AMA Journal of Ethics^®

Case

Mrs. Jones is an 82-year-old nursing home resident with a longstanding history of heart failure, who is now hospitalized in the cardiac ICU for the third time this year. She is a retired teacher, with 4 children and 8 grandchildren. She did not list a religious preference when admitted to the hospital. The attending cardiologist, Dr. Rosenberg, is a heart failure specialist, and is an active member of an Orthodox Jewish congregation.

On day 3 of her hospitalization, Mrs. Jones developed a fever, which was subsequently determined to be caused by a MRSA line infection from a venous catheter. On day 4, her renal function began steadily deteriorating, until her serum potassium reached dangerous levels.

She has been unconscious for 2 days, and, according to hospital records and her children, she has no advance directives to guide end-of-life care. Dr. Rosenberg requests a family conference with Mrs. Jones's children (her husband is deceased) to discuss their mother's prognosis and the appropriate next steps in treatment.

"I'm afraid that your mother's health is steadily deteriorating," Dr. Rosenberg tells Mrs. Jones's family. "She has a serious infection that has failed to respond to traditional antibiotics."

"How did she get this infection, doctor?" Mrs. Jones's daughter Jennifer asks.

"That's a good question. It's likely the result of an IV line we placed during her admission," Dr. Rosenberg replies. "Your mother's infection is caused by a resistant strain of staphylococcus that is common in intensive care units and hospitals, but we have more aggressive antibiotics we can use. I should also tell you that her kidneys are failing, and we'll need to begin dialysis to ensure that her electrolytes and fluid status are kept at normal levels. Despite this, I think there's a strong possibility she'll pull through."

At this point, Mrs. Jones's eldest son Franklin interrupts. "Look, doctor," he says, "My cousin was on dialysis for years, and, until he died, he was really miserable. I don't want my mom to have to go through that at this age. I think enough is enough. She's been in the hospital 3 times this year alone."

"I understand your concern," Dr. Rosenberg says, "but you should realize that your mother may not require long-term dialysis. Her kidneys may recover, but at this stage, dialysis is the only solution left to correct her electrolyte imbalances. If we don't lower her potassium, she'll likely develop a fatal arrhythmia."

Franklin looks at the rest of the family, who are shaking their heads. "Honestly, I think you shouldn't treat her any further. Even if it's not permanent, starting dialysis just isn't a path we want her to start on. And the 'aggressive antibiotics'—I don't see any reason to pour more substances into her already tired body. It's obviously her time to go. Can't you just give her something to make her comfortable?"

Dr. Rosenberg pauses for a moment and then tells Franklin. "We fully intend to keep her comfortable and continue treating her pain. As you know, I'm committed to doing what's best for your mother. But in good conscience, I can't stop treating your mother as long as there are reasonable courses of action that I could take to preserve her life. According to the principles that guide my practice of medicine, I cannot withhold life-saving treatment from any patient—especially antibiotic therapy and temporary dialysis, both treatments with uncontroversial efficacy."

Commentary 3

The conflict between the family and the physician in decision making concerning the end-of-life care for Mrs. Jones is a common occurrence in medical practice. A psychologist colleague told me of the problems she and her siblings had with her mother's attending physician when she was hospitalized for multiple complications of terminal cancer. Her mother and the children had requested that further treatments be discontinued. The attending physician insisted on continuing aggressive treatments to combat the infections and other organ failures.

The Family's Decision

It is common for physicians and patients to disagree over when treatment can appropriately be withheld or withdrawn if they come from different faith traditions that have different ways of viewing life and death. Because faith traditions view the sanctity of life and the meaning of death differently, physicians and patients who do not share the same religion often disagree over medical treatment near the end of life.

Let us consider the case of Mrs. Jones from a Buddhist's perspective, for example. A Buddhist is by definition an individual who aspires to live his or her life according to the teaching of the Buddha. Mrs. Jones and her family are not known to be particularly religious, so let's suppose that they are Buddhists in the same sense as people who profess to be Christians, but do not actively participate in church attendance or activities. They would at least be familiar with some of the basic tenets, or Dhamma, of Buddhism. They would see "death as a normal process, a reality that will occur as long as ones remain in this earthly existence."¹

Death can be perceived as a process resulting from the impermanence of life itself. For those who believe in rebirth, death is not the end of life, but simply a transition.² Death is the last of the "Three Messengers": Old Age, Sickness, and Death,³ that one will encounter along the course of one's life. Buddhists are admonished to constantly contemplate the facts that:

1. We are subject to old age and cannot escape it.
2. We are subject to disease and cannot escape it.
3. We are subject to death and cannot escape it.
4. There will always be dissolution and separation from all that we cherish.
5. We are owners of our deed (karma), whatever deed we do, whether good or bad, we shall become heirs to it.⁴

Mrs. Jones's children seem to be assessing her condition in a manner consistent with the principles described above. In Buddhist terms, they are holding to the "Right View," the first aspect of the Noble Eightfold Path that understands the true nature of existence as consisting of suffering, impermanence, and non-self (insubstantiality).⁵ This does not mean that they are fatalistic or nihilistic, only that they see things as what they truly are in a more detached way.

The Physician's Decision

The dilemma facing Dr. Rosenberg is much more daunting and complex. Let us consider what a Buddhist doctor would do, assuming that he is fully aware of a Buddhist's beliefs and subscribes to the Dhamma.

Any physician endeavors to treat his patients with compassion, a concept essential to Buddhism. His goal is "to overcome sickness and relieve suffering. The Hippocratic philosophy of medicine declares that nothing should be more important to a physician than the best interest of the patient who came to him for care."⁶ A Buddhist physician in Dr. Rosenberg's shoes would be aware of the same principles we discussed earlier. He may be struggling with a major question, however whether withholding further treatments for Mrs. Jones constitutes a violation of the First Precept, which exhorts us to abstain from killing or destroying life. There are additional important criteria that a Buddhist physician needs to consider regarding the First Precept. It is noted that for a killing to be considered a fait accompli, it has to meet 5 criteria:

1. There is a living being, in this case, the patient.
2. An awareness that it is a living creature.
3. There is an intention to kill.
4. One must make an effort to kill.
5. The living being dies.⁷

There is no doubt that criteria 1, 2, and 5 would be met if further treatments were withheld. One can forcefully argue that a physician in Dr. Rosenberg's circumstances harbors no intention to destroy the life of Mrs. Jones, and indeed, he strives to treat her with compassion. If he chooses to stop treatment now, he is actually not making any effort to harm or to prolong the suffering of the patient. He probably makes the dying and passing of Mrs. Jones more humane. It appears from this reasoning that the First Precept is most likely not being violated.

There are yet other relevant criteria to guide and determine the degree of karmic demerit stemming from the action of destroying a life. One has to consider whether the living being is big or small; useful to others or dangerous and offensive; whether the intention (to kill) is full of hatred, malice, or good will; whether there is an elaborate preparation and deep conviction to harm with no consideration of outcome and consequences, or whether the deed is done in a blind rage.⁸ A critical point of which a Buddhist physician needs to be fully cognizant when he decides to continue treating Mrs. Jones is whether he is really concerned about what his colleagues think or any criticism he may face. This situation is succinctly described by physician-author Sherwin Nuland in the final chapter of his book How We Die.⁶

Finally there comes a time when the physician in Dr. Rosenberg's situation has to take a step back and wonder why he does not follow the "Middle Path," one of the most important practices that enabled the Buddha to attain enlightenment. In such practice he needs to avoid all extremes in the care of Mrs. Jones that of total neglect on one end and ceaseless efforts to keep her alive at the other. He could then assume an attitude of "equanimity," a gracious state of poise and neutrality, where one admits that it is thus beyond one's power to do anything to avoid the inevitable death of Mrs. Jones.