A Different Drummer

February 28, 2005

Million Dollar Baby is now deservedly one of the most honored films in history. But this is just the start of one of the most important movie-inspired ethics debates ever. Somehow, the film and its critics both distort medical aspects of end-of-life decision-making almost beyond recognition.

The patient always has the right to refuse treatment. The Oscars are over, but unless doctors and medical ethicists step in to use the film as an opportunity to educate the public, I am very afraid that this film is going to cause a great deal of suffering for dying patients and their families. The film is so compelling it is sure to shape the public's perception of end-of-life issues for decades. There is a great responsibility in taking on a subject as important as the right to refuse therapy. There is an obligation to the public to make sure they know their real options.

Indeed, the movie's depiction of Hilary Swank's character (the Baby) as paralyzed on a ventilator and begging a friend to "pull the plug"- by sneaking into the hospital, turning off her respirator and giving her a shot of adrenaline - completely ignores the reality of routine medical ethics. Where was the patient's doctor? That doctor had a moral, legal and religious duty to honor the patient's wishes!

Failing to honor a patient's instructions for these end-of-life procedures is actually illegal - and theoretically could result in criminal prosecution of any doctor who insisted on keeping a patient alive artificially against the patient's will.

Unfortunately, the medical premise of Million Dollar Baby is dead wrong, because Baby could have refused the ventilator without a quibble, merely by asking. Since the famous Karen Quinlan case 30 years ago, U.S. doctors have been prohibited from insisting on unwanted therapy against a patient's wishes.

Pope Pius XII, himself, understood as much in 1952, when he condemned "extraordinary means" to maintain life against the will of patients. The major religions are in agreement. I have worked with chaplains and rabbis of all faiths to help patients make these decisions - and most of the priests I work with have written advanced directives to ensure they are never placed on a ventilator against their will.

Gray areas do arise when a patient is unconscious. Difficult ethical cases come up all the time. But a rational, talking patient could have refused the ventilator, the IV fluids, medicines, surgery - or a dozen other treatments needed to stay alive. Is the film really suggesting the doctors took the patient to surgery to remove a leg, in order to save her life without her consent?

Other films depict end of life issues accurately, and these are critical to the public understanding. Margaret Edson's Pulitzer-winning play Wit was made into an award winning HBO film with Emma Thompson. Wit is so moving and so accurate that it is now a standard part of medical school education. Who's life is it anyway? with Richard Dreyfus accurately portrays issues as they were perceived 30 years ago. Another current film, The Sea Inside, approaches the real-life assisted suicide of Ramon Sampedro. Frankly, The Sea Inside is the real debate over real end-of-life issues that Baby should have been.

The ultimate story, in my opinion, is the searing story of Dax Cowart, a severely burned patient at Parkland Hospital in the 1960s. Cowart endured years of painful therapy, begging to die. He survived, went to law school, and though severely disabled, continues to advocate for assisted suicide for others in the situation he was in. Literally, he does not believe the life he has now justifies the years of painful therapy he endured.

Apparently unaware of this medical reality, the creators of Baby came up with a thoroughly Orwellian and barbaric plot twist in order to solve a non-existent problem - by having the Clint Eastwood character sneak into Baby's hospital room to pull the plug.

But if the movie's depiction of a typical ventilator scenario was absurdly unrealistic, the talk-show and op-ed page debates that have followed it seem even more ludicrous. While conservatives Rush Limbaugh and Michael Medved huff and puff about "the sacred right to preserve life" and disability activists protest the depiction of Baby, nobody seems to have grasped a key fact: This is a total non-issue in American hospitals today!

Like most ICU doctors, I learned a great deal about end-of-life decisions during 20 years of caring for people. I do my best to treat pain and depression in these patients, while also doing everything I can to show them that life can be worth living. More than once over the years, I found myself referring to the inspiring example set by paralyzed actor Christopher Reeve, who lived a rich and creative life on a ventilator, while also becoming a hero to millions. Like Reeve, severely disabled scientist Stephen Hawking and scores of other disabled Americans are honored precisely because they've made the decision to soldier on, despite pain and obstacles.

Nonetheless, disabled patients - like all other patients - enjoy the right to refuse therapy. Jehovah's Witnesses are permitted to refuse life-saving blood, and all patients are free to refuse life-saving surgery. To insist otherwise would be to transform the ICU into Orwell's "Big Brother" - a tyrant who would ride roughshod over a patient's innate right to allow nature to take its course, and to die in dignity.

Like most people, I sometimes found myself wondering during my earlier years: What would happen if I became severely disabled? Would I choose to turn the ventilator off? And then it actually did happen, several years ago. Suddenly I faced the same questions that had confronted Reeve and many other disabled patients. Fortunately, I recovered, but I will never forget walking in the shoes of a critically ill patient.

Anyone walking in the shoes of severely disabled patients would find it truly terrifying. Some states of life are worse than death. I applaud Reeve and others who continue life-sustaining therapy - but if any person had decided otherwise, I certainly wouldn't have wanted medical staffers forcing tubes down throats and keeping person's alive against their will.

As a medical doctor and a patient, I've been given a rare glimpse into both sides of this important public issue. And that experience has taught me a crucial lesson: We need to focus on real problems at the end of life-and not on the boogey man!

I am very afraid that patients seeing this film will be misled on their real options, and will wind up fearing Frankenstein ventilators run amok.

As both doctor and patient, I urge all of us to ignore the medical distortions contained in this film - and to treat it as an opportunity to explore the deep and searching questions that will face us at the end of life.

James Murtagh has spent 20 years as Intensive Care Unit physician at a major Southeast hospital. Among his many duties, has been assisting patients with end-of-life problems. He is also an author who deals with these issues. You can write to Dr. Murtagh at jmurtag@mindspring.com .