1. The document discusses life sustaining treatments and the ethical issues around withdrawing or withholding such treatments. It provides an overview of key concepts like ordinary vs extraordinary treatment and examines cases like Karen Ann Quinlan and Brother Fox. 2. The Karen Ann Quinlan case from 1976 established that family members can decide to withdraw life support for patients in a persistent vegetative state. The court ordered her respirator withdrawn. 3. The Brother Fox case from 1979 also involved withdrawing life support from an unconscious patient per his prior wishes. The highest court approved removing his respirator.

1. AINB Ethics in Life Sustaining Treatments Discussion
Unformatted Preview PHHE 435/535 Ethical Decision Making for Health Professionals
Module 7A Life Sustaining Treatments Master of Public Health Program – Copyright ©
2017. Board of Trustees of Northern Illinois University. All Rights Reserved. Objectives •
Life saving – moral dilemmas • Identify components of ethical analysis • Written case brief
Life Sustaining Treatments • Not restoration • Not meant to be a cure Photo Credit: Zdenko
Zivkovic • Prolong patient’s life 1 Life Sustaining Treatments • Ventilator – Enable to live
longer with the disease Life Sustaining Treatments Photo Credit: Gr8what • Dialysis Life
Sustaining Treatments Photo Credit: Georgina Eltonten • Surgery 2 Life Sustaining
Treatments • When is it reasonable to employ life-sustaining treatments? • When is not
reasonable…? Life Sustaining Treatments Photo Credit: Lucas Kerper • Technology to
support respiration when spontaneous respiration is no longer possible Life Sustaining
Treatments Photo Credit: Jeffrey • Life saved – creates moral dilemmas 3 Life Sustaining
Treatments • Ordinary or extraordinary medical treatment? Photo Credit: KagedFish •
Ambiguous Life Sustaining Treatments • Enables a person with medical problem to breath
Photo Credit: Communications and Marketing • Does not address a medical problem Life
Sustaining Treatments Photo Credit: Communications and Marketing • Long term /
permanent use of ventilator creates most ethical issues • Withdrawal may mean earlier
death for some 4 Life Sustaining Treatments • Difficult for physician and proxy • Causal
relationship between withdrawal and death Which is the sole significant cause of death?
Disease Withdrawal Death Moral Issues • How can we consider moral issues? 5
Components of Ethical Analysis Components of Ethical Analysis Photo Credit: touched by
light • Story Components of Ethical Analysis • Ethical Analysis – Situational Awareness
Photo Credit: Billy Danze – Facts 6 Components of Ethical Analysis • Prudential Reasoning
Patient’s Perspective Proxy’s Perspective Provider’s Perspective Court’s Perspective Photo
Credit: Karina Valdes – – – – Components of Ethical Analysis • Court Decision Components
of Ethical Analysis Photo Credit: janmennens • Ethical Reflection 7 Photo Credit: Binuri
Ranasinghe Case Studies Case Study •
http://archives.law.virginia.edu/dengrove/writeup/karenann-quinlan-and-right-die Case
Study • Conflict between Photo Credit: LoisGillieAndrews – Parents – Physicians – Ad litem
guardian 8 Case Study • What behavior is according to right reason? • How can the moral
agents find a way to live well • Avoid the worse Ethical Analysis • Situational awareness
Photo Credit: Billy Danze – Facts of the case? Ethical Analysis Photo Credit: Matthiew Rbnt •
Irreversible PVS, not experience benefit or burden, body in constant state of flexion, not

2. expected to survive after removal of respirator 9 Ethical Analysis Photo Credit:
JourneyCare/Midwest • No advanced directives Ethical Analysis • With no decision-making
capacity, proxies had to decide. Could not relay information that wasn’t given – No
substituted judgement – No best interest – Rely on reasonable treatment standard Ethical
Analysis • Physician not want to withdraw respirator – No substantial history in this area –
NJ Attorney General opposed withdrawal – Physician’s lawyer argued imposed death
sentence 10 Good / Bad Features • Expect Karen’s death – Death not good – Would not
experience the process of dying – Regret and mourn death Good / Bad Features • Karen’s
life was not good for her because she lacked awareness • Yet life is an important good Good
/ Bad Features • Suffering of Karen’s parents bad – Over tragic situation – Legal proceedings
11 Good / Bad Features • Physician’s distress at withdrawing respirator Recognize action
leads to death of patient Legal action Advice from lawyer No established medical tradition
Photo Credit: LoisGillieAndrews – – – – Prudential Reasoning • Enhance good whenever one
can reasonably do so • Eliminate the bad features in the situation whenever possible
Patient’s Perspective • Not have a perspective • Not a moral agent, because lost capacity •
Not left advanced directives 12 Proxy’s Perspective • Father – primary moral agent •
Decided to request withdrawal of life support – result in death • Was there a reasonable
justification? Proxy’s Perspective • Bad features of dying not the same as someone else who
had not had severe brain damage • No hope of recovery, no suffering • Death would not take
much more away from Karen Proxy’s Perspective • Actual death not cause much more harm
to parents • Karen already has suffered substantial loss 13 Proxy’s Perspective • No real
harm to society • Already has lost her possible contribution Proxy’s Perspective • Resources
in supporting life support might be wasted since it does not do good supporting a person in
PVS Proxy’s Perspective • Father convinced that withdrawal of respirator was the more
reasonable response • Less worse option 14 Provider’s Perspective • Were not convinced
removal was morally justified • Why? Provider’s Perspective • Upset about removing life
sustaining treatments from living patients because: Photo Credit: Alucco7 – Not accepted
medical practice – No ethical analysis in this area developed – Threat of legal action
Provider’s Perspective • Position weakened by what? • Forcing treatment on a helpless
patient Photo Credit: Alucco7 • Over objections of proxy 15 Provider’s Perspective • Could
have responded by stepping aside Photo Credit: Alucco7 • Chose not to take this route Court
Decision • Reversed lower court decision Photo Credit: robotsrule159 • Found a person’s
right to privacy can be asserted by a guardian when the patient is incompetent Court
Decision Photo Credit: robotsrule159 • Constitutional right to privacy extends to decisions
about medical treatment 16 Court Decision • Physician was ordered to withdraw • Instead,
weaned patient from device • Transferred to nursing home Photo Credit: robotsrule159 •
Died 10 years later from infection Ethical Reflections Photo Credit: robotsrule159 •
Decision by both Proxy and NJ Supreme Court seemed reasonable • Efforts by physicians to
continue and eventually wean not seem reasonable after court decision Ethical Reflections •
Brought no good/benefit to Karen • Imposed 10 years of expensive but useless care Photo
Credit: janmennens • A reasonable ethical response would have been to withdraw from case
17 Ethical Reflections • Generated lots of controversy in society Photo Credit: janmennens •
Setting precedence Continue Photo Credit: Tracy Sorensen 18 PHHE 435/535 Ethical

3. Decision Making for Health Professionals Module 7B Life Sustaining Treatments Master of
Public Health Program – Copyright © 2017. Board of Trustees of Northern Illinois
University. All Rights Reserved. Brother Fox Photo Credit: Joe Catron • New York (1979)
Brother Fox • 83 years old • Arrested during surgery • Had discussed with not being kept on
a respirator • Physicians refused • Multiple appeals Photo Credit: Joe Catron • Brother Fox
died 1 Ethical Analysis Situational Awareness – Facts • Permanently unconscious, no hope •
Had made known his wishes • Apply substituted judgement, indicated desires •
Hospital/physicians refused Photo Credit: Billy Danze • Take to court Situational Awareness
– Good/Bad Features Photo Credit: Myles Lopez • Expected to die after withdrawal 2
Situational Awareness – Good/Bad Features Photo Credit: Myles Lopez • Use/expenses of
resources not benefit that any good patient could experience Situational Awareness –
Good/Bad Features • Hospital and staff distressed about withdrawing respirator • Not long
after the Quinlan case Photo Credit: Myles Lopez • Not a recognized practice Prudential
Reasoning Photo Credit: Karina Valdes • Patient’s Perspective – although he had lost
decisionmaking capacity and consciousness, had made known his wishes • Removal was
reasonable, given the circumstances 3 Prudential Reasoning • Proxy’s Perspective – acting
according to the wishes of Brother Fox Photo Credit: Karina Valdes • Behaving ethically
Prudential Reasoning • Provider’s Perspective – acting against patient’s wishes Photo
Credit: Karina Valdes • Not unreasonable, given time in history Court Decision • Highest
court (Court of Appeals) approved decision to withdraw • Incapacitated patient, no hope for
recovery • Had given clear instructions 4 Court Decision • Clear and convincing evidence •
Highest level of evidence in civil cases • Very few states require it – New York, Missouri
Ethical Reflection Photo Credit: janmennens • The moral question: Ethical Reflection • Was
Brother Fox’s prior decision to refuse treatment morally reasonable? Photo Credit:
janmennens • It seems reasonable, given the circumstances 5 Ethical Reflection Photo
Credit: janmennens • Hospital’s decision seems reasonable for the time, but would not be
seen that way in the present Ethical Reflection • District Attorney’s actions to prolong the
ordeal more difficult to justify • But since patient was not suffering Photo Credit:
janmennens • And helped to clarify situation in New York Case Study 6 William Bartling
(1984) • Seriously ill – Severe emphysema, hardening arteries, abdominal aneurysm, lung
cancer, collapsed lung, need respirator to breathe, depressed • Multiple hospitalizations
William Bartling (1984) • Appeared to physicians that patient would never leave ICU •
Despite experiencing depression, still had decisionmaking capacity • Wanted to have
respirator withdrawn William Bartling (1984) • Physicians were going along with that
decision, but were advised against it by their lawyers • Patient’s lawyer went to court to
have request honored 7 Ethical Analysis Situational Awareness – Facts • Still had decision-
making capacity, despite being depressed • 70 years old, incurable lung cancer, little hope of
leaving ICU Photo Credit: Billy Danze • Maintain decision over long period of time
Situational Awareness – Facts • Physicians seem prepared to honor request Photo Credit:
Billy Danze • Refused by hospital administration and legal counsel 8 Good / Bad Features •
After withdrawal, death would occur • Patient was conscious, and would experience death
Photo Credit: Myles Lopez • Both death and suffering bad Good / Bad Features Photo Credit:
Myles Lopez • Continuing the life support would continue patient’s distress • Patient’s

4. hands were tied (literally) • Not according to patient’s wishes • Was aware of what was
going on Good / Bad Features Photo Credit: Myles Lopez • If request not honored, patient’s
family would be in distress over this as well as original medical condition 9 Good / Bad
Features • Hospital/staff worried over legal liability after conferring with legal advisors
Photo Credit: Myles Lopez • Although concerns are understandable, not well grounded
Photo Credit: Karina Valdes Prudential Reasoning Prudential Reasoning • Patient’s
Perspective – wanted the treatment that was bringing him more burden than benefit
stopped • Did not want to live with both ventilator and cancer Photo Credit: Karina Valdes •
All things considered, this was reasonable 10 Prudential Reasoning • Proxy’s Perspective –
no real role since patient still had capacity. However, if patient had lapsed into coma, would
have been able to have request honored Photo Credit: Karina Valdes • Does this seem
reasonable? Prudential Reasoning • Provider’s Perspective – although had concern for
criminal prosecution, Photo Credit: Karina Valdes • There had been cases in California, New
Jersey, and New York that had established the right of patients to refuse respirators
Prudential Reasoning • Provider’s Perspective – • Due to questionable legal advice,
hospital/staff wanted to avoid exposure to prosecution Photo Credit: Karina Valdes • Set up
conflict between patient and institution 11 Prudential Reasoning • Provider’s Perspective –
Photo Credit: Karina Valdes • Should have sought a declaration of immunity to protect
themselves Court Decision • Trial Court did not support patient’s decision • Only honored
right to withdraw if comatose or terminally ill • Would not allow patient’s hands to be
untied to withdraw himself Court Decision • Court of Appeals later reversed decision •
However, patient died during the process 12 Court Decision • Ruled right to refuse
treatment not restricted to comatose/terminally ill • Based on right of privacy Ethical
Reflection • A primary moral agent can make a decision between two ethically reasonable
options, not necessarily between an ethical and unethical choice Photo Credit: janmennens •
Patient’s ultimate choice was not morally irresponsible Ethical Reflection • The right
answer in this case provided by the patient Photo Credit: janmennens • Best able to
determine how to achieve his own good – or avoid the worse 13 Ethical Reflection •
Respirator was not a cure • Only sustained life with incurable lung cancer Photo Credit:
janmennens • Benefits not outweighed burden Ethical Reflection • No need for the hospital
to use the legal system to force unwanted treatment on the patient Photo Credit:
janmennens • Could have avoided putting patient and family through ordeal if they had
sought legal protection for honoring request Ethical Reflection • Previous court decisions –
Satz v. Perlmutter (1980) 14 Ethical Reflection • Previous court decisions Photo Credit:
janmennens – Florida Supreme court affirmed lower court decision to honor request of
conscious patient to have respirator removed Conclusion Photo Credit: Ben Seldelman 15