First, Do No Harm

The 89 year old woman died of dehydration starvation after six days without food and fluids, despite evidence that she had repeatedly asked for water. A scene from a drought-stricken Third World country or Nazi Germany? No. Ella Bathurst died October 28, 1984 at a prestigious Midwestem hospital.

Mrs. Bathurst had been living alone until she fell and fractured her hip. She was treated at the hospital and then she was transferred to a nursing home. When she developed problems in swallowing, she was transferred back to the hospital for rehydration therapy. After three days, at the insistence of Mrs. Bathurst's daughter, the IV was discontinued and food and fluids were withheld. According to hospital records, Mrs. Bathurst was "alert and responsive" most of the time, yet she was not consulted regarding the withdrawal of food and water.

Similar cases are occurring more frequently as a traditional medical standard - the presumption to treat is being eroded. Under common law, competent patients are able to refuse treatment, provided the decision is reasonable and based on sufficient information for informed consent. In the case of an incompetent or comatose patient, the usual method of determining treatment was for the physicians involved in the case to discuss treatment options with the family of the patient. It was presumed that the patient would want beneficial treatment and would not want to die of dehydration and starvation. Likewise, it was presumed that the family would want the best care for the patient. Physicians themselves swore to the Hippocratic Oath: "First, do no harm."

How is this presumption in favor of treatment being eroded in our society? Generally, through five means: the medical profession, pro-euthanasia organizations, state legislation, court opinions, and the media.

1. As an indication of where segments of the medical profession are heading, in March 1986 the judicial council of the American Medical Association (AMA) ruled that it is ethical for physicians to withhold "all means of life-prolonging treatment" from people in "irreversible" comas even if death is not imminent. The AMA included food and water as "medical treatment," thereby supporting physicians who would starve comatose people to death. Another frightening problem with this ruling is that no one can predict with absolute certainty the outcome of a particular medical condition. Numerous patients, such as Sgt. David Mack of Minneapolis, have awakened from what physicians diagnosed as "irreversible" comas.

2. Pro-euthanasia organizations like Concern for Dying and the Society for the Right to Die (formerly the Euthanasia Society of America) are increasing support for the pro-death mentality. In addition to other educational efforts, Concern for Dying holds seminars for medical, theological, and law students to expose them to the goals of the euthanasia movement. The Society for the Right to Die focuses on influencing politicians to vote for pro-euthanasia legislation. It also files briefs in court cases dealing with the issue.

A more radical pro-euthanasia group is the Hemlock Society, whose co-founder, Derek Humphrey, assisted his cancer-stricken wife to commit suicide. The Hemlock Society distributes a "how-to" suicide manual and has proposed legislation in California, Arizona, Florida, and Washington that would allow physicians to kill terminally-ill patients by lethal injection.

3. State legislators and judges have focused on three legal mechanisms which further erode the presumption to treat:

a. Living will legislation has already been passed in a large majority of states and the District of Columbia. Although the laws vary, basically a living will is a directive in which a person authorizes a physician to withhold or withdraw medical treatment or care should he or she become incompetent. Like the AMA ruling, many of these laws define even food and water as "medical treatment." Because living will legislation is vague and the directive is often signed in advance of the diagnosis of a particular disease or medical condition, the door is left open for serious abuse.

b. Durable power of attorney statutes have passed in some states. These laws allow a person to appoint someone else to make medical decisions should he or she become comatose or incompetent. Since the only limitation on the appointee's power to refuse treatment is that it be done in the patient's "best interest," durable power of attorney statutes can be very dangerous. 'This is especially so in view of the belief of many that the seriously ill and the elderly are "better off dead."

c. Some courts have invoked the so-called "doctrine" of "substituted judgment" in order to withdraw beneficial medical treatment from incompetent patients in states where there are no durable power of attorney statutes. In these cases, someone authorized by the court determines what the patient would request if he or she were to become competent for a moment. Again, the appointee has nearly unlimited power to remove all care - including food and water - from the patient.

The Minnesota Supreme Court in 1984 used this mechanism to grant a court-appointed conservator the authority to remove a respirator from Rudolfo Torres, who suffered brain damage as the result of an accident at Hennepin County Medical Center in Minneapolis.

4. The media - newspapers, television, radio, and movies - have added to the confusion surrounding the euthanasia issue by neglecting to carefully examine legitimate objections to the death-related legislation and court decisions just described. In addition, by focusing on the sensational "hard cases" and by disseminating inaccurate and biased information, the media contribute to public support of the pro-euthanasia philosophy.

It appears that the presumption-to-treat standard will have to be specifically spelled out in the law in order to ensure that the rights of the elderly, the ill, and the incompetent be protected. With the law presuming that patients want beneficial medical treatment and food and water, once again a physician who withholds such care would be liable for damages under malpractice laws and could even face the loss of his or her medical license.

Medical decisions should always be based on medical, not social, reasons. The "quality" of a person's life, financial concerns, and the effect of treatment on a patient's caregivers and family are social reasons and should not be used by a physician to justify the withholding of beneficial medical treatment.

There is a point in everyone's life when death cannot be held off, no matter what means are used. Therefore, it is not morally nor medically required that every possible treatment be given a patient nor that life be preserved at all costs. However, when the benefits of a treatment outweigh the burdens, it should be administered; and food and water, as basic human needs, should not be withdrawn or withheld.


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