Cost-Benefit Ethics: The Case of Tirhas Habtegiris
Tirhas Habtegiris was dying of cancer. The 27 year-old legal immigrant was being kept alive on a ventilator at the Baylor Regional Medical Center in Plano, TX. Tirhas was desperately hoping to hang on until her mother could arrive from East Africa, but a joyful reunion and sad goodbye never took place.
On December 1, 2005, hospital authorities informed her brother that Baylor would be forced to discontinue her care in ten days. The brother and sister wanted just a bit longer to bring their mother to the States so that she could see her daughter one last time. But on December 12, the hospital withdrew the ventilator and in fifteen minutes, she died. The basis for the hospital’s decision was a seldom-used statute under the Texas Advanced Directive Law.1 It states that doctors do not have an obligation to provide life-sustaining treatment ten days after serving notice that such treatment is medically “inappropriate.” Tirhas died without ever seeing her mother again.
Tirhas Habtegiris was poor, black, and had no health insurance. The family, even with the assistance of the hospital, could not find a nursing home willing to take her to extend her treatment and life until her mother’s arrival.
The Habtegiris case raises a number of issues, including whether a cost-benefit analysis should be used as a primary ethical criterion in cases of life and death. The medical center recently issued a statement patently denying that the decision was made on economic grounds. It states: “Although patient privacy laws make it difficult to discuss the case in detail, ultimately, the treating physicians concluded that due to the patient’s severe terminal illness, the only compassionate course of action was to allow death to come naturally.” It further noted that it is unethical to provide non-beneficial treatment or harmful treatment “when death is inevitable from a terminal illness, even if the family is demanding that such treatment be provided.”2
I would like to take the statement at face value, but it’s hard for me to believe that the hospital would have stopped the ventilator on an insured or fully paying patient. Surely the sentiments of family solidarity and the significance of rituals surrounding final departure would have warranted extending the care a few more days—had economics not been in the equation. So we ask, should we make ethical judgments in particular cases of life and death, based on a cost-benefit analysis?
We must assert that good stewardship of finite, material resources and financial solvency are ethical goods that on the whole need to be pursued and protected. A health care institution that has to close its doors for financial reasons is not serving the health and welfare of human beings. But it is one thing to operate on the general grounds of stewardship and financial solvency, and quite another thing to make a life and death decision in a particular case on the basis of economics.
Most hospitals laudably do provide millions of dollars each year of “charity care” in which they will never receive any private or public reimbursement. The Baylor hospital statement asserts that they do the same, “including critical care in the ICU, when the treatment is beneficial rather than harmful to the patient.”3 But they insist, with full support from the hospital’s ethics committee, that in this case continuing the treatment was not only futile, it was harmful. But, harmful to whom?
Hospitals and society do not have infinite resources to do everything possible in all medical cases. Given the technology we have today, such a path would bankrupt the medical establishment and likely the nation in fairly short order. Moreover, there certainly is futile treatment, and society needs to recognize such. We as patients need to learn that we need not and should not pursue every course of action, when the treatments are medically futile.
But in given cases where death is imminent, the cost-benefit analysis must be kept at bay in the physicians’ or hospital’s decision making process. It is just too easy to cross the line into discrimination on the basis of race, economics, nationality, and other attending circumstances that easily skew our judgments. Moreover, a cost-benefit analysis in a given case, especially at the point of death, reduces human existence and human dignity to economics. And as Jesus put it, “People do not live by bread alone” (Matt. 4:4).
Tirhas Habtegiris’ value as a human being was not based on her ability to pay. Her value was secured by her creation in the image of God, thus precluding any counter medical judgments that rendered her dignity and worth to be second-rate. Had Tirhas’ family (and especially her mother) been at her bedside, the doctors should have gently tried to dissuade the family from continuing the ventilator, which was only extending the dying process. It was futile and death was imminent. I personally have offered such counsel as both pastor and ethics consultant. But the imminence of death and the cost of continuing treatment are not the only variables to be considered in this situation.
Most humans have a deep drive to be with their closest family members and friends when they leave this world. Tirhas wanted the woman who bore her and nurtured her to be there as she entered “the valley of the shadow of death” (Ps. 23:4). As her cousin Meri Tesfay said, “She wanted to get her mom over here . . . so she could die in her mom’s arms.4
When confronted by such requests, hospitals—even with their need for financial stewardship and solvency—should surely have the wisdom to provide a few more days to grant a patient one last legitimate wish. Ethical decisions are far more than the application of detached rules, the calculation of end results, or the assessment of cost-benefit ratios. They require wisdom that comes from God, and that is also in touch with our deepest human needs and longings.
Such wisdom is not some ambiguous, humanistic notion of compassion, which merely tugs at our hearts and is oblivious to reality—medical or economic. It is rather, a commitment to sustaining those sentiments in life that reflect our humanness, finitude, dependency, and dignity. We deeply desire to be connected to those with whom we have bonded as spouse, children, parents, and friends; especially at the moment of death, such sentiments should be wisely guarded.
After all, medicine and economics, while God-given gifts and moral goods in their own right, should be at the service of sustaining and honoring that which is truly human—our dignity, value, and most precious relationships.
1 See Chapter 166 of “Advanced Directive Law,” http://www.capitol.state.tx.us/statutes/docs/HS/content/htm/hs.002.00.00....
2 Baylor Health Care System, “Media Statement: Tirhas Habtegiris,” www.baylorhealth.com/aboutus/press/2006/011606.htm.
4 Janet St. James, “Woman’s death highlights health insurance crisis,” www.wfaa.com/cgi-bin/bi/gold_print.cgi.