Case 8: Death be not proud

The soon-to-be-held 2019 Michigan High School Ethics Bowl (coming to you this February 2nd and 3rd in Palmer Commons) will be quite a doozy with cases dealing with anonymity in media, children’s rights, cultural autonomy, gerrymandering, immortality, legislation, limitations to freedom of expression, mortality, professional responsibilities, resuscitation, sexual misconduct, social obligations, tenure, theft, and universal human rights, to name but a few of the topics directly address by the case studies

I was lucky enough to get to write one of these. Below is my case. If you’ve got any good answers, I’d love to hear them.

Case 8: Death Be Not Proud

You are the parent of a 13-year-old, Annie, who has long suffered from sleep apnea due to her enlarged tonsils and is often fatigued and unable to focus in school. You decide to take her to the hospital to have her tonsils removed to relieve her sleep apnea. Annie has not spent much time in hospitals and on the day of the surgery is understandably nervous about the procedure. As you wait, she says, “If something ever happens to me, make sure you keep me on one of those,” pointing to a mechanical ventilator.

The surgery is performed and after four hours in recovery, Annie wakes up. She coughs up some blood. A nurse says that this is normal. Her surgeon has written in her medical record that her carotid artery is abnormally close to the pharynx, increasing the risk of hemorrhage. The next day, Annie continues to cough up blood so severely that her oxygen saturation level falls to dangerous levels. Complications ensue, and though at the time you are told your daughter’s condition has “stabilized,” a day later she is on a ventilator. Two days after that, she is declared brain dead.

The declaration of brain death was made when Annie’s pupils did not react to light, she had no measurable gag reflex, her lungs filled with carbon dioxide when disconnected from a ventilator, and an electroencephalogram showed no brain activity. However, Annie’s skin is still warm. When you sit by her bed or talk to her, you sense that she feels your presence. You can issue directions such as “squeeze your hand” or “wiggle your big toe” and within about 2-10 seconds her hand or big toe will be squeezed or wiggled. Some of your doctors and nurses describe this as a spinal cord reflex, a “Lazarus sign,” which gives the mere appearance of life. Her heart still beats.

Michigan, like all other states, follows a version of the 1981 Uniform Determination of Death Act which states that someone who has sustained the “irreversible cessation of all functions of the entire brain, is dead.” And while “a reasonably brief period of accommodation” is given to allow families to gather before a patient is removed from ventilation, eventually the “needs of other patients and prospective patients in urgent need of care” require the hospital to remove a patient from ventilation.

You have refused to take her off ventilation for three weeks. A death certificate has been issued (“Brain death. No hope of brain recovery.”) and a senior executive has stated that the hospital will no longer provide care for your daughter.

Study questions:

  1. Can a child make a free, informed choice that we are morally bound to respect? At what age or under what conditions? Did Annie make such a choice?
  2. Before the 1960s, cardio-respiratory failure was the only way to die; i.e., it was the definition of death. With the availability of ventilators, patients without a spontaneous heartbeat could have their respiration and heartbeat sustained mechanically. Some of these patients may be unconscious, in a “persistent vegetative state,” but still have brain activity. They are not dead by any accepted definition. But under new “brain death” criteria, those who have no brain activity are considered to be dead, and health care facilities do not offer medical treatment to cadavers. Is brain activity the best way of diagnosing death? Are there other better ones?
  3. Should health care facilities by required to treat patients who have previously requested treatment, or whose families request treatment, even after they meet the criteria for “brain death”? What if only the family’s private funds are involved? What if Medicaid funds are involved (approximately $150,000 per week)?

Author Bio: Barry Belmont is a Lecturer in the Department of Biomedical Engineering at the University of Michigan. His primary academic interests lie at the interface of (bio)medical instrumentation and human subjects, including both the scientific and ethical aspects of the work. He earned his PhD at the University of Michigan in biomedical engineering by studying multimodal noninvasive hemodynamic monitoring techniques on healthy and critically ill subjects. He runs a Bioethics Discussion Group which meets biweekly to host roundtable discussions on a host of biomedical issues (e.g., the role of big data in health care, family interests in medicine, vaccination, among the topics). This past summer he taught an introductory engineering course at Shanghai Jiaotong University in which students were tasked with designing a medical device and to ponder its consequences.