Welcome to Ethics Consult -- an opportunity to discuss, debate (respectfully), and learn together. We select an ethical dilemma from a true, but anonymized, patient care case, and then we provide an expert's commentary.
Last week, you voted on whether it's ethical to turn off a patient's life support for the purposes of securing a tax break.
Is it ethical to turn off Cornelius's life support, which will likely lead to his rapid death, for the purposes of securing a tax break for his estate?
Yes: 49%
No: 50%
And now, bioethicist Jacob M. Appel, MD, JD, weighs in.
Since most jurisdictions expect family members -- either as healthcare proxies or decision-making surrogates -- to honor the end-of-life preferences of their loved ones, the first question to ask in this scenario is how the hospital should handle the situation if Cornelius were himself fully competent and making such a request.
The assumption is often made that all patients who are suicidal or wish to end their own lives are mentally ill. This is not the case. Many patients want to end their own lives actively or to withdraw medical care for highly rational reasons. These might be medical reasons -- such as concern over pain, loss of dignity, or resignation to a terminal prognosis.
They may also transcend health-related matters. An elderly woman might prefer that money spent on nursing care be saved so that she can leave a legacy for her church or pay for her grandchildren's college educations. A utilitarian philosopher, plagued with a fatal disease, might not want to squander scarce healthcare resources.
All states will honor a request from a mentally sound patient not suffering from a psychiatric condition to withdraw care -- no matter what the underlying purpose or motive. Under limited circumstances, seven states (Oregon, Washington, California, Vermont, Montana, Hawaii, and Colorado), as well as the District of Columbia, allow patients to end their lives through active methods.
That means that if Cornelius's mind is intact and he wants to turn off his life support to avoid paying estate taxes, doctors will have to honor his request. (Despite the well-known adage about the certainty of death and taxes, it seems even taxes can be avoided on occasion.)
This scenario is more complicated, as Cornelius is not able to make his own decisions. Rather, his children -- as is often the case -- have been called upon to render decisions for him. They clearly have a potential conflict of interest, though, in that they stand to inherit more money if their father dies within the calendar year. That fact alone does not change the standard for determining Cornelius's fate: Dr. Benway must do what the patient would have wanted.
However, when such a possible competing motive exists, medical providers and courts may look for more convincing evidence to indicate that the family really is expressing the patient's wishes. Written documentation, conversations witnessed by third parties, or even the patient's overall life conduct may help clarify the appropriate decision in cases such as this. Under rare circumstances, a hospital ethics committee or a court (depending on the jurisdiction) may replace or overrule a proxy or surrogate who they do not believe is serving the patient's wishes honestly.
Cases like that of Cornelius appear not to be only hypothetical. A peculiarity of George W. Bush-era tax legislation was that the inheritance tax on wealthy Americans expired on Dec. 31, 2009, and did not resume again until Jan. 1, 2011. Rich folks who died in the interval saved vast sums of money. At that time, trusts-and-estates attorney Andrew Katzenstein told the Wall Street Journal that at least a dozen clients had inserted provisions into their healthcare-proxy forms allowing their proxies to make decisions based on the tax code. One client even inquired whether seeking euthanasia in the Netherlands, where physician-assisted suicide is legal, would qualify him for the tax break. According to Katzenstein, it would have.
Jacob M. Appel, MD, JD, is director of ethics education in psychiatry and a member of the institutional review board at the Icahn School of Medicine at Mount Sinai in New York City. He holds an MD from Columbia University, a JD from Harvard Law School, and a bioethics MA from Albany Medical College.
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