Death Support in Texas

I have received several notices about this story unfolding in a Texas hospital, where a woman is threatened with death, despite her wishes to remain alive. Do we think that Terri Schiavo's end was an aberration? As one commentator put it, this most recent case is as if Terri's "husband" and her parents both wanted her to live but the hospital insisted she die.

The sister of the Texas patient, Andrea Clarke, has issued an appeal for help. It's hard to read without sympathizing.

No doubt medical experts will cite complexities involved and the fact that the decision was reach through due process by an expert panel, all perfectly legal. I am no doctor, nor an expert. But I can see red flags. When it comes to what's legal and sanctioned by experts, for example,Roe v. Wade comes to mind. Either experts and processes will be allowed to continue to "improve" our society with "progress" in such things as human cloning and non-sexual marriages and euthanasia and infanticide, or citizens posssessed of common sense will deny them such powers.

The hospital in this recent case is, by the way, St. Luke's.

Comments

[Terry Bohannon]

An e-mail from the Houston Coalition for Life today included a quote from Terri Schiavo's brother:

"We at The Foundation, Center for Health Care Ethics are seeing a growing number of hospital ethics committees emerging in our nation at an alarming rate. The story of Andrea Clark demonstrates the dangers of these unelected, self-appointed, and anonymous committees that are rushing to remove the care from patients in private, without a public hearing or any type of appeal.”

[Jennifer K]

Who pays for the care for these types of patients? Hospitals are closing in CA because they are legally obliged to provide care and people (often illegal immigrants) don't or can't pay for it. I am sympathetic if the family that insists on keeping her on life support is willing to pay for the FULL cost of her care. Otherwise, Christians who believe everyone is entitled to the nth degree of medical care should pay for it. You should have the choice of purchasing insurance for the nth degree of medical care or not.

[James Altena]

The family's appeal for help is posted to the web site of the "Democratic Underground," a site for "pro-life" Democrats. It is noteworthy (and disturbing) that the sister (of the victim) writing the appeal feels the need to reiterate repeatedly that "this is not a Schiavo case," and that a number of respondents feel the need to make gratuitous attacks on President Bush (who as governor signed the legislation now being turned against the victim -- I suspect its current use was not foreseen by him), Schiavo supporters, and even conservative pro-life groups. Apparently self-identified Democratic "pro-lifers" are only "pro-life" in certain circumstances and to a limited degree. Telling, too, that it needs to be "underground" in the Democratic Party.

So, Jennifer K, you apparently thinks that "care for these type of patients" should not be given if for some reason the family itself cannot pay for it. Would you please explain how your mercenary calculus of life and death here squares with Jesus' words about how we care for "the least among us"?

[William Luse]

I'll ignore Miss K's advocacy of the proposition that if people are expensive it's all right to murder them.

Still, Mr. Altena alerts us to some important points, especially that in her letter of appeal the sister says "...this is not like the Shiavo case, where there was brain death," wherein she demonstrates a despicable ignorance of Terri's condition, and implies thereby that Terri's state-enforced murder by starvation and dehydration was fine with her.

But she is right when she says that her sister's (Andrea Clarke's) case is not like Schiavo's, who could not - even had she been conscious - have made a morally licit request to have her feeding tube removed. Clarkes's case reminds me more of Christopher Reeve's. It's hard to tell for a certainty because the only medical details come from Melanie Childers (Clarke's sister), whose misrendering of Terri's condition does not inspire trust. I was puzzled, for example, to find no talk of the doctors having tried to wean Miss Clarke from the respirator. This was done in the Quinlan case, and successfully.

However, the Texas law that allows ethics committees to make these decisions in defiance of the wishes of family and patient sounds like a work of mischief to me.

[David R]

I'll ignore Miss K's advocacy of the proposition that if people are expensive it's all right to murder them.

Mr. Luse, she said no such thing, be fair now. Jennifer K brings up a very valid question regarding the place of the government when it comes to providing health care. I'm guessing anyone from a country with universal healthcare (I’m from Canada myself) will be rather familiar with the question. Very often it's not as black and white as "don't murder people". A few years ago a friend's young brother died of a rare form of cancer called Neuroblastoma. The family had petitioned the government to pay for an experimental treatment that might have saved his life. It would have cost millions of dollars and the government wouldn't pay. Basically those millions could have been used to hire doctors, or buy more MRI machines, and in the grand scheme of things that was more important. I know that every life is precious and cannot be boiled down to dollars and cents, but when the government becomes the provider of health for everyone, it must be utilitarian.

The reality that these days we are able to medically stave off death really can be an ethical minefield, one which my family is struggling through at the moment. Over the past five years my grandmother has suffered a series of debilitating strokes which have drastically reduced her mobility, her speech, her ability to swallow and even breathe. Any one of these strokes could have ended her life, but by the grace of God she is still with us. And we treasure her presence even as we hate to see her in pain. I don't feel that the question of what measures should be used to prolong life should be answered flippantly. I'm not claiming any moral superiority over any answer and I'm certainly not saying that Andrea Clarke should be killed. I am saying that these situations are rarely as simple as we like to pretend they are.

[GL]

With all due respect, Andrea Clarke's case and Terri Schiavo's case are not the same. All Terri Schiavo needed to live was nutrition and hydration. Andrea Clarke is on a respirator and dialysis. If in fact she has made her wishes known, as her family claims, to be provided life support until "natural death," then her wishes should be honored. If she has not, however, it could well be argued that the "respirator and dialysis" are preventing natural death, that in fact the hospital is using machines to artificially keep her alive when her body has already begun the process of shutting down for a natural death. As David R. says, these are not easy cases. Let's not assume that in every case in which someone wants to discontinue every form of life support that it is, as in Terri Schiavo's case, an act of murder. I believe there are two extremes here: (1) a desire to prematurely and artificially end a life when a "normal" life is no longer possible (Schiavo) and (2) a desire to artificially prolong a life when it is time for natural death to occur. Both are unChristian and determining exactly when one has crossed into one of those errors is not easy.

In an article last year on Pope John Paul II's last days, the Washington Post reported:

Long-standing Catholic doctrine links continuation of extreme measures of life-support to the possibility of recovery. Under that approach, it can sometimes be morally permissible to cut off such measures if there is no hope of improved health and a patient's family would be excessively burdened.

See Pope's Feeding Tube Brings End-of-Life Questions Closer.

Certainly, Andrea Clarke's family should have the opportunity to show that she wanted life support and that there is hope, but let's not have a knee-jerk reaction that euthanasia is occuring every time a respirator and dialysis is turned off before a patient has died. If an error is to be made, we should err on the side of life, but we must recognize some times artificially prolonging the dying process is the error and accepting death is the proper course.

[Douglas]

"I believe there are two extremes here: (1) a desire to prematurely and artificially end a life when a "normal" life is no longer possible (Schiavo) and (2) a desire to artificially prolong a life when it is time for natural death to occur. Both are unChristian and determining exactly when one has crossed into one of those errors is not easy."

Well said. It is a tragic and complex problem.

Some consideration must be given to the living as well. Human bodies on respirators and dialysis have become the breeding grounds for potentially catastrophic superbugs.

[Christohper]

I too would ask where are the resources going to come from to pay for miss Clarke? I am not arguing that it should not be done, but would like to know who is going to be taxed at a higher rate to pay for it? My family is supported by an average middle class income. The simple fact is that we are in the 45-50% tax bracket. So many of us look at that federal return and think that is our taxes. We fail to think of the state, local, sales, gas/tag/etc., phone, and of course all the corporate taxes that are passed back to us in the cost of the goods and services we buy.

James, William, and/or anyone else - let's be honest and admit that it will be a government funded program that will keep miss Clarke alive, and let's admit that you will be taking money (by the point of the sword - by taxing) from me to pay for it. How much are you going to raise my taxes? 10%? 20%? Remember, government is horribly inefficient at these sorts of things - try to be realistic...

[Gene Godbold]

Dear Douglas,
It is true that hospitals can be breeding grounds for antibiotic-resistant microbes (~55% of all hospital pathogens are resistant to more than one antibiotic). But the indiscriminate use of antibiotics among livestock as growth enhancers (you get an average 5% yearly increase in mass) was probably a much larger contributer to the development of these organisms.

Incidentally, I have read that, if the Group A streptococci (Streptococcus pyogenes) develop resistance to penicillin, then every single human microbial pathogen will have been demonstrated to possess multiple resistance to common antibiotics.

[GL]

Christopher,

Its not just taxpayers; its anyone who has to pay for medical insurance, whether Ms. Clarke has insurance or not. Hospitals end up eating a lot of this and recover it by charging more for other services, which in turn is paid by either the government (state and federal), insurers, or individuals. In the case of the government, it either then borrows more or taxes more to cover it. In the case of the insurers, they raise premiums and cut benefits.

William is correct that saving money is no excuse for murder, but artificially prolonging the dying process is not murder. We do not have anywhere near enough information in the Clarke case to make a judgment and what we do have is almost entirely from the family who has a position to promote. (I am not saying they are deceiving the public or even that they are not correct in all they say. I am saying they are biased, as anyone of us in their position would be.)

To dismiss the cost involved in keeping someone like Andrea Clarke on a respirator and dialysis is to fall into yet another class of error with moral implications. One reason why middle class families cannot afford more children, cannot afford to have mothers stay home with the children they have and, in some cases, cannot afford health insurance is because of the escalating cost of taxes and health insurance. One reason employers cannot pay higher wages so that one wage earner could support his family is because so much of the cost of having an employee goes to taxes and health insurance.

The issue to be resolved is whether the withdrawing treatment in any given case is (1) prematurely and artificially ending a life when a "normal" life is no longer possible (Schiavo) or (2) whether it is permitting natural death and ending artificially prolonging that process. If it is the former, then no economic calculation can justify withdrawing the treatment. If it is the latter, then the impact of the cost of the treatment on the rest of society is a valid moral consideration.

[Patrick]

I have never been in such a situation, so for me to make a judgment would be fairly wrong I believe. That being the case good points are made in the comments above and I nod my head at even conflicting arguments.

Yet, I wonder about this whole issue. Clearly this is not just about life. More so, this is about an obsession with life. In decades prior to our own people died, and they died regularly. People faced death, often in stupid and unjust circumstances, and so had to really develop a strong sense of God's ultimate salvation and life.

In Jesus' time such an issue as this would not have ever been considered because the woman would have been long dead. Yet now, we are so able through science and medicine to prolong and heal and otherwise transform the "natural" way of things we've run into all manner of ethical questions.

This makes me think a little bit about heaven. And it makes me think of Scripture, in which God clearly has a different view about life and death than we do. We, especially now, cling to the barest threads of life, as though this was all there is, and to let go of that is to send someone into oblivion. We fear death, we fight death, we will make extreme decisions and judgments in order to keep death away. Yet, life and death are a lot more fluid subjects, from what I can tell.

The Schiavo story was abhorent not because she was allowed to die, in my estimation, but because they tortured her to death. They did to her what they would never do to the worst prisoner of war. Other cases, however, we have families holding onto a life because they cannot face death, and in doing that cannot face their own faith that death has in fact been conquered. People are frozen in the hope they might be returned to this life. People are kept forcibly breathing and people are kept in the worst possible life when they, according to nature, would otherwise be quite dead and enjoying the bounty of life eternal.

Certainly there is the question of how we view life, and how we view the least among us, and how we respond to those who are sick. However, what seems left out is the questions on the other end which make us face the reality that our present conception of heaven is a very anemic thing. We have, in all our churches, such a poor view of what is beyond, such a almost nonexistent eschatology which speaks neither of jugdment nor of hope beyond death, that we restrain that which comes as much as we can.

We should debate whether it is right to let this woman off the ventilator. We should also debate whether it is more Christian to let her join Christ in Paradise on this very day.

Not being in such a situation I can't make a judgment. Yet, for me, I would much rather be in heaven than restrained by tubes, unconscious, in a dank hospital while others cling to my life for me.

[Christopher]

GL,

As much as I would like it, I am not sure there is a workable distinction between #1 and #2. Often, what looks like a #2 case turns out to be a #1 case. In other words, the person recovers to some extant in a way that satisfies some of the parties involved. No doubt this is what miss Clarke's family is hoping and praying for. Terri's "husband" (he was not Christianly of course - having taken another wife) successfully argued in court that she was a #1, whereas our sympathies lie with #2. What I mean by "workable distinction" is a from a government/societal policy and tax perspective. When the coming socialization of medicine (we are part way there with the influence of Medicare, Medicaid, and the VA system) occurs, #1 and #2 will be endlessly debated - oh, I can here the belly aching now. Touchstone will have to form a separate blog just to cover it.

What impresses me more about this debate is how quickly, arrogantly, even ruthlessly my Christian and secular neighbors show up with a sword and extract $cash$ from my family. I would like to see more honesty from them as to what they really propose and what seems so moral to them. Unless anyone think this is a tangent, simply recall how the "tax collectors" are thought of in the New Covenant.

So Mr. Luse and Mr. Altena, how much are your tax collectors going to extract from my family? Let’s put a realistic number on it…

[Christopher]

GL,

Looks like reversed #1 and #2 in my last post - hopefully you get the gist...

[GL]

Patrick,

Ditto.

[GL]

Christopher,

I agree, it is very often hard to distinguish between 1 and 2. That's the reason I will not take one news account written from the view of only one of the sides in the matter as sufficient information on which to form an opinion. I know(and understand why) many of you do not trust the courts after Schiavo, but the Clarke case is matter for a neutral magistrate to hear and decide (hopefully applying just rules of law applied to accurately determined facts).

[Gintas]

I might be too young to go on about this, but it seems that in days past, life and death decisions were God's responsibility. Now often it's ours. Much Promethean fun is to be had with modern science, eh?

[Gina]

I find it hard to believe what I'm reading here.

The decision to take Clark off her life support only happened a week ago. She'll be turned off on Sunday. There's no time for a magistrate or committees! She won't get any kind of judicial appeal, thanks to the Texas law.

This is a woman who has insurance, who is suffering from complications to surgery, and for whom the hospital and insurance company have decided it's time to go. In short, she could be any one of us. According to the KHOU story, the ethics committee decision was based on a judgment of quality of life, that "she is miserable." Yet the family says she wrote out her wish to live when the doctor brought this up.

If it is too expensive to keep such patients alive (St. Luke's Episcopal has already killed off several other people using the same "ethics" committee process), how are other states managing who don't have a futility law?

[Ranee Mueller]

I do not know whether or not this woman is having extraordinary measures used to prolong her life. What is disturbing to me is that the decision is solely the hospital's, and that it can be put through so quickly.

[Gina]

Are a respirator and dialysis extraordinary measures? Post-operative care? Yes, in these days of pushing patients out the door a day after they cut them open, Andrea Clark's insurance company no doubt views her 5-month stay in the hospital as outrageous.

We should consider giving up any pro-life rhetoric if going down the "who pays" route. Abortion advocates will argue, too, that flooding the world with unwanted babies is too expensive and unethical. Are we unwilling to put rubber to our calls to protect the life of the sick, the aged, and the otherwise inconvenient?

David R.: America has an approval system for experimental treatments, too. I have the same insurance provider as Andrea Clark, Blue Cross. They pore over every lab test and office visit for "medical necessity." I am quite sure they do the same for her.

[Jennifer K]

There's a reason economics is called the dismal science. My father-in-law has cancer, and so far his treatment has cost about $300,000. Most insurance policies have a $1,000,000 lifetime limit. This doesn't mean that a human life is worth $1,000,000; it means that when purchasing insurance, there are limits on what will be provided under what guidelines and most of us (or our employers) don't purchase beyond $1,000,000.

My husband and I devote part of our charitable giving to medical care for the poor. We don't, however, have a million dollars for my father-in-law's future care. I would find it surprising if fellow Christians come up with the second million dollars for medical care for my father-in-law (age 53-61 in his cancer battle) and I do not expect them to. I do not think this is the obligation of the government, i.e. my fellow taxpayers. In our family, we see the situation much as Patrick does. There is a time to recognize that death is a mercy, that christians (and nonchristians) need not fear it, and that christian maturity may mean saying, "I have fought the good fight, I have finished the race."

Despite the negative comments claiming my views are akin to murder, I will continue to hold them. Our family is not entitled to the resources of others because of our medical situation. We will continue to CHOOSE to give to certain charitable medical organizations. And we will continue to believe that letting people die is in many cases a moral choice.

[Christopher]

We should consider giving up any pro-life rhetoric if going down the "who pays" route.

You can not avoid it - it's reality, as much as breathing and eating. Someone will have to provide the resources. Since private companies can not and stay in business, it we be me through my taxes. You have already seen fit to take almost half my labor away from me. How much more do you think I can sustain? Put a figure on it - 60%? 70%?

[GL]

I have been reading a little more about Ms. Clarke's case. The following is from Wesley J. Smith's article, Death by Ethics Committee: Refusing to treat lives deemed unworthy of living, at NationReviewOnline:

Andrea Clarke may become an early victim of one of the biggest agendas in bioethics: Futile-care theory, a.k.a., medical futility. The idea behind futile-care theory goes something like this: In order to honor personal autonomy, if a patient refuses life-sustaining treatment, that wish is sacrosanct. But if a patient signed an advance medical directive instructing care to continue — indeed, even if the patient can communicate that he or she wants life-sustaining treatment — it can be withheld anyway if the doctors and/or the ethics committee believes that the quality of the patient's life renders it not worth living.

This article was too light on the details about Ms. Clarke's case to fully understand the all the issues. Assuming, hypothetically, that a patient has an advance directive which would call for life support and assuming that the patient is conscious and still expresses that wish, I am at a loss to understand why a health care provider should be allowed to refuse to honor that wish.

I know nothing about the law in question, but were I representing her family, I would file an action in federal court challenging the Texas law as violating the Due Process Clause and, perhaps, the Equal Protection Clause of the 14th Amendment and seek a temporary restraining order stopping the withdraw. If the hospital ethics committee is the last available avenue for the family, that, on initial impression, seems to deny a person life without due process of law. If a directive rejecting life support must be honored but one requesting life support may be denied, that seems to raise potential Equal Protection Clause problems. Of course, knowing nothing about the law, there may already be precedent closing that as a possible remedy.

Apparently the Houston hospital has offered to pay the cost to transfer Ms. Clarke to a hosptial in Illinois. If the family is serious about saving their sister's life, they should take the offer and not risk her life trying to make law in Texas.

[Gina]

Update from Andrea Clark's sister on Democratic Underground:
"Some of you might remember my posting on DU about my sister, Andrea Clark, for whom St. Luke's Episcopal Hospital in Houston was threatening to terminate care. Andrea would have died had St. Luke's been successful. Because of DU and others, Andrea is now being transferred to a facility in Chicago, Illinois. They have no futile care law in Chicago, so Andrea will be okay there.

Andrea is now showing some signs of improvement, although slight. She has endocarditis, which takes about four months, at best, to resolve itself. It's going to be a long road back for her, if she makes it, but I want to thank the mods here and Skinner, for helping us to get the word out.

I have to tell you, too, that the right to life people were with us on this all the way. And we never made a secret of the fact that we were Democrats, either. They are an absolutely formidable force. I don't know what we would have done without them. They pinned St. Luke's Episcopal Hospital to the wall with calls, emails, blogs, radio interviews, etc. St. Luke's is so utterly happy to get my sister out of that hospital ALIVE, if it weren't so tragic, it would be almost comical.

Anyway, just wanted to let you know that this had a happy outcome, and express our family's thanks for your help."

[GL]

I have not raised this before, but now that Ms. Clarke is in Illinois, I will: Why wasn't there not an offer to admit Ms. Clarke from a religiously-affiliated hospital in Texas that does not exercise its right under Texas law to withdraw care because of the teachings of the tradition with which it is affiliated? Has no Texas hospital made known it disagreement with and commitment not to exercise its rights under the futile care law?

For an interesting discussions related to this question see Euthanasia in a Texas Hospital? on the Catholic Matriarch in my Domestic Church aka Catholic Mom blog, which alleges an agreement among hospitals not to accept transfer of patients set to be denied care under the law, and the post by Celine at the open book blog in the tread titled The case of Andrea Clark which sets forth the statute in question, including language requiring a transfer to another hospital if one can be found.

So, were there no pro-life hospitals in Texas whose commitment to life exceeds their loyalty to their industry? Or do these hospitals refuse transfers because they would then have the financial burden of continuing such care? These are hard questions which those of the same tradition as such hospitals need to ask?

[SRM]

Apparently Ms. Clark has not been moved to Illinois. According to the article linked below, officials at St. Luke's have backed off from the plan to discontinue her care tomorrow, and have scheduled a meeting Tuesday to reevaluate her case.

Relocation of heart patient on life support called off