CLINICAL CASE FOR DISCUSSION
Mabel S.
Lawrence P. Ulrich, Ph.D.
Lawrence.Ulrich@notes.udayton.edu


Some Issues Raised:

Mabel S. is 69 years old and is suffering from coronary artery disease. She has suffered periodic attacks of angina for the past 3 years. In addition to the coronary artery disease she has extensive arthritis which causes her severe pain which antiinflamatory medication can only control in minimal ways due to the stomach irritation which is a side effect of maximum doses of the medication. She also suffers from frequent migraine headaches from which she has experienced only slight medical relief. She also suffers from diabetes which requires daily injections of insulin. Ms. S. is a widow (has been for 15 years) with three children, all of whom live in neighboring states. One of the children, Marie, has extended an invitation to her mother to come live with her but Mabel interprets the invitation to be rather half-hearted. Living with Marie would be difficult at best since Marie has one small child, one preadolescent, and one early adolescent. All three children exhibit behavioral problems which cause Mabel considerable discomfort when she visits. A son, Charles, makes a good living and has offered to set Mabel up in a retirement home in the city where he lives. But that seems to be the extent of Charles' willingness to look after her. A third child, Derek, has always experienced strained relations with his mother. While he keeps in limited contact with her, he seems to be disinterested in participating in the care of his aging mother. Mabel has a few women friends with whom she plays cards occasionally (when her hands can hold the cards) and a gentleman friend, a neighbor, with whom she occasionally goes to a movie or a play. Otherwise, her time is spent keeping her modest house, watching television, and reading mystery novels.
   Mabel's cardiologist, Dr. Simpson, has explained to Ms. S. the seriousness of her coronary artery disease and is trying to persuade her to have coronary bypass surgery. The tests show that she needs four bypasses and that lesser technological interventions will not benefit her. He clearly explains that she would not survive a heart attack in her current state and that, when she experiences such a heart attack, she will suffer a great deal of pain. However, she is somewhat of a surgical risk due to the diabetes but, with a successful surgery, she could very well live for many years. Without the surgery, she will probably not survive another year or so and her attacks of angina will become more frequent and the medication will become less and less effective. Her children are trying to persuade her (with varying degrees of enthusiasm) to have the surgery. Her friends are all strongly encouraging her to have the surgery.
   However, Mabel is reluctant to have the surgery. On the one hand she fears that she may have to go to a nursing home, if the surgery is less than successful. She abhors this prospect. On the other hand, if the surgery is a success, she will still have to cope with the progressing arthritis, continuing migraines, and all the other deteriorating maladies of aging. None of her options seem particularly desirable and this is causing her to become depressed. She talks more and more about her life being nothing but trouble for her and has made an appointment with her doctor to talk with him about providing her assistance in committing suicide. She lives in a state where suicide is legal.

Some Discussion Questions:

1. Is Mabel a terminal patient?
2. Is Mabel capable of making such a serious decision?
3. Is a "troubling" end-of-life and a desire for a "peaceful" sufficient warrant for assistance in suicide?
4. Does the osteopathic medical profession respond adequately to patients like Mabel?
5. What is the physician's obligation to Mabel with regard to the assisted suicide issue? . . . if he can't provide aid-in-dying?
6. How might an ethics consultation be helpful in resolving the disputes in this case?