‘Right-to-Die’ Confrontation : Feeding of the Comatose: a Medical, Legal Frontier

For almost three years Paul Brophy, 48, a former firefighter and paramedic, has lain in a coma at a chronic care hospital here, kept alive against his previously stated wishes by feedings through a tube surgically placed in his stomach.

He has no awareness of his surroundings and does not move, except reflexively to withdraw from being touched.

Brophy had been in excellent health until three years ago, when a blood vessel ruptured in his brain. He never regained consciousness after delicate neurosurgery.

Ironically, long before Brophy fell ill--partly because he had seen so many seriously injured accident victims in the course of his job--he repeatedly had told his wife to “pull the plug” if he should ever end up in a coma. A state probate judge has agreed with Brophy’s wife and legal guardian, Patricia, that her husband would rather be dead. But he ruled nevertheless that the feedings must be continued.

The legal battle over whether Brophy’s food and water can be stopped has become the latest confrontation between “right-to-life” and “right-to-die” advocacy groups.

And, like the Karen Ann Quinlan case in New Jersey a decade ago, this controversy has broad implications.

Until now, most such disputes have centered on whether to disconnect a respirator. But that focus increasingly has shifted to whether to stop food and water.

“This is a new area for the law,” said Prof. Alexander M. Capron of the USC Law Center. “Feeding symbolizes our caring for a person. Patients such as Paul Brophy are very vulnerable and dependent, so physicians and families have to be on their guard that factors other than the patient’s welfare will not overwhelm decisions.”

In addition to the Brophy case, similar cases are pending in New Jersey and Florida.

These cases may have a direct bearing on treatment decisions for an estimated 10,000 other comatose individuals nationally who are being kept alive in persistent vegetative states, at medical costs in excess of $100,000 a year each.

Effect on Other Groups

Medical and legal experts also believe that these cases may affect the care of other groups of patients, such as the demented elderly and the handicapped. And, they say, the cases may set an important precedent for balancing an individual’s right to refuse medical care against society’s ability to override that person’s wishes.

“If a court can tell Mr. Brophy that over his objections he has to be kept alive in a vegetative state for 30 years, we’ve sacrificed the most important part of the constitutional protections--to be free in one’s self and to be left alone,” said Cambridge attorney Frank Reardon, who represents Brophy’s wife of 27 years, Patricia.

But Dr. Richard A. Field, the physician-in-chief at New England Sinai Hospital, where Brophy is a patient, disagrees. He insists that while Brophy is badly brain damaged, he is still “very much alive.”

“We are being asked to terminate this man’s life with premeditation,” Field said. The doctors and the hospital “want to be excused” from being the executioners, Field said.

In recent years, the rights of patients to reject medical care have been strengthened through the courts--even if those choices might appear to be misguided or to perhaps hasten their deaths.

In California, the legal right to stop food and water for adult patients was recognized by the Court of Appeal in 1983 in the celebrated Barber case in which two Kaiser physicians were cleared of murder charges for halting intravenous nutrition to a comatose patient who had been removed from a respirator.

Elizabeth Bouvia Case

But, as a practical matter, the issue is far from settled, as illustrated by the case of Elizabeth Bouvia, 28.

In her ongoing case, judges have consistently rejected the quadriplegic, cerebral palsy victim’s pleas that her doctors be compelled to help her starve to death at a Riverside hospital. Since then, Bouvia has said she has changed her mind about starving to death. But in recent days, her lawyers have asked a court to force doctors at a Lancaster hospital to remove a nasogastric feeding tube inserted against her will.

And in a related controversy, the state Department of Aging last year advised nursing homes and families to reject doctors’ orders to pull out nasogastric feeding tubes from unconscious dying patients--in the absence of an explicit court order to remove the tube.

Some physicians believe food and water should not be considered medical care at all, but as a basic human need that is part of nursing and comfort care. USC’s Capron, however, said that most courts have found that food and water are medical treatments and thus are no different than other therapies, whose value is assessed on a case-by-case basis.

The Massachusetts case began on the night of March 22, 1983, when Brophy developed a splitting headache, rolled over in bed and fell unconscious.

Brophy regained consciousness at a local hospital, where a ruptured aneurysm was diagnosed. He was transferred to New England Medical Center in Boston to undergo neurosurgery. There, physicians advised him of the risks of such an operation, including permanent brain damage and even death. But without an operation, they told him, the blood vessel was likely to bleed again, perhaps killing him.

Just before undergoing neurosurgery, Brophy told one of his daughters: “If I can’t sit up to kiss one of my beautiful daughters, I may as well be six feet under.”

Brophy never woke up after the surgery. Since then, he has lain in a hospital bed without moving. One eye is closed, the other wanders aimlessly. His left hand is clenched so tightly that the fingernails break through the skin. He breathes through an opening in his neck. He depends on others for every need.

His wife visits him three times a week.

Brophy was a devout Catholic and one of eight children in a large and tightly knit suburban Boston family. His wife is a nurse who works part time with the mentally retarded and is active in the Catholic Church. They have five children.

Patricia Brophy said her husband is a “friendly, logical, and sensible man and a jack-of-all-trades.” He enjoyed hunting and fishing trips with his children and his brother, Leo.

Long before he became ill, Brophy had spoken with his wife about his desire not to be kept alive in a coma. Awareness of such injuries was never far from Brophy’s mind, Patricia Brophy said, recalling an incident in the late 1970s when her husband and his partner were commended for bravery for pulling a man with extensive burns from a burning truck--only to learn later that the man had suffered greatly before dying months later.

Brophy, according to his wife, threw the commendation into the wastebasket and said he wished that he had arrived on the scene five minutes later when it would have been “all over.” And he told his brother, “If I’m ever like that, just shoot me. Pull the plug.”

And referring once to the Quinlan case--in which a New Jersey woman’s parents ultimately won court permission to have her respirator disconnected--Brophy said: “I don’t ever want to be on a life-support system. No way do I want to live like that; that is not living,” Patricia Brophy, in court testimony, quoted him as saying.

‘A Big Leap’

Although Brophy never specifically discussed with any member of his family the issue of whether food and water should be withdrawn, Probate Judge David Kopelman said he was convinced on the basis of Brophy’s other statements that if he were able to see his current condition, he would forgo such feeding in order to terminate his life. Yet the judge ruled in October that the feedings were neither “burdensome” nor “painful” and must be continued.

“It is a big leap from saying (as Brophy did), ‘I don’t want any heroic measures,’ to saying, ‘I want to be dehydrated to death,’ ” said Peter Gubellini, an attorney appointed by the judge to represent Brophy.

“It is absolutely wrong to stop feeding an individual in this condition,” Gubellini said. “We must not become a society that determines who is going to live and die based on their quality of life or their ability to contribute to society.”

For a time after her husband fell ill, Patricia Brophy “had a lot of hope for a long time” that his condition would improve. And in December, 1983, she authorized an operation known as tube gastrostomy to create a portal directly into his stomach for feedings, a procedure that is is safer and less painful for long-term support of unconscious patients than tubes placed through the nose or mouth into the stomach.

During the next year, as she participated in a support group at the hospital for families with a chronically ill member, Patricia Brophy began to question her husband’s treatment.

The turning point came after she had a Fire Department ambulance take her husband home for four hours on Christmas in 1984, only to see him remain totally unresponsive to the family festivities.

“I had to make sure in my own mind that this wouldn’t be killing him and this would be what he wanted,” she said in a recent interview. “The physicians have convinced me that Paul has no interactions inside or outside his body. I see him very slowly starving to death now. This is more cruel and abusive than just to let him go.”

Clergy, Ethicists Consulted

With the unanimous support of the Brophy children and other relatives, she began consulting with clergy, ethicists and, eventually, a lawyer. From the start, the hospital opposed discontinuing her husband’s feeding.

Brophy’s doctors and the attorneys on both sides in the case agree that if his condition takes a turn for the worse, he will not receive “active medical intervention,” such as intravenous antibiotics or a respirator, to keep him alive.

When a Massachusetts appeals court takes up Brophy’s case later this year, the central question it must decide is whether a patient in a persistent coma--but not terminally ill--can be allowed to starve, if that is what he wishes.

Another unresolved issue is whether Brophy’s death from starvation would be painful. New England Sinai’s Field described starvation as a “cruel, abusive and barbaric way to die.” But other medical authorities believe that patients in persistent comas cannot feel pain. After hearing conflicting expert testimony on this point, Kopelman ruled it could not be determined with certainty whether Brophy could experience physical pain and suffering.

Ethical Integrity

While the Brophy case was in progress, the Massachusetts Medical Society adopted a resolution that, while not specifically about the Brophy case, supports the family’s position. That resolution says that stopping food is consistent with the ethical integrity of the medical profession if appropriate safeguards are followed.

Patricia Brophy said that if she wins the case on appeal, she will take her husband home from the hospital to die. She recalled that her 90-year-old grandmother died at home in the late 1950s “with no tubes in her” after she stopped eating and developed a fever.

“If we win, it will be a hollow victory,” said Patricia Brophy’s lawyer, Reardon. “It means the family will grieve and watch their father die. It will be a bad time.”