The Right-to-Die Case That No Doctor Wants

‘There Is No Way Anybody Is Going to Pull That Tube’

Dr. Jacquelin Trestrail

As lawyers gather again this morning in an El Cajon courtroom to debate whether 92-year-old Anna Hirth will be allowed to exercise her “right to die,” the local medical community finds itself in an awkward position.

Though it has grown increasingly common for doctors, in concert with patients or their families, to terminate life-sustaining care for the irreversibly ill, the publicity and legal complexities surrounding Hirth’s case have grown so daunting that no area physician will come forward to assume the duties that will lead to the La Mesa woman’s death.

“Since the case has so much notoriety, there is no way anybody is going to pull that tube,” Dr. Jacquelin Trestrail, president of the San Diego Medical Society, said Tuesday. “They would have every right-to-life person parading in front of their office saying, ‘You’re going to kill that person!’ ”

Or, as Dr. Kevin Glynn, chairman of the biomedical ethics committee at Mercy Hospital, said: “Why would I want to step into a maelstrom like that? I’d be crazy.”

Hirth choked on some food and lapsed into a coma in February of last year. Since then, she has been kept alive at Hacienda de La Mesa nursing home with with nutrition and water from a nasogastric feeding tube.

Termination Order

Hirth’s fate seemed settled March 24, when Superior Court Judge Milton Milkes signed an order affirming the right of her daughter, Helen Gary, to direct that her mother’s treatment be terminated.

Milkes order required the woman’s physician, Dr. Allen Jay, to remove the nasogastric feeding tube or else to find a doctor willing to take on the job. If no doctor could be located within two weeks, Milkes’ order authorized the staff of the La Mesa nursing home to remove the tube.

But Jay--who since last fall has fought Gary’s wish that her mother be allowed to die--has refused to end Hirth’s feeding, citing ethical considerations and doubts that her condition is irreversible. Jay argues that Hirth is not entirely comatose and might one day emerge from her stuporous state. He said he has been unable to find a doctor willing to take over the case. And nurses at the home have expressed their unwillingness to take the step that experts say would lead to Hirth’s death within a couple of weeks.

The result: Hirth continues to linger, while Milkes--three weeks after signing his order--considers either modifying it or finding some way to enforce it.

Ethical Factors

And in the meantime, area doctors--especially those who take a professional interest in medical ethics--are musing about the ramifications of the case, weighing the thorny ethical and practical problems it presents and joining in the uncertainty about how San Diego’s first right-to-die case will be resolved.

The physicians seem to agree on only one thing--that they are uncomfortable with any circumstance in which a court, or some other authority, requires a doctor to take actions he considers unethical.

Trestrail said that, if Jay decides to appeal Milkes’ order, the California Medical Assn. is prepared to file a friend-of-the-court brief defending the physician’s right to stand by his principles without outside interference.

“You go along with the tenets which I believe all organized medicine subscribes to--you believe the patient has a right to life or a right to death, if they so choose,” she said. “But we also believe a doctor should not be forced to do what he morally objects to.”

Glynn said the threat posed by the case to the independence of physicians’ ethical judgments helps explain the visceral reaction it has engendered in the medical community.

“I feel very strongly that we in organized medicine must come out very, very strongly against the authority of any governmental agency to force a physician to do something against his conscience,” Glynn said. “If Dr. Jay or any other physician is forced to do something to Mrs. Hirth against his conscience, that sets the precedent to condemn murderers or get rid of anybody else we want.”

Cases Usually Quiet

Typically, Glynn and other doctors noted, such cases do not turn into public, bitter conflicts. Almost every day, they said, doctors, patients and families agree to end life-sustaining care--either with or without a “living will” or similar document stating the patient’s wishes.

“Most of these things are handled in a way much more subtle, much less in the public eye,” said Dr. Michael T. Long, chief of staff at Grossmont Hospital.

Dr. Albert L. Lizarraras, chairman of the bioethics committees of the county medical society and Alvarado Community Hospital, said that “what happens in the real world is there are many times when patients are in nursing homes and are terminal, with let’s say a malignant disease. It’s elected by the family and the physician that we’ve gone so far and now let’s let the person die with dignity. . . . . Everybody looks the other way, including the nursing home, and it’s no problem.”

The American Medical Assn. and some local medical societies have issued guidelines for making such decisions. Most hospitals have established ethics committees to consult with physicians who feel uncomfortable about making life-ending judgments. And a series of court cases--many of them won by Gary’s lawyer, Richard Scott of Santa Monica--have firmly established the right of a patient or the patient’s family to call a halt to life-sustaining care, regardless of their doctor’s wishes.

But as the Hirth case has made abundantly clear, none of the guidelines or court rulings have made the decisions to terminate treatment easy.

‘A Tough Burden’

“There is a legal right not to have treatment; Richard Scott is right about that,” said Daniel T. Broderick III, an attorney and physician who is president of the San Diego County Bar Assn. “And yet he and the family are asking a doctor or nurse--some human being--to be the executioner, or to carry out the will of the family or of the person who doesn’t want to live anymore. And that’s a tough burden to put on somebody.”

Lizarraras said: “I just can’t imagine most people being eager to run in and pull the tubes on some poor woman they’ve never seen or taken care of, and watch her starve to death. That’s not what medicine is all about.”

Glynn warned, though, against exaggerating the drama involved in carrying out such a court order. When a decision is made to remove a feeding tube, an effort usually is made to spoon-feed the patient, he said. If the patient is unable to eat, then it is his ill health--not the acts of his doctor--that causes his death, Glynn said.

“From all the corners of Judeo-Christian culture and ethics, we’re on very strong moral grounds if we talk about letting a person die who’s biologically dying,” said Glynn, a self-avowed adherent of the right-to-life movement.

With the San Diego medical community apparently unwilling to take that step, however, what resolutions to the impasse in the Hirth case do the doctors have to offer? The suggestions boil down to end runs around Milkes’ order.

Glynn proposes that Gary take her mother home. “She could care for her any way she wants or not care for her any way she wants,” he said.

Trestrail urges that Hirth be removed from San Diego. “Maybe if they moved the patient out of our jurisdiction, up north, if they could find a home to take her, they could diffuse the situation and find another doctor to do it,” she said.

Scott said Tuesday that he doubted the legal battle over Hirth’s fate would be resolved by moving her out of San Diego--and he said he did not think she should suffer further, given that her rights have been vindicated in Milkes’ court.

“I don’t think Mrs. Hirth should have to have second-rate medical care just because she’s won this lawsuit,” he said.