Death Has Become a Choice

In past weeks, two tragic end-of-life cases have caught national attention. One is the case of Jahi McMath and the other is the case of Marlise Munoz. Both McMath and Munoz remain on life support, but McMath's parents want to keep their daughter connected to the ventilator, while the Munoz family wants the pregnant woman disconnected from any life-sustaining interventions. Both cases are heart wrenching and both cases are also raising fundamental questions about how we understand death. Despite the tragedies of our everyday lives where people die in accidents or in violent acts, most people in the United States do not die simply. Today when most people die, they do so because someone -- a loved one, a guardian, a physician -- makes a decision.

McMath is a 13-year-old girl who was declared brain-dead by doctors at Children's Hospital in Oakland, Calif., yet a prolonged heartbeat has led McMath's parents and family to the view that she is still alive. They live in hope of a miracle. McMath went in for surgery that most of us would consider "routine" -- a tonsillectomy to correct her problems with sleep apnea. But something had gone terribly wrong. McMath seemed to have suffered cardiac arrest and severe bleeding. After careful examination by the physicians, she was declared brain-dead and the hospital sought to remove her from the ventilator. Her family fought back. Eventually, McMath was released to her family and transferred to another, unknown medical facility.

Munoz collapsed from a blood clot when she was 14 weeks pregnant. After examination and diagnosis, the doctors at Peter Smith Hospital in Ft. Worth, Texas, have also pronounced her brain-dead. In her case, however, the hospital has refused to remove the ventilator, as the family had requested, because it would harm (kill) the fetus, which is now in its 20th week. Texas law mandates that she be sustained for the well-being of the fetus.

These are not the first cases that have raised ethical questions, particularly of how we understand death and brain death. Over the last 40 years, there have been many difficult cases that have led us to think about end-of-life issues. The cases bear the names of the patients involved: Quinlan, Brophy, Cruzan and Schiavo. But those patients, unlike McMath and Munoz, were not brain-dead. They were in a persistently vegetative state. A persistently vegetative state means that a person has no higher cognitive awareness of what's going on around them, yet the patient still has some brain stimulation. When a person is brain-dead, all the parts of the brain are dead and these patients cannot maintain normal blood pressure or body temperature. These patients would require medications and life-support technology to keep them breathing.

It is important to remember that, at present, when the cells of the brain die they cannot be restored. Other organs, such as the heart, can be replaced through transplant surgery. This is not the case with the brain. When it is dead, it is dead. This reminds me of the maxim of St. Thomas Aquinas, that grace builds on nature. Aquinas' point seems to be that God works through nature. In nature, the brain is essential to who we are and what we do. And the biology of the brain is that when it is dead, it is dead.

The ethics and legality of the Munoz case is complicated by her pregnancy. We, in the United States, have a complex public policy towards pregnancy. On the one hand, if she were able, Munoz could have an abortion. But she didn't. Before her collapse and brain death, she and her husband had made a decision to have a child. Texas, like at least 31 states, has a law restricting the ability of doctors to end life support for terminally ill pregnant women, regardless of the wishes of the patient or the family.

This brings us to another ethical question that needs to be asked, but rarely is in America. What about the cost of care in these cases? In the United States, we pay for health care through either public or private insurance pools. Most experts would estimate the cost of the care received by brain-dead patients to be about $7,500 a day. Many people are contributing to their care. In a world of limited resources, which is the world we live in, how resources are used is an ethical question. It is a question of stewardship. And, in a world of limited resources, every determination of where we use our resources is also an implicit decision not to use them elsewhere.

The long-term tragedy is that we will continue to see cases like this. As medical technologies develop and advance, we will be able to do more to sustain life. It is imperative that we recognize what we are doing and why. In the evolution of modern medicine, death has become a choice. And those choices come with important moral responsibilities.