In a recent Public Discourse essay, Philip Hawley, Jr., recounts the tragic death of Texan Chris Dunn. Hawley admirably defends a bioethics grounded on the intrinsic and inviolable dignity of all persons.
Unfortunately, his account of the case was based upon incomplete and sometimes factually incorrect reporting by other news outlets. An examination of court records presents a different picture of some key details of Dunn’s medical condition and the decision-making process undertaken by his family members and physicians.
On an ethical level, Hawley’s assertion that Dunn was subject to “death by committee” supposes an improper standard: namely, he assumes that the hospital and attending physician are guilty of murderous intentions until proven innocent. On the contrary, a review of the facts indicates it was possible and even plausible they did not intend to cause Dunn’s death. Moreover, Hawley fails to account for important implications of the conscience rights of doctors, who should not be bound to continue medical treatments that they believe to be causing more harm than good.
A More Complicated Picture
This is not simply a case of a hospital or a doctor versus the patient and his family. Rather, this is a case of an incapacitated patient who was terminally ill, whose parents disagreed about the best course of treatment, and whose doctors believed that life-sustaining treatment was causing suffering, as is plainly evident from court documents.
When Chris Dunn was admitted to Houston Methodist Hospital on October 12, 2015, he was unresponsive and on a ventilator. Since Dunn lacked an advance directive, was unmarried and childless, and was sedated and delirious, his parents were triggered as his legal surrogates. Throughout the next month, Dunn’s doctors and members of the Methodist Bioethics Committee met repeatedly with the family to explain Chris’s medical condition and prognosis. Problems arose because Dunn’s parents were divorced, neither had legal power of attorney, and they had differing judgments about which kind of treatment was in Dunn’s best interest.
The Methodist Bioethics Committee met on November 13. The committee approved his doctor’s medical judgment that the life-sustaining treatment was medically inappropriate and decided to allow his doctor to discontinue life-sustaining treatment after eleven days. His surrogates were unable to find an alternative doctor or hospital willing to treat him.
Meanwhile, according to the probate court records, Dunn’s social worker filed an application seeking guardianship for a qualified family member or third party who could provide a single voice about his care. The legal battle over the guardianship of Dunn remained unresolved when, still on the ventilator, he died on December 23.
It is important to note that Houston Methodist Hospital voluntarily agreed to continue life-sustaining treatment while the dispute over Dunn’s guardianship was ongoing. The hospital never applied for guardianship and, in fact, provided the court with names and known locations of family members. Dunn died before the matter was resolved, while the hospital continued to provide him with life-sustaining treatment.
Under the 1999 Texas Advance Directives Act (TADA), Dunn’s surrogates were entitled to be present at the ethics committee hearing to review his attending physician’s decision to cease life-sustaining treatment. Under Texas law, this includes such measures as mechanical breathing machinery. Last year this law was modified to prohibit Texas ethics committees from sanctioning termination of artificially administered nutrition and hydration (AANH) by physicians if the patient or surrogate objects. Exceptions are made in rare cases in which AANH itself would directly cause systemic and organic malfunction and/or death.
Did Anyone Intend to Kill Dunn?
Hawley’s argument insinuates that the hospital and the attending physician intended to kill Dunn. But, we cannot say that the doctors necessarily sought the death of Dunn as an end in itself or as a means to some other end, such as saving the hospital money. It is entirely possible, even plausible, that the doctors—and Dunn’s father, in his role as surrogate—could have understood Dunn’s death as an unintended but foreseen side effect of a morally legitimate object. That object, by their own profession, was to stop the suffering caused by the treatment to sustain his life.
It is entirely plausible that the doctors believed that mechanical ventilation could not be expected to offset Chris’s deteriorating respiratory status, which included fluid buildup in the lungs, and that the ventilator itself had negative side-effects: damage to the lung tissues, risk of leaks and atelectasis, pain and discomfort due to the tube and involuntary forced respirations, increased need for sedatives, pain medications, and restraints, intermittent suctioning, and a risk of infection. Each of these is known to aggravate delirium and may diminish the ability to consent to treatment.
It is plausible that the doctors had good reasons to believe that the pancreatic cancer was untreatable. They may have believed that attempts to maintain the status quo would be medically ineffective, would not save his life, and would increase physical pain and bodily damage while possibly hastening death. In short, it is plausible that the doctors intended the cessation of unnecessary pain, suffering, and further bodily deterioration directly caused by mechanical breathing machinery.
A person in possession of his mental faculties is not morally bound to choose treatments whose negative effects are disproportionate to any good that could come from them. By the law of transitivity, it would seem to follow that neither his doctor nor his surrogates are either. Some may say that patients are the only ones able to judge the proportionality of suffering due to life-sustaining treatments. In this case, those treatments decreased the ability of the patient to judge.
Due to confidentiality, our information is limited to the public record. The physicians who cared for Dunn stated that their patient was suffering from his life-sustaining treatments, and the hospital ethics committee who met with the family surrogates and doctors agreed that it was medically inappropriate to cause that suffering. It is telling that, even with the assistance of the hospital over several weeks to find another care provider, none would accept Chris’s transfer, indicating that other doctors agreed with the attending physician’s prognosis.
We must therefore be cautious in offering our own judgments. The same moral law that demands that physicians “do no harm” has implications for all of us: namely, doubts about others should be interpreted for the best. To do otherwise would be to injure them.
Needed Reform and Rights of Conscience
None of this is to say that the TADA is without problems. Indeed, Texas’s professional medical organizations and pro-life organizations have worked to reform this law to improve it. In previous legislative sessions, in addition to prohibiting withholding AANH, they sought to improve the procedural justice and transparency of committee procedures and extend the waiting period to give hospitals and families more time to find alternative care facilities in the face of disagreement among patients, surrogates, and their doctors.
Some reformers seek to go much further. They seek to abolish any sort of hospital committee review process of doctor-patient disputes. In their view, justice requires nothing less than an absolute right of patients and surrogates to demand indefinite extraordinary life-sustaining treatment in all possible scenarios, effectively raising autonomy and “life at all costs” to the level of first principles.
The problem with this idea is that, while it is cloaked in the language of human dignity, it actually violates it. For doctors are persons too, and as such enjoy inviolable rights of conscience as aspects of their dignity. If, in their reflective medical judgment, a course of treatment would actually harm rather than heal the patient, then the doctor is bound in the order of natural law by that judgment. Proponents of the absolute right of surrogates would entail a power of surrogates to marshal the power of the state to force doctors to violate their consciences. Doctors should not be compelled to perform acts that they believe would needlessly cause damage and suffering to their patients.
There needs to be some way of balancing the dignity and rights of patients and their surrogates, as well as the equal dignity of doctors. Most doctors want some sort of process that protects their conscience rights and shields their medical practice from unjust lawsuits.
But, as sound moral theory has always attested, conscience can err, because an agent’s judgment may or may not align with the moral law. The challenge for legislators and citizens of good will is twofold. First, they should reform committee processes in ways that, as much as possible, safeguard patients from erroneous judgments while protecting the conscience rights of doctors. Second, families and other institutions of civil society need to educate doctors, nurses, hospital administrators, and other medical practitioners from their youth in the knowledge and practice of sound moral principles, in order to properly form their consciences.
Meanwhile, outside observers in cases like this need to realize that interpreting doubts for the best might mean that we err more often than not in our judgments. But it is better to err in this way than the converse, for it is better to have a good opinion of an evil person than to have an evil opinion of a good person.
Deirdre Cooper is a public policy analyst at Texas Alliance for Life. Beverly B. Nuckols, MD, MA (Bioethics) is a family physician, a member of the Board of Directors of Texas Alliance for Life, and a blogger at WingRight.org.