Sunday, 17 November 2013

Tim Bowers: tragic accident raises serious questions about the limits of autonomy

Tim Bowers, newly married with his wife expecting their first child had a tragic fall while hunting that rendered him a quadriplegic.

His family pressed doctors to bring him out of his medically induced coma only one day after the accident to ask him if he wanted to continue living. He chose not to have the breathing tube replaced and died hours later.


The Daily Mail chronicles the events of that day:
Confronted with the devastating prognosis, Bowers' family asked doctors at Fort Wayne's Lutheran Hospital a hard question: Could Bowers be brought out of sedation so he could be told of his condition and decide for himself whether he wanted to live or die? The doctors said yes.
Tim - who has a step son - previously talked with his wife, Abbey, who he married on August 3, about never wanting to spend his life in a wheelchair, so his family knew which way it was likely to go, though it meant never seeing his unborn child. 
His sister - one of three - has seen this situation happen in her job. But her medical training also meant she understood the severity of her brother's injuries. His C3, C4 and C5 vertebrae were crushed. 
Though his brain was not injured, his body was irreparably broken. Surgery could fuse the vertebrae, but that would only allow Bowers to sit up.
He would never walk or hold his baby. He might live the rest of his life in a rehabilitation hospital, relying on a machine to help him breathe. He'd never return to those outdoor activities that gave him such peace.
'We just asked him, do you want this? And he shook his head emphatically no,' Jenny Shultz said.
These events create serious questions about the ethics of applying autonomy in these circumstances as well as the wisdom of posing such a grave question as: do you want to die? to a person so recently traumatized.


Editor of the disability website, New Mobility, Tim Gilmer, posed the begging question: How could Tim Bowers truly understand what might lie ahead for him just minutes after being aroused from a sedated state?


Just as it is difficult to imagine what life would be like with a severe Spinal Cord Injury, the decision to allow Bowers to be made conscious and to pose the ultimate question in these circumstances is deeply disturbing. Gilmer goes on:
True, his sister, a nurse, had seen quads in ICU, but had she ever visited a rehab hospital or gotten to know quads of a similar level as her brother who had gone on to live fulfilling lives? It’s understandable that his sister and family wanted what they thought was best for him, but was anyone in the family, most of all Bowers himself, competent to truly know his potential as a quad?
What is most reprehensible, in my opinion, is the role the hospital and doctors played, or rather, didn’t play. What was the big hurry in forcing a sedated patient to wake up and make such a decision? Where was the Hippocratic Oath — the moral lynchpin of the medical profession — to first “do no harm,” when it was most needed?
Another New Mobility contributor, Bob Vogel added to the debate:
Although with a severe SCI, recovery is highly unlikely, it does happen. I have a friend who crushed his C4-6 vertebrae in an accident and was told he was a complete C4 quad. Against all odds, two weeks later, the swelling in his spinal cord and spinal shock went away, and he woke up with complete sensation and movement.
Did the doctors provide the Bowers with information about possibilities of a fulfilling life, and were they familiar with examples of high quads living active lives, even if there is no return?
The article doesn’t explain why Bowers chose to die so soon, while he and his family were still in shock. Wouldn’t it have been better to at least explore the possibilities? Was it a financial decision? Could he have been uninsured, underinsured, in a difficult financial situation or unable to imagine how he might make a living or otherwise provide for his family? It isn’t uncommon for a severely injured person, especially when the injury is so new, to feel pressure to go off life support and leave his family with any savings they might have.
In my opinion, this story smacks of the “Million Dollar Baby” bias, where a fighter becomes a quadriplegic and asks her trainer to kill her — which he does. I feel that movies like this and media portrayals of high-level paralysis are in large part to blame for this kind of snap decision. And with this highly influential movie, the tragic character was a fictional invention. 
Australian quadriplegic, Shane Clifton, commenting on The Drum website is highly critical of the 'life not worthy of life' sentiment underlying the opinion and the problems with consent in such circumstances:
While I understand and sympathise with Bowers' decision, I am appalled that the doctors gave him the option to end his life at that time. Admittedly, Bowers had previously said to his wife that he didn't want to spend his life in a wheelchair. But this view merely betrays the fact that he shares the common able-bodied assumption that life with a spinal cord injury (SCI) is not worth living. Clearly, his family and doctors (as well as the global news media, which generally reported on the event without raising any concerns) shared the same opinion.
At stake is the issue of medical consent. Of course, people should be given the right to make decisions about their own future. But for consent to be meaningful, the patient needs to be fully cognisant of all relevant facts. In this case, there is simply no way that a patient - one day after a horrifying accident - is in a position to know what it might be like to live with a severe SCI.
In fact, research on quality of life (QOL) for ventilated quadriplegics suggests that "There is relatively strong evidence that people with high-level ventilator-dependent SCI rate their QOL as relatively good in the years after injury" - and that life satisfaction increases with time. And this is to say nothing of the fact that many people experience substantial recovery in the weeks and months following the initial accident. Just because someone needs ventilation in the early weeks does not mean that it will be permanent. Of course, it may be - but even then, it is possible to live a life full of accomplishment and meaning.
Of course, this life is difficult - indeed, impossible - to envision one day after a horrifying injury, lying on a bed, plugged into a spider web of tubing, unable to move. And because it is impossible, then so is meaningful consent.
In my view, Tim Bowers' doctors have failed in their duty of care, and it makes me wonder how this has come about. Is this decision (and its widespread endorsement) an indication of a loss in our appreciation of the sanctity of life? Is it part and parcel with the push for legalisation of "the right to die"? Has economic pragmatism and cost benefit analysis prevailed? 
Yes, Bowers had the right to refuse mechanical support to breathe but it remains highly questionable whether or not he could consent with full knowledge only a day after the accident and whilst likely still under the effects of the sedation.

Director of Second Thoughts,
John Kelly spoke at the
 EPC International Conference in
Toronto in November
This highlights the known problems with consent inherent in euthanasia and assisted suicide laws and also the problem of doctors making judgments about capacity and freedom from coercion. Doctors have no more competence to make moral judgments than you or I and, clearly, outside of their competencies, are perhaps only a little more aware than a non-medical person about rehabilitation and life with a disability.

And yet we would be giving doctors the choice to end our lives if euthanasia ever became law. Bowers made a choice - but what kind of choice was that, really?




4 comments:

  1. If Tim Bowers had been a Swiss or Dutch citizen and he had had this accident in his own country, he would very likely have decided to continue living, at least for a while. At least until he could properly assess his new disabled life. He would have felt secure knowing there was no hurry to make the decision because the option of euthanasia is always there. The restrictive laws in Australia and the UK make people do tragic things out of desperation. This is not rocket science, it's simple logic.

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  2. Nic, you miss the point completely. The Bowers tragedy is about the nature of consent. It would matter little where he was or what his ultimate decision was. Because euthanasia law is predicated upon being 'voluntary', discussions about the nature of consent are important. Bowers agreed to an end that was his right to make - the withdrawal of burdensome or futile treatment. But what I'm questioning is the nature of the decision which calls into question the whole nature of consent for euthanasia and whether or not it could ever be said to be truly voluntary.

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  3. I'm not sure I totally understand. Are you saying that if the patient had said "Yes I want to live" that would be rational and voluntary consent to treatment... But if he had said "No I want to die" that would be irrational and involuntary consent to euthanasia?

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  4. No Nic, I'm questioning whether his decision, in those circumstances, was an informed and rational consent. If they had waited a while and allowed him to have both a clear mind and a full explanation of his options, then any decision could be correctly understood as rational.

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