Ethics Cases G-L

Cases G-L

Gilgunn-Massachusetts General Hospital
In the Matter of Guardianship of L.W.
Johnson Controls
Linares, Sammy

Alpha Lists: A-F G-L M-R S-Z

Return to For the Public - Table of Contents

Return to For Affiliates - Table of Contents

Gilgunn-Massachusetts General Hospital

In mid May of 1989, Catherine Gilgunn, a 71 year-old resident of Charlestown, Massachusetts, fell in her home and injured her left hip. She had been hospitalized three times before to repair a broken hip, and was reluctant to go to the hospital one more time. She had been in generally poor health for many years, with diabetes, heart disease, and chronic urinary tract infections. She was recently diagnosed with Parkinson’s disease, and also recently received a mastectomy for breast cancer. Moreover, she had suffered a stroke the year before, from which she never fully recovered.

Catherine’s 30 year-old daughter Joan, her primary caregiver, allowed her mother to delay going to the doctor for several weeks. Medical complications secondary to diabetes began appearing. Joan took her mother to Massachusetts General Hospital (MGH) on June 7, 1989. Nine days later, before surgery could be performed, Catherine suffered two grand mal seizures, followed by repeat seizures that could not be controlled until June 29^th. Before the seizures could be brought under control, she suffered extensive brain damage, resulting in a coma. Joan, who was the surrogate, informed the physicians (with the approval of Mr. Gilgunn and the other five children) that Catherine always said she "wanted everything done" that was medically possible. With the encouragement of the hospital’s Optimum Care Committee (OCC), Mrs. Gilgunn’s attending physician wrote a DNR order on July 5^th, despite these expressed wishes. Dr. Ned Cassem, the Chair of that committee and acting as the consultant, took the view that the family’s opinion was not relevant, since CPR was not a "genuine therapeutic option." The social worker notes concurred that the family’s inability to prepare for the inevitable did not "justify mistreating the patient." Because of his inability to argue strongly on medical grounds against Joan and her family’s beliefs, the doctor revoked the DNR order two days later.

The following month a new attending physician, Dr. William Dec, took over the case. The new attending physician couldn’t convince Joan of the inappropriateness of CPR for her mother. Dr. Dec asked the OCC to review the case again. Dr. Cassem, still acting as a consultant on behalf of the committee, once again endorsed a DNR order because CPR would be "medically contraindicated, inhumane, and unethical." Dr. Dec, with the approval of the MGH legal counsel, wrote the DNR order. He also began to wean Catherine from the ventilator, since he regarded her as imminently dying. Her blood gases were not monitored during the weaning, because Dr. Dec did not expect her to survive on her own. Three days later, on August 10, 1989, Catherine Gilgunn died.

Joan Gilgunn sued the physicians and the hospital, alleging neglect and infliction of emotional distress. On April 21,1995, the jury returned a verdict in favor of the physicians and the hospital. They stated that although Catherine Gilgunn would have chosen to be resuscitated, such resuscitation would have been medically futile. Alexander Morgan Capron, an attorney-ethicist at UCLA, in writing his analysis of the case, points out that the American Thoracic Society position paper on life-sustaining therapy holds that life support "can be limited without the consent of the patient or surrogate when the intervention is judged to be futile." The paper defined "futile" as an intervention

that would be highly unlikely to result in a meaningful survival for the patient…Survival in a state of permanent loss of consciousness…may be generally regarded as having no value for such a patient.

In contrast to this typical approach in the literature, following the judge’s instructions, the jury found that the care withheld from Catherine Gilgunn was futile simply because it would not provide a cure. They never addressed the issue of "meaningful existence." Hence, for Capron, the case gets us no further

in developing public policy on the acceptability of physicians’ following counsel of the type offered by the Thoracic society--namely, that they are entitled to withhold care that does not offer sufficient likelihood of producing a "meaningful" existence for their patient.

Capron noted further that, because the plaintiff’s case was based on the claim that the defendant’s conduct had negligently inflicted emotional suffering on Joan (not Catherine), the real issue in the case did not get addressed, namely:

That the hospital at the time lacked adequate procedures to resolve the dispute between the family and the physician in an appropriate fashion and to maintain the treatment modality preferred by the patient until the issue was resolved.

[Sources: Capron, AM, "Abandoning a Waning Life," Hastings Center Report, 25, 4 (1995): 24-26. Gina Kolata, "Court Ruling Limits Rights of Patients," New York Times, April 22, 1995, 6. American thoracic Society, "Withholding and Withdrawing Life-Sustaining Therapy, Annals of Internal Medicine 115 (1991): 478-85. Kevin O’Rourke, Healthcare Ethics USA, 3 (1995): 6-7.]

Principles & Concepts: human dignity, autonomy, proportionate/ disproportionate means, futility, nonmalificence, best interests.

Return to Top

In the Matter of Guardianship of L.W.

While this case pertains explicitly to Wisconsin and may not carry precedence in other states, it very clearly states some criteria and guidelines for considering best interests. Though the criteria and guidelines for considering best interests vary from state to state, these particular guidelines and criteria may be useful for decision-makers and ethics committees to consider as a model process. The Wisconsin Supreme Court held that an incompetent individual in a persistent vegetative state has a constitutional right to refuse all life-sustaining medical treatment, including artificial nutrition and hydration. The Court emphasized that its decision only pertained to wards in a persistent vegetative state with no reasonable chance of recovery to a cognitive and sentient life, a condition which must be determined by the individual's attending physician, together with two independent neurologists or physicians. A guardian may exercise the ward's limited right to refuse, where the ward is in a persistent vegetative state, by applying objective criteria to determine whether withholding life-sustaining medical treatment, including feeding tubes, is in the ward's best interests. Criteria the guardian must consider and the procedure for the guardian to follow are:

If the ward has previously clearly stated his or her wishes, either to withhold or remove life-sustaining treatment, or not to remove or withhold life-sustaining treatment, the guardian must follow the wishes of the ward.

If the ward has not previously expressed his or her wishes regarding the treatment, the guardian must presume that continued life is in the best interest of the ward. This presumption can be overcome if the guardian determines in good faith that withholding or withdrawing treatment is in the ward's best interests by considering the following four factors:

The degree of humiliation, dependence, and loss of dignity probably resulting from the condition and treatment;
The life expectancy and prognosis for recovery with and without treatment;
The various treatment options;
The risks, side effects, and benefits of each of those options.

The guardian must assess these factors from the standpoint of the patient, and should not substitute his or her own view of the quality of life of the ward.

The guardian should also consider the opinion of an ethics committee, if one is available at the facility where the ward is receiving medical care.

The guardian should consider the opinions of a spouse, next of kin or an individual who has been a close friend or associate for a significant period of time.

Further, a guardian must adhere to the following procedures:

Notice of the decision to withhold or terminate life sustaining treatment must be given to any "interested parties," including: the ward; the ward's spouse; next of kin; an individual who has been a close friend or associate for a significant period of time; the ward's physician and the facility/agency where the individual is receiving his or her medical care; the individual's guardian ad litem, if any; an agent under a durable power of attorney for health care; and any official or representative of a public or private agency, corporation or association concerned with the ward's welfare.

"Formal" notice is not required, but the notice must inform the interested parties of the decision and allow adequate time for parties to respond.

If none of the above interested parties objects, the guardian may make the decision without a court hearing.

If an interested party objects, the court will presume that continued life is in the best interests of the ward, and the burden will rest on the guardian to show both the existence of a persistent vegetative state to a high degree of medical certainty and that the decision to withhold or withdraw treatment is in the ward's best interests and is being made in good faith.

[Source: In the Matter of Guardianship of L.W., 167 Wis.2d 53, 482 N.W.2d 60 (1992) & Wisconsin Coalition of Aging Groups].

Principles & Concepts: autonomy, beneficence, human dignity, substituted judgment, futility, best interests, proportionate/ disproportionate means, surrogate decision-making.

Return to Top

Johnson Controls (UAW v. Johnson Controls)

This case illustrates how health care ethics is not only limited to clinical ethics, but also encompasses organizational ethical issues such as occupational hazards and safety concerns, human resource policies, environmental health, and other issues affecting the work place, as well as the complexity of the relationship between law and ethics in general. A 1990 U.S. Supreme Court case in which it was argued that women could not be discriminated against in the workplace on the grounds that they might become pregnant. Among many other items, Johnson Controls manufactures batteries, a principal component of which is lead. Johnson Controls had developed a fetal protections plan in an attempt to balance the adverse health effects of lead exposure against developments in civil rights law. Prior to the Civil Rights Act of 1964, Johnson Controls employed no women in the manufacture of batteries. Thereafter, the employer adopted a program to notify female employees of the dangers involved, and to obtain written acknowledgement of that warning. Despite these warnings, over the next several years, eight employees became pregnant while exhibiting significant blood-lead levels. The company responded by excluding any woman who could not medically prove her infertility from positions in which lead was present. The restrictions further excluded all women from any job which might result in transfer or promotion into an exposed position.

In 1987, displaced employees alleged that the battery manufacturer’s fetal protection plan constituted gender discrimination in violation of Title VII as amended by the Pregnancy Discrimination Act of 1978. The trial court granted summary judgment for the employer, finding that the plaintiffs had failed to prove essential elements of their claim. An eleven member panel of the Seventh Court of Appeals concurred, finding that airborne lead within the battery plants represented a significant fetal health hazard. The court described previous appellate decisions allowing such policies under the business necessity defense, and agreed that this theory should control. In finding for the employer, the circuit court never addressed the impact of the Pregnancy Discrimination Act, nor stated whether it was adjudicating a case of overt discrimination or disparate impact; it simply chose which defense would control.

In a unanimous decision, the U.S. Supreme Court reversed the Seventh circuit Court Decision, finding policies which represent such overt gender discrimination unlawful under traditional Title VII analysis unless the plan meets a narrow "bona fide occupational qualification" (BFOQ) defense. A majority of the court found that Johnson Controls’ plan could not be maintained, since that defense could not be stretched to encompass the company’s concerns for fetal safety. [Source: Rutgers Law Review 1992; 44: 479-529. No. 89-1215, 499 U.S. 187 (1991).]

Principles & Concepts: beneficence, autonomy, nonmalificence, justice, paternalism.

Return to Top

Linares, Sammy

This case brought recognition to surrogate decision-making on behalf of minors and endures as an example of the confusion these kinds of cases can generate. On August of 1988, eight month old Sammy Linares swallowed a balloon and suffocated. He was taken to Rush-Presbyterian Hospital in Chicago where he was placed on a ventilator. It was finally determined that he had extensive, irreversible brain damage and was comatose (most likely in a persistent vegetative state). Against the wishes of both parents, the hospital refused to allow Sammy to be taken off the respirator, citing "hospital policy." After repeatedly pleading with the hospital to no avail, Rudy, the baby’s father, disconnected the respirator in December, only to have nursing staff reconnect it. Finally, on April 26, 1989, holding back hospital staff and police at gunpoint, Rudy disconnected the respirator from his 16-month-old son. Sammy died just 30 minutes later. Rudy then dropped the gun, and was taken into custody. He was immediately charged with first degree murder and assault with a deadly weapon. The grand jury threw out the murder charges, but Rudy was ultimately convicted of assault. [Source: 17 Law Medicine & Healthcare 295 (1989).]

Principles & Concepts: best interests, human dignity, right to life, benefits & burdents, proportionate/ disproportionate means, respect for autonomy.

Return to Top