The Case of Melinda and Matt: Ethical Indicators of Futility in Critically Ill New Mother

Melinda Roberts is a thirty-one-year-old African American female who, two years prior to her present illness, had completed an advance directive and had also appointed a durable power of attorney for health care. The appointed surrogate was her husband of four years, Matthew. Melinda is an attorney who has practiced in the public administrator’s office since her completion of law school six years ago.

When she was seventeen years old, Melinda had had an episode of myasthenia gravis. She was seriously ill and spent four weeks in an intensive care unit before her symptoms subsided. Since that time, she has had no major health problems. She and Matt had talked about her illness when they were beginning family planning a couple of years ago. Likewise, her obstetrician knew of the illness, but there were no indications to prevent her from a normal pregnancy and delivery. Melinda has been a guardian for many state wards and has a wide understanding of legal and ethical implications regarding end-of-life issues. She has named Matt as her health care surrogate when she directed that treatment is not discontinued.

In Melinda’s final trimester, she began experiencing extreme weakness in her lower extremities and was examined and admitted to the hospital. She quickly began to experience difficulty in breathing and was transferred to the intensive care unit. She and her doctor discussed the possibilities of a recurrent episode of myasthenia gravis and the implications for her and the fetus, which was thirty-three weeks in gestation at that point.

During the discussion with Dr. Ryan, she reminded him of her advance directive and stated that her wishes concerning continuing treatment remain the same with the impending birth of their first child. “If there is any chance that I can ever see and hold my child,” she directed, “I want to have that chance. So, you keep me alive.”

Almost immediately, Melinda’s status began to deteriorate. She became unable to breathe and was resuscitated and incubated in an emergency situation. Her situation continued to deteriorate, and she became febrile and septic. The situation looked so grave that, following further deliberation, the baby was delivered by way of Cesarean section. Matt was blessed with a healthy baby boy and burdened with the grave status of his wife. After two weeks, Matt was asked to sign a consent for a tracheotomy for Melinda. She remained comatose and unable to have the ventilation support weaned in any way. Her kidneys appeared to be shutting down and the outlook for her situation was poor. Matt signed the consent but felt as though he was beginning to lose faith that doing more things to Melinda was really the best thing for her.

Melinda has now been in the ICU for five weeks. She is unable to breathe on her own and is receiving mechanical ventilation as well as nutrition and hydration. Matt and her physicians are distressed with the futility of her situation and have begun to talk about withdrawing treatments. Melinda’s only sister, Mary, and her parents are at her side day and night and are emphatic about honoring her wishes as recorded on her advance directive. Matt is under considerable stress caring for the new baby, spending time with Melinda, and keeping his job on hold. He has asked Dr. Ryan and others on the team for assistance. He feels depressed and desperate.

Questions:
1. What is the ethical issue here? (Since ethics “happens” when values clash, what differing ethical conflicts are present here?)
2. Using the clash of values that includes her family’s desire to honor Melinda’s advance directive, give the best argument you can develop to uphold that position. What weaknesses are found in your argument that would enable someone from another perspective to argue against you?
3. Respect for persons must include respect for their autonomy. Melinda made a decisive choice to have treatment continued. What situational factors can be used in support of Matt’s wavering commitment to support her choice?
4. “Futile” treatment often is reduced to mean what physicians judge to be “medically futile.” Are there ethical indicators of futility that could be used to support Matt’s growing conviction?
5. What role do Melinda’s parents and sister play in this drama?
6. If an argument is made that Matt’s position to discontinue life-sustaining (or death prolonging?) treatments is insensitive to what the family is experiencing, what insights would you offer here? What support personnel for the family (and Matt) might be present during this discussion?
7. What is the strongest argument you can make if you choose a value to be placed above the value of autonomy? And what value would that be? (Remember that respect for persons includes not only the autonomy of the person but the essential social being of every person.)

Case Study Prepared by Rosemary Flanigan, Director of Ethics Committee Development and Education, and Helen Emmott, Nurse Consultant, Midwest Bioethics Center, Kansas City, Missouri.

Bioethics Forum 13 (2), Summer 1997