A Doctor’s Dilemma : Ethics, Medicine Prompt Refusal to Let Woman Die

When Dr. Allen Jay decided to practice medicine, his goal was to alleviate suffering and help his patients live long, healthy lives.

Now, the 50-year-old Del Cerro physician is under a court order to take an action that will mean almost certain death for an elderly woman he has cared for since 1979.

He can’t do it.

“Human life is precious, and it is my duty, first and foremost, to protect my patient’s best interest,” Jay said. “I assure you, killing a patient is never in that patient’s best interest.”

Vexing Moral Quandary

Much to his dismay, Jay is at the center of a lingering controversy over the life of 92-year-old Anna Hirth, a semi-conscious La Mesa woman whose family members recently won a court decision granting her a legal “right to die.”

In an interview Tuesday, Jay spoke at length about the vexing moral quandary he has faced since Hirth’s relatives asked him to remove a nasal feeding tube that has kept the frail woman alive at a La Mesa nursing home for 13 months.

“Initially I was angry and hurt and asking myself, ‘Why me? Why am I being asked to do this terrible thing, something that directly conflicts with my medical and moral beliefs?’ ” said Jay, who was reluctant to discuss the case with reporters until Tuesday.

“I had trouble sleeping. . . . I asked myself how, if I were to do this, I would ever explain it to my two children.”

Jay also described in detail how Hirth--despite tests indicating her limited brain activity--responds when he places a stethoscope on her chest during his weekly visits. He noted that Hirth frequently opens her eyes when her name is called, and appears to visually track voices and movements.

And he wondered how society--if it holds human life to be sacred--could permit a judge to require Jay to take a step that would trigger Hirth’s death by starvation or dehydration within a week’s time.

“It’s not like turning off a respirator,” Jay said. “This would be active starvation, which, for someone who is obviously capable of feeling, would be a horrible, horrible way to die.”

Hirth, described by Jay and relatives as a vivacious, feisty woman until she became mentally and physically enfeebled, choked on some food and fell into a coma in February of last year. Since then, she has been kept alive at Hacienda de La Mesa nursing home by sustenance administered through a nasogastric tube.

When Hirth’s condition failed to improve, Helen Gary, the woman’s lone surviving daughter, asked Jay to terminate the life-sustaining treatment. Gary and other relatives insisted that Hirth had abhorred the thought of existing in a vegetative state. Gary said that, at one point, her mother told her that “I would rather be dead than live like that.”

As further proof of their mother’s wishes, relatives said Hirth had even volunteered for a time at a Jewish home for the aged, but resigned because she could not bear the sight of patients lingering and waiting to die.

Took Case Eight Years Ago

Despite such arguments, Jay refused to remove the feeding tube. The internist said such a step would be both medically and ethically improper, and argued that Hirth was not entirely comatose and might one day emerge from her stuporous state.

“I’m not profound enough to know whose life is worth living and whose life is expendable,” said Jay, who began caring for Hirth eight years ago after her son, Aaron, brought her to him.

When Jay declined to comply with the family request, Gary hired Santa Monica attorney Richard Scott, the noted right-to-die advocate who represented cerebral palsy victim Elizabeth Bouvia in her successful campaign to refuse force-feeding.

The two-day, non-jury trial in the controversial case was heard last month before Superior Court Judge Milton Milkes. In a highly unusual move, Milkes at one point moved the legal proceeding to Hirth’s bedside in an effort to personally assess the elderly woman’s condition.

During the brief visit, Milkes stood at Hirth’s bedside and posed a question that indicated the judge’s dilemma in reaching a verdict in the case: “If I were in your place,” he asked, “and you were in my place, what would you decide?”

Hirth gave no indication that she heard the judge. Two days later, Milkes ruled that both human decency and legal precedent mandated that the elderly woman be allowed to die.

“When life has lost all function, it is not life which is extended,” the judge said at the time. “Rather, it is death which receives a reprieve.”

No Doctors Want Case

Under Milkes’ order, Jay was instructed to supervise removal of the tube or find another physician to do the job by April 6. If none could be recruited, Hacienda de La Mesa was permitted to terminate the treatment under the court’s authority.

Last week, Jay’s attorney informed the court that the physician had contacted “30 or 40” medical colleagues but had been unable to locate one willing to assume care for Hirth. Nurses at the home, meanwhile, have declined to remove the tube either--for moral reasons or out of fear that they could somehow be held liable for the woman’s death.

Given the conflict, Milkes stayed his order and set a new hearing for next Wednesday to decide the question of who will assume responsibility for ending the life-sustaining care.

While questions over Hirth’s fate linger, Jay is attempting to persuade an outside group to enter as a third party in the case. He has contacted the San Diego County Medical Society and the California Medical Assn., both of which have expressed interest and forwarded his materials to their attorneys.

“I would think that if a judge can order a physician to do something that is not in the patient’s best interest, regardless of the philosophical beliefs involved, then that would be of concern to groups representing those in the medical profession,” Jay said.

The physician also has continued efforts to find another doctor to assume care for Hirth. In addition to contacting physicians directly, Jay has posted notices in Alvarado and Grossmont hospitals, but no one has come forward.

He even asked Scott--who is a licensed physician as well as an attorney--to take over the medical case. Scott called the request “absurd” and declined.

“It seems to me that everyone--including Mr. Scott--is willing to have someone else do something they believe is right, but nobody has got the stomach for it themselves,” Jay said. “They all see fit to lay it at my feet.”

Scott, meanwhile, says he is irritated by Jay’s expressions of moral angst and skeptical of his claims that he is unable to locate a physician willing to assume care for Hirth.

Called ‘Poor Loser’

“Dr. Jay doesn’t seem to realize that the trial is over, the order has been made and he cannot just abandon his patients when the moral temperature goes up,” Scott said. “If Mrs. Hirth were alive and well, she could say ‘Get the damn tube out of me’ or she could keep it, even get four tubes. But she is incompetent, and it required a court of law to decide what her rights were. Now it seems Dr. Jay is simply behaving like a poor loser.”

Jay, meanwhile, stands by his belief that removing the feeding tube would violate the religious and moral beliefs he holds dear. If Hirth were being kept alive artificially by a respirator or some other “heroic” machine, Jay said, he would have no qualms about terminating treatment.

But Hirth’s organs are functioning fine, and removing nourishment is “something that would kill you or me,” said Jay, a religious man who is active in his synagogue. “I think it’s a chapter from Leviticus that says, ‘Neither shalt thou stand idly by the blood of thy neighbor.’ To me that means you cannot be actively or passively involved in the injury or suffering of another.”

Just a few days ago, Jay visited Hirth and experienced his most recent confirmation that life-sustaining care for the elderly woman should not be cut off.

“I gave her a light pinch on the shoulder--just a little pinch like one might give a small child,” Jay recalled. “She immediately grimaced and turned away from the stimulus. I have to ask myself, if she was entirely comatose, incapable of feeling, would she have done that?”