Dilemma for San Diego Area Medical Community : Physicians Balk at Patient’s ‘Right to Die’

As lawyers gather again this morning in an El Cajon courtroom to debate whether 92-year-old Anna Hirth will be allowed to exercise her “right to die,” the San Diego area medical community finds itself in an awkward position.

Although it has grown increasingly common for doctors in concert with patients or their families to terminate life-sustaining care for the irreversibly ill, the publicity and legal complexities surrounding the case of Anna Hirth have grown so daunting that no San Diego area physician will assume the duties that will lead to the La Mesa woman’s death.

“Since the case has so much notoriety, there is no way anybody is going to pull that tube,” Dr. Jacquelin Trestrail, president of the San Diego Medical Society, said Tuesday. “They would have every right-to-life person parading in front of their office saying, ‘You’re going to kill that person!’ ”

Or, as Dr. Kevin Glynn, chairman of the biomedical ethics committee at Mercy Hospital, said: “Why would I want to step into a maelstrom like that? I’d be crazy.”

Mrs. Hirth’s fate seemed settled March 24 when Superior Court Judge Milton Milkes signed an order affirming the right of her daughter, Helen Gary, to direct that her mother’s treatment be terminated.

Milkes’ order required the woman’s physician, Dr. Allen Jay, to remove the nasogastric feeding tube that is supplying nutrition and water to the comatose woman or to find a doctor willing to take on the job. If no doctor could be located within two weeks, Milkes’ order authorized the staff of the Hacienda de la Mesa nursing home to remove the tube.

But Jay--who since last fall has fought Gary’s wish that her mother be allowed to die--has refused to end Mrs. Hirth’s feeding, citing ethical considerations and doubts that her condition is irreversible. He said he has been unable to identify a doctor willing to take over the case. And nurses at the home have expressed their unwillingness to take the step that experts say will lead to Mrs. Hirth’s death within a couple of weeks.

The case--San Diego’s first courthouse right-to-die drama--has produced front-page headlines, generated debates at local law schools and drawn right-to-life advocates to demonstrations outside the nursing home where Mrs. Hirth has been since a stroke rendered her helpless in February, 1986.

Mrs. Hirth continues to live in a vegetative state while Milkes--three weeks after signing his order--considers either modifying it or finding some way to enforce it.

Meanwhile, area doctors--especially those who take a professional interest in medical ethics--are musing about the ramifications of the case.

The physicians seem agreed on only one thing--that they are uncomfortable with any circumstance in which a court, or some other authority, requires a doctor to take actions he considers unethical.

Trestrail said that if Jay decides to appeal Milkes’ order, the California Medical Assn. is prepared to file a friend-of-the-court brief defending the physician’s right to stand by his principles without outside interference.

“You go along with the tenets which I believe all organized medicine subscribes to--you believe the patient has a right to life or a right to death, if they so choose,” she said. “But we also believe a doctor should not be forced to do what he morally objects to.”

Typically, Glynn and other doctors noted, such cases do not turn into bitter public conflicts. Almost every day, they said, doctors, patients and families agree to end life-sustaining care--either with or without a “living will” or similar document stating the patient’s wishes.

‘Looks the Other Way’

“What happens in the real world is there are many times when patients are in nursing homes and are terminal, with let’s say a malignant disease,” said Dr. Albert L. Lizarraras, chairman of the bioethics committees of the county medical society and Alvarado Community Hospital.

“It’s elected by the family and the physician that we’ve gone so far and now let’s let the person die with dignity. . . . Everybody looks the other way, including the nursing home, and it’s no problem.”

The American Medical Assn. and some local medical societies have issued guidelines for making such decisions. Most hospitals have established ethics committees to consult with physicians who feel uncomfortable about making life-ending judgments. And a series of court cases--many of them won by Gary’s lawyer, Richard Scott of Santa Monica--have established the right of a patient or the patient’s family to call a halt to life-sustaining care, regardless of the doctor’s wishes.

But as the Hirth case has made abundantly clear, the guidelines and court rulings have done nothing to make the decisions to terminate treatment easy.

‘A Tough Burden’

“There is a legal right not to have treatment; Richard Scott is right about that,” said Daniel T. Broderick III, an attorney and physician who is president of the San Diego County Bar Assn. “And yet he and the family are asking a doctor or nurse--some human being--to be the executioner or to carry out the will of the family or of the person who doesn’t want to live anymore. And that’s a tough burden to put on somebody.”

With the San Diego medical community apparently unwilling to take that step, what resolutions to the impasse in the Hirth case do the doctors have to offer? The suggestions boil down to end runs around Milkes’ order.

Glynn proposes that Gary take her mother home. “She could care for her any way she wants or not care for her any way she wants,” he said.

Trestrail urges that Mrs. Hirth be removed from San Diego. “Maybe if they moved the patient out of our jurisdiction, up north, if they could find a home to take her, they could diffuse the situation and find another doctor to do it,” she said.

Scott said Tuesday that he doubts the legal battle over Mrs. Hirth’s fate would be resolved by moving her out of San Diego, and he said he did not think she should suffer further, given that her rights have been vindicated in Milkes’ court.

“I don’t think Mrs. Hirth should have to have second-rate medical care just because she’s won this lawsuit,” he said.