As the AP and the Indianapolis Star reported last week, Tim Bowers, a 32-year-old man from Decatur, Indiana, was hunting deer from a tree stand last week and fell 16 feet, breaking his neck and leaving him dependent on a ventilator and most likely paralyzed for life. The next day, doctors took him off the ventilator to ask him whether he wished to continue, given the likely prognosis, and he chose to stay off the ventilator. He died a few hours later, surrounded by family and friends.
The story first made local, then national news in large part due to the mixed feelings it engenders. On the one hand, this appears to be a case where a patient’s doctors respected his autonomy and choice, which many found praiseworthy. He was asked what he wanted, he answered, and he got what he asked for. On the other hand, many wonder whether he was responding emotionally or even irrationally to the situation, whether medical professionals at this point could confidently predict his future limitations, and thus whether it was right to “ask the patient” at this time and in this way. In the end, any opinion about all this involves a large degree of speculation, due to the limited information we have about a largely private event.
In a couple recent interviews with local news stations I said much the same. Unfortunately, this comes off as the sort of “two-handed philosophy” (“On the one hand…”, “On the other hand…”) that is as common as it is unsatisfying. But it is also appropriate. The case of Tim Bowers is truly a triumph of autonomy, a case where he had a chance to make a decision. In addition, people who knew him have asserted that he was consistent in never wanting to live in a wheelchair.
At the same time, did he truly comprehend what life as a paraplegic or quadriplegic would be like? Paraplegics often say that healthy people – or themselves when they were younger and not paraplegic – underestimate the quality of life of a paraplegic. Was Bowers overwhelmed by the severity of his accident, the life changing and tragic consequences, in a way that clouded his judgment? Did he have enough information to decide?
And, at a deeper level, if these were problems with his decision making, then how long should his doctors have waited to ask him what he wanted? What information should he have been given? Should he have been kept on a ventilator for weeks or months, perhaps even put though a procedure to create a tracheostomy (a hole in the throat, necessary if a person remains on the ventilator for more than a week or two), before he was deemed to have absorbed enough information, or comprehended his situation, to be able to make a decision? Down this road lies justice delayed, and thus denied.
The fact that the doctors took out his endotracheal tube as soon as they did suggests that the family may have specifically requested this, to ask him what he wanted sooner rather than later, perhaps because his previously stated wishes suggested that he would not want this.
While the case is unusual, it raises many of the same questions about autonomy, beneficence, rationality, and informed decision-making that many of us at the Center study in our research and teach in our work with students, doctors, and researchers. And at its core Bowers’ accident was a tragedy, for a man and his loved ones, and there was no easy answer for how to respect his wishes and thus provide truly “patient-centered” care.
Peter H. Schwartz, M.D., Ph.D.
IU Center for Bioethics