In Oakland, California, the tragic case of Jahi McMath has resurrected the debate over end of life issues, the circumstances under which hospital patients should be removed from life support, and the definition of life—or death— itself.
McMath, 13, was declared brain dead on December 12, three days following tonsil surgery. McMath, who had undergone procedures to treat sleep apnea, went into cardiac arrest and coughed up blood in the recovery room at by Children’s Hospital Oakland. A judge and five doctors, including doctors at Children’s Hospital and an independent neurologist at Stanford, have declared the girl brain dead.
Now, the hospital is refusing to insert a feeding tube and perform a tracheotomy on McMath, and is unwilling to allow outside doctors to fit her with the breathing and feeding tubes necessary to transfer her to another facility. Citing religious beliefs, Jahi’s family believes she is still alive and wants their daughter transferred to a long-term care facility. They have asked the courts to intervene. But the hospital, already declaring her dead, stated it cannot assist in performing medical procedures on dead people on ethical grounds.
On Tuesday, the family was granted a last-minute extension on a restraining order preventing the hospital from removing Jahi’s ventilator. Now, the family has until 5 p.m. on January 7 to find another facility for her.
Already, the public is making comparisons between this right-to-die case and that of Terri Schiavo. Schiavo collapsed in 1990 after suffering from cardiac arrest, suffered brain damage and went into a coma. Doctors subsequently diagnosed Schiavo as being in a persistent vegetative state, also known as a prolonged coma. Schiavo died in 2005 at 41 after she was removed from a feeding tube in Pinellas Park, Florida following a court order, a number of legal appeals, and a national debate which included intervention from President Bush, who signed legislation passed by Congress authorizing the federal courts to intervene in the case.
The Schiavo family has lent its support to Jahi’s family, citing “a very deep problem within the U.S. healthcare system — particularly those issues surrounding the deaths of patients within the confines of hospital corporations, which have a vested financial interest in discontinuing life.”
Yet, despite the temptation to make comparisons between these two right-to-die cases, there are substantial differences between Jahi McMath and Terry Schiavo. For one, Schaivo’s husband eventually won his 15 year long struggle to have his wife’s feeding tube removed, over the objections of her parents. A Florida court determined that Terri Schiavo had made statements that she would have wanted her feeding tube removed if in a vegetative state. At this point, there does not appear to be a division among McMath’s family, and no legal determination of Jahi’s wishes.
Further, and more importantly, Jahi has been declared legally dead with no blood flow to the brain, and no electrical activity in the brain, including the brain stem. While Schiavo— who was severely brain damaged and in a persistent vegetative state with limited brain activity— was able to breathe without a ventilator, McMath’s heart would stop beating immediately, given that her brain has completely stopped functioning.
Regardless of your opinion on this subject matter, everyone can agree the case of Jahi McMath is a sad one. And her situation is significant because it pushes the envelope on end-of-life issues. What is the definition of death, and to what lengths should doctors go to keep people alive, whatever “alive” means? How valuable is “living” without any quality of life to speak of, yet with clear evidence of death or near death? And who makes the decision to end or extend the “life,” the courts, the patient or the patient’s family?
Some would define death as when the heart and breathing stop, while others would define death as a permanent lack of consciousness, or a complete breakdown of the body’s cells and tissues, or a loss of brain activity. Ardent right-to-life supporters may reject the scientific definitions of death, even the scientific evidence that someone is no longer living.
The U.S. Supreme Court weighed in on the issue in 1990 with Cruzan v. Director, Missouri Dept. of Health. In that case, the high court ruled that people had the right to refuse medical treatment, but that did not extend to incompetent individuals, because there is no guarantee that families would act in the interests of incompetent patients. The court also allowed the requirement of “clear and convincing evidence” that a patient wished to be removed from life support. The Cruzan decision led to the development of advance health directives, also known as living wills, which are written instructions given by a patient concerning the care and treatment he or she wants, once that patient is no longer able to make those decisions.
Meanwhile, in 2005— at the time the Schiavo case was attracting national attention— 85 percent of people polled said they would support removing themselves from life support—“pulling the plug” if you will. And this past November, a Pew survey on end of life decisions found a growing minority of people believe doctors should do everything possible to keep a patient alive. In the study, 66 percent said a patient should be allowed to die in at least some situations, with 31 percent believing medical professionals should do everything in their power to save a life—up 9 percentage points since 2005, and 16 points from 1990.
There is still much we do not know about the circumstances surrounding Jahi McMath’s brain death. Further, a federal judge has ordered that the McMath family and the Children’s Hospital attend a mandatory settlement conference in an attempt to avoid trial. Nevertheless, with cases like Jahi’s, we are assured the debate over decisions of life and death will not go away anytime soon.