that she is sure that he would rather die than continue to live paralyzed. His doctor, I. M. Hopeful, on the other hand has treated many patients who are quadriplegic and assures the couple that most of his patients regain the will to live after six months of undergoing treatment. He consequently recommends that Jack undergo rehabilitation and approaches the hospital ethics committee for advice on the matter. In this situation the main factors to evaluate include: patient autonomy, informed consent, and limited medical resources. This paper contends that these three reasons support the patient’s decision to refuse treatment on a ventilator and additionally outweigh any opposing claims made by the doctor, namely: mental incompetence of the patient, statistical evidence, and sanctity of human life.

The most fundamental issue in this controversy is the matter of patient autonomy. In the United States, the ideal of freedom, particularly personal freedom to do as we wish, is highly regarded, provided that in the process of pursuing our freedom we do not cause harm or injury to others. This idea comes from respect for individuals and the choices they make and implies that there is an implicit bias towards individual liberty and personal autonomy with regards to decision making. Jack expressed a wish to refuse treatment and to consequently be allowed to die. Although his physician may feel his goal is to provide medical care to improve the quality of his patient’s life, his first goal is to respect his patient, which in this instance requires that he respect Jack’s desire to forgo treatment. The idea of patients refusing treatment is a relatively new concept in Western medicine. It was previously understood that doctors are knowledgeable of their patient’s best interests and are the most qualified to make decisions concerning those matters. With the advent of hospital ethics committees, the Nuremberg code, and increased patient liberty in decision making, this view is no longer popular. In fact the medical practice has increasingly begun to move away from this paternalistic stance on patient treatment. In acknowledging Jack’s right to make decisions about how he should be treated we are respecting his autonomy and inherent right as an adult human being to make personal decisions that he regards as in his best interest. This right to autonomy does however assume that Jack is mentally competent to make decisions for himself.

If Jack is found to be incompetent to make medical decisions, which is highly probable considering the traumatic and grave results of his accident, then his physician would have some justification for declining to act initially as the patient requested. Nevertheless, in the situation described here the appropriate actions to be taken would still follow the patient’s request, since prior to his accident Jack obtained an advance directive naming his wife as his health care agent. Therefore, even if we conclude that Jack is mentally unfit to make decisions about his health care there is no reason why his wife cannot make them for him. In fact, allowing Ima to decide which treatment will or will not be pursued is the most consistent with Jack’s autonomy both before and after his accident. Not only does she have the greatest knowledge of what Jack would prefer and how he would like to be treated, but she was also specially requested by him to make decisions on his behalf. Since his wife is also in agreement with Jack’s decision it seems that the doctor should act in accordance with the patient’s wishes.

In addition to the belief that the patient is mentally not competent to make decisions about whether or not to continue his life, other evidence for why the patient should accept treatment at least in the short term is the overwhelming statistical evidence which indicates that most patients that are permanently quadriplegic regain the will to live. This supports the physician’s claim that after rehabilitation Jack may once again wish to live out the remainder of his life. Although this may be a reasonable assumption on the part of the doctor, it does not give him the authority to override his patient’s decision. It is quite possible that the patient will complete the therapy and rehabilitation and still remain firm on his wish to end his life. In such a case not only will his autonomy and personal wishes have been disregarded for six months of his life, but there may be no remediation of his depression. Due to the permanence of his condition and the medical certainty that he will never return to anything remotely resembling the type of life he had before the accident, it seems that an additional six months of misery for the patient are not worth the cost of his right to self-determination. Therefore, Jack should be informed of these statistics from his physician but then allowed to decide what course of action to take. Doctors provide their patients with statistics and life expectancy information before and after treatments on a regular basis. Their patients are then allowed to decide given the information available which treatment option (if any) to pursue. Many times patients choose options other than what their physician recommends because of financial costs or different inherent risks that may be more or less important to them individually. For Jack, being able to move around and use his body is an important part of his life and he is well within his rights to refuse treatment if he feels that it will not improve his condition, which in the case of paraplegia it cannot. Since paraplegia is irreversible, the best that rehabilitation can do is to give him advice on how to continue in his permanently debilitated state and attempt to improve the state of depression he is most likely experiencing. This will not resolve the problem of his physical inability and therefore likely not change his mind on the matter.

Furthermore, another issue to consider is the limitations of available medical resources. A vast majority of the American population lacks sufficient health care. Considering the overwhelming amount of medical ailments left untreated each year either due to lack of resources or inadequate insurance, it is hard to justify continued governmental expense to treat someone whose medical costs will be astronomical, who is likely to receive little benefit from the treatment itself, and who has repeatedly expressed a desire to abstain from treatment. The cost of keeping an individual alive on a ventilator is over $1,000 each day. If the patient or the patient’s family wishes to pay these fees privately they are certainly entitled to do so. However, due to the enormous cost of keeping a patient alive on ventilators and other life supporting technology most individuals who receive such treatments do not pay privately. Their medical costs are covered by governmental programs like Medicare and Medicaid. Given that neither the patient nor his family desires the treatment it seems absurd that the government should waste its already limited and precious resources to treat the patient. Clearly since the only movement Jack is capable of making consists of eye blinks, considerable amount of medical funds would be spent on his continued existence for actions such as feeding, breathing, etc. He firmly believes that this treatment will not provide him with any additional joy or benefit. Furthermore, since his condition is irreversible this treatment would not be a temporary procedure until he regains function of his body (as is the case with temporarily comatose patients), but rather a permanent state of affairs throughout the remainder of his life.

Another argument that the doctor or proponents of the treatment may express is the sanctity of human life. The belief that human life holds infinite value and should always be preserved is the same argument often expressed by anti-abortionists and those opposed to euthanasia. However, this position is flawed. It is very easy to imagine a situation where one’s quality of life is so bad that one’s life is no longer worth living. This is most often seen in terminal patients slowly dying of painful and debilitating illness. In fact, it is these patients that are most in need of treatment refusal and euthanasia because they reach a point where every added minute they live is one spent in torture and complete irreversible misery. This pain may be physical or mental. An extremely active person such as Jack, who loved to be outdoors, would be mentally tortured by the inability to move any part of his body. Is his pain and misery not as noteworthy as that of a terminally ill cancer patient who is given pain medications that cause his life to end? There seems to be an unfair dichotomy between physical and mental suffering, where physical pain is significant but mental anguish is not.

Obviously, there are situations where mental anguish may not be serious enough to warrant ending a life Take for example, a young teenage couple whose parents disapprove of their relationship. As a consequence of their post pubescent hormones they may feel their inability to remain together is painful enough that they wish to take their lives. However, they would be treated as depressed or mentally incompetent. This is due to their inability to make proper decisions for themselves due to their young age and their mental state caused by overly emotional sentiments at a situation (being single) which is only temporary at best. Jack on the other hand, is a fully competent adult who is making a decision for himself based on a permanent, serious, and severe injury. To compare his mental state with that of a teenager facing depression because of a breakup or an individual who has lost his job and feels overwhelmed with remorse, is a disservice to him and paternalistic on the part of his physician. The difference is that Jack’s decision is informed, competent, and rational and his illness is dire and irreversible. Additionally, he is not being actively killed but rather passively refused treatment, which is consistent with the medical profession’s stance on passive vs. active euthanasia, which will not be addressed in this paper.

Why is it then that Jack’s doctor feels that his life is worth saving? Why would ending Jack’s life as he wishes be wrong? It seems that the best reason offered philosophically for not taking an individuals life or helping him to end it comes from Don Marquis who contends that the reason killing a person is immoral is that it deprives them of a future of value. This explains why it would be wrong for suicidal teenagers to take their lives, or why it would be wrong to take the life of someone who has the potential for a future of value. However, in the case of Jack, as a result of his accident he no longer has a future of value. In fact, because of his predilection for physical activity it is very certain that his future will be full of unhappiness and sorrow. Furthermore, Jack is not the first example of a patient existing on a ventilator who has requested (or whose family has requested) to be taken off. Many individuals do not feel that living in this manner really constitutes living by their definition of the term and feel that they should be removed if the situation should present itself. When elderly or terminal patients express their wish not to be resuscitated they are marked as DNR on their charts and the doctors and nurses attending to them follow those instructions. It appears as if the only difference here is that Jack’s doctor doesn’t believe that he should give up hope. This decision is not the doctor’s to make and is inconsistent with the majority belief in medicine that patients without hope for improvement have the right to refuse continued survival on a ventilator. Given the lack of value of his future life and his consequent insistence on being allowed to die, it seems logical that his physician should follow his wishes. Modern technology now allows us to prolong life without necessarily improving the quality of that life. It does not follow that because it is possible to keep Jack alive on a ventilator we should do so. .

In conclusion, if this situation was presented to the hospital ethics committee, they should proceed by following the patient’s request that he be removed from the ventilator and allowed to die. As difficult as this result may be for his physician to accept, it is in best agreement with both the wishes of the patient and the values that the medical profession stands for: patient autonomy and informed consent. The patient has made an informed decision based on statistical evidence provided by his doctor and the medical knowledge concerning the consequences of paraplegia. In addition, an added safeguard of his wife as a healthcare agent has been implemented in the case that he may be incompetent to make the decision for himself. Since both are in agreement there appears to be no reason for the doctor to hesitate other than his own personal beliefs. When practicing medicine, it is necessary that doctors look beyond their personal beliefs and prejudices and act in accordance with their patient’s best interests and preferences. As heartbreaking as this devastating accident is and the loss of Jack’s life would be, the greater travesty would be keeping Jack alive on a ventilator against his will.