When Is It Time to Let Go?

Peter Singer

 

Pneumonia used to be called “the old man’s friend,” because it often brought a swift and relatively painless end to a life that was already of poor quality and would otherwise have continued to decline. Now a study of severely demented patients in U.S. nursing homes in the Boston, Massachusetts, area shows that the “friend” is often being fought with antibiotics. Are doctors routinely treating illnesses because they can or because doing so is in the best interests of the patient?

The study, carried out by Erika D’Agata and Susan Mitchell and published in the Archives of Internal Medicine, showed that over a period of eighteen months, two-thirds of 214 severely demented patients in nursing homes were treated with antibiotics. The mean age of these patients was eighty-five. On a standard test for severe impairment, where scores can range from 0 to 24, with the lower scores indicating more severe impairment, three-quarters of these patients scored 0. Their ability to communicate verbally ranged from nil to minimal.

It isn’t clear that the use of antibiotics in these circumstances prolonged life, but if it did, how many people would have wanted their lives to be prolonged if they were incontinent, needed to be fed by others, could no longer walk, and their mental capacities had irreversibly deteriorated so that they could neither speak nor recognize their children?

The interests of patients should come first, and I doubt that longer life was in the interests of these patients. Moreover, when there is no way of finding out what the patient wants, and it is very doubtful that continued treatment is in the interests of a patient, it is reasonable to take account of other factors, including the views of the family and the cost to the community. Medicare costs for people with Alzheimer’s disease amounted to $91 billion in 2005, and they are expected to increase to $160 billion by 2010. For comparison, in 2005, United States foreign aid totaled $27 billion. Even if we consider only the Medicare budget, there are higher spending priorities than prolonging the lives of elderly nursing-home patients suffering from severe dementia.

D’Agata and Mitchell point out that the use of so many antibiotics in these patients carries with it another kind of cost for the community: it exacerbates the increasing problem of antibiotic-resistant bacteria. When a dementia patient is transferred to a hospital to deal with an acute medical problem, his or her resistant bacteria can spread and may prove fatal to patients who otherwise would have made a good recovery and had many years of normal life ahead of them.

One may suspect that a misguided belief in the sanctity of all human life plays some role in decisions to prolong human life beyond the point where it benefits the person whose life it is. Yet on this, some religions are more reasonable than others. The Roman Catholic Church, for instance, holds that there is no obligation to provide care that is disproportionate to the benefit it produces or unduly burdensome to the patient. In my experience, many Catholic theologians would accept a decision to withhold antibiotics from severely demented elderly patients who develop pneumonia.

Other religions are more rigid. Pneumonia has been unable to play its traditional friendly role for Samuel Golubchuk, an eighty-four-year-old man from Winnipeg, Canada. Golubchuk suffered a brain injury some years ago and ever since has had limited physical and mental capacities. When he developed pneumonia and was hospitalized, his doctors proposed withdrawing life-support. His children, however, said that discontinuing life support would be contrary to their Orthodox Jewish beliefs. They obtained an interim court order compelling the doctors to maintain life support.

Since November 2007, Golubchuk has been kept alive with a tube down his throat to help him breathe and another into his stomach to feed him. He does not speak or get out of bed. His case will now go to trial, and—at the time of writing, March 2008—it is unclear when a verdict will be reached.

Normally, when patients are unable to make decisions about their treatment, the wishes of the families should be given great weight. But doctors have an ethical responsibility to act in the best interests of their patients, and the families’ wishes should not override that. One relevant fact, therefore, is how much awareness Golubchuk has. This is in dispute. The family believes that he can interact with them, but this isn’t clear. In any case, he is unable to give any opinion on whether he wants to be kept alive.

For the family, establishing their father’s awareness could be a double-edged sword, since it could also mean that keeping him alive is pointless torture. It seems likely that it is in his best interests to allow him to die peacefully. But that, of course, is not the issue for his family. The issue is what, in their view, God commands them to do.

From a public policy perspective, the central issue raised by the Golubchuk case is how far a publicly funded health-care system like Canada’s has to go to satisfy the wishes of the family when these wishes clash with what is, in the view of the doctors, in the best interests of the patient. There has to be a limit to what a family can demand from the public purse, because to spend more money on long-term care for a patient with no prospect of recovery means that there is less money for other patients with better prospects.

In the case of a family seeking treatment that in the professional judgment of the physicians is futile, there is no requirement to provide expensive long-term care. If Golubchuk’s children wish their father to remain on life-support—and if they can show that keeping him alive is not causing him to suffer—they should be told that they are free to arrange for such care at their own expense. What the court should not do is order the hospital to continue to care for Golubchuk at its own expense and against the better judgment of its health-care professionals. Canadian taxpayers should not be required to go that far in order to support the religious beliefs of their fellow citizens.

Peter Singer

Peter Singer is DeCamp Professor of Bioethics at the University Center for Human Values at Princeton University. His books include Animal Liberation, How Are We to Live?, Writings on an Ethical Life, One World, and, most recently, Pushing Time Away.


  Pneumonia used to be called “the old man’s friend,” because it often brought a swift and relatively painless end to a life that was already of poor quality and would otherwise have continued to decline. Now a study of severely demented patients in U.S. nursing homes in the Boston, Massachusetts, area shows that the …

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