MCN Notepad ... Editorial On M$B Controversy

Movie-Inspired Debate Over "Euthanasia" Is Absurd

"Million Dollar Baby" Deserves An Oscar -
But The Medical Ethics Debate Has Gone Off The Track
By James J Murtagh, M.D.

Dr. Murtagh has spent 20 years as Intensive Care Unit physician at a major Southeast hospital, assisting patients with end of life problems. He is also an author who deals with these issues.

When they open the envelope for "Best Picture" at the Oscars next week, I'll be rooting hard for Million Dollar Baby - the dazzling new Clint Eastwood film about a woman left paralyzed after sustaining a neck injury during a boxing match.

Because I like the movie so much, it's no fun to report that both the film and its critics have made a major mistake: they forgot that it's illegal for doctors to treat alert, rational patients against their will. Somehow, the film distorts the medical aspects of end-of-life decision-making almost beyond recognition.

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!

No one has to guess what Swank wants. She's not unconscious, she's not a vegetable, she's not depressed. She's depicted as completely rational. Which means that her wishes must be obeyed. As a matter of fact, 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 totally 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, however. 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? Had Baby refused the operation, she would have died from infection, and she would have spared the Eastwood character his torment, and her own attempt to end her life by biting her tongue.

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 Eastwood 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 unit 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 Reeves 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 my 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 J. Murtagh Jr.
Atlanta, Ga

Author Resume

Murtagh is a doctor of pulmonary, critical care and sleep medicine. Murtagh's career combines both writing and science. He has earned awards as an essay writer, as a Merit scholar and as a Westinghouse science award recipient. After graduation with top honors from a six-year combined medical program at University of Michigan medical school, Murtagh did his residency in internal medicine at Parkland Hospital in Dallas Texas. He then sub-specialized in pulmonary and critical care at the National Institutes of Health (NIH), where he served as a staff scientist in molecular biology for five years. Later, he took the lead in the emerging field of Sleep Medicine.

In 1991, Murtagh became assistant professor at Emory University medical school. He earned tenure in less than four years, and was awarded more than $2 million in grants for innovative research, and was awarded three patents for DNA detection methods. Murtagh became a prolific writer, authoring more than 40 articles (in Journal of Biologic Chemistry, Biotechniques, Nucleic Acid Research), and contributed to books on more general medicine topics and on bioethics. Murtagh became a scientific advisor to Boehringer Mannheim. He served at Atlanta VA hospital and at Grady Memorial County Hospital on joint appointment.In recent years, Murtagh has devoted substantial effort to medical ethics and medical writing.

A Selected List of Articles by Dr. Murtagh

1) 1) Murtagh JJ Jr.: Gout: Modern management of an ancient disease, J Dallas Med. Soc. 71(5):314, 1985.
2) 2) Murtagh JJ Jr.: Pulmonary worm disease: The untold story. J Dallas Med. Soc. 1986;72(2):176.
3) 3) Murtagh JJ Jr.: In defense of recombinant DNA research. In: Science and Ethical Responsibility (SA Lakoff, ed.). Readington, MA: Addison-Wesley Publishing, pp.187-203, 1980
4) 4) Murtagh JJ Jr.: When pharmacist and physician disagree. In: Difficult Decisions in Medical Ethics (D Ganos, ed.). New York: Alan R. Liss, Inc., p. 195 1983.
5) 5) Murtagh JJ Jr., Price SR, Van Meurs KP, Angus CW, Moss J, Vaughan M: Signal transduction by guanine nucleotide-binding proteins: Possible molecular basis for multiple forms of Go_ mRNA. Trans Assoc Am Phys 1988;CI:235
6) 6) Murtagh JJ Jr., Eddy R, Shows TB, Moss J, Vaughan M: Different forms of Go_ mRNA arise by alternative splicing of the transcript of a single gene on human chromosome 16. Mol Cell Biol 1991;11:1146-55
7) 7) Chu CS, Trapnell BC, Murtagh JJ Jr., Moss J, Dalemans W, Pavirani A, Lecocq JP, Cutting G, Guggino W,.Crystal RG: Variable expression of the cystic fibrosis gene in the human airways: Variable deletion of exon 9 coding sequences in cystic fibrosis mRNA transcripts in normal bronchial epithelium EMBO 1991;10:1355-63
8) 8) Murtagh JJ Jr., Mowatt MJ, Lee CM, Mishima K, Nash T, Moss J, Vaughan M: Guanine nucleotide-dependent signaling pathways in the intestinal parasite Giardia lamblia : Isolation of a gene encoding a 20 kDa ADP-ribosylation factor. J Biol Chem, 1992;267:9654-62
9) 9) Holloway B, Erdman DD, Durigon EL, Murtagh JJ Jr. The exonuclease-amplification coupled capture technique improves PCR diagnosis of human parvovirus B19 infection. Nucleic Acids Research, 1993; 16:3905-3906
10) 10) Murtagh JJ Jr., Lee FJS, Deak P, Hall LM, Monaco L, Lee CM, Stefens LA, Moss J, Vaughan M. Molecular Characterization of a Conserved, Guanine Nucleotide-Dependent ADP-Ribosylation Factor in Drosophila Melanogaster. Biochemistry, 1993, 32:6011-18
11) 11) Murtagh JJ Jr., The multigene families of guanine nucleotide-binding proteins: Evolutionary and computational analysis, Computers and Chemistry, 1993; 17:165-175
12) 12) Murtagh JJ Jr., Moss J, Vaughan M: Alternative splicing generates four distinct Goa transcripts: elucidation of molecular mechanisms. Nucleic Acids Research,1994;22:842-9
13) 13) Murtagh JJ Jr., Bai X, Vaghmar R. Zipper DNA Recombination: Multipurpose Adapters enhance Solid Phase sequencing and cloning. In Uhlen M, Hornes E, Olsvik Ø (eds.), Advanced in Biomagnetic Separation. Eaton Publishing, Natick, MA, 1994, pp. 49-60
14) 14) Somers VA. Leimbach DA. Murtagh JJ Jr. Thunnissen FB. Exonuclease enhances hybridization efficiencyBiochimica et Biophysica Acta. 1379(1):42-52, 1998 Jan 8.
15) 15) Rivera-Marrero CA. Burroughs MA. Masse RA. Vannberg FO. Leimbach DL. Roman J. Murtagh JJ Jr. Identification of genes differentially expressed in Mycobacteriumtuberculosis by differential display PCR. Microbial Pathogenesis. 25(6):307-16, 1998 Dec.