On the tape, the cries of one child grew louder, then diminished as the class followed Dr. Beyda to her room and then met in a break room. Her case unfolds below, just as the discussion evolved.
"We don't do anything but taking care of the critically ill and injured child." So "the less they see of me, the better off they are. And that's how the parents actually judge how well their kids are doing, is by how often they see a critical-care physician in the room...They very quickly learn how well their child's doing."
"[W]e deal with...the life and death issues of pediatric ethics." We ask "the same question that perhaps you're posing, and that is, I have the expertise to save a life; I also have the expertise to ask the question, 'Should I?' And that sometimes is very difficult for parents, because they know I do both, and they're not sure which part I'm coming from."
"When I first meet them they want me to, obviously, deal with the first issue, and that is save their child's life. They're not really interested in addressing the second part of that until maybe 24 or 48 hours later, after we start talking about what the ramifications are of their child living...We talk about ethical issues on every single patient every day on rounds, whether there's an ethical issue or not."
Patient 1
Three weeks before the class visit, a mother and two children were seriously injured in a motor-vehicle accident. "This is one of the children. Unfortunately he survived vegetative and has been on life support and unresponsive." There is no chance for recovery, Beyda says, but the parents want the child supported indefinitely, which the staff will do. "He'll survive on a ventilator, with extensive technology and support. He'll need 'round the clock nursing...Is this a burden to society? Do we have a right to question the burden of paying for this? "
Patient 2
"It's going to take a long time for her to catch up. If we can at least keep her alive, and do so without causing her long-term damage, then that's something that would, of course, be of benefit. Her parents are very open, very supportive, very understanding. We have some parents who just want things done. If the child doesn't eat, doesn't respond, then they want no part of it. It's kind of like, 'Fix 'em, and if you can't fix 'em, we don't want 'em.' Those are very difficult issues... About 20 percent of the time, parents are like that."
The sound of a child screaming in pain and crying "Mommy" grows louder.
Patient 3
"The child...that's encased" and unable to move "is encased for her protection. She is a 6-year-old girl with HIV who has multiple cerebral aneurysms. The reason she's screaming out, she has incredible pain in her head." Beyda's staff is trying to "figure out whether we should go in and operate on the aneurysms...or whether the HIV is a priority...[T]he HIV will take its toll" over time.
Later, a student questions Beyda about the child's continuing to live in agony. Won't any drugs help?
"The drugs aren't doing anything. We've got her on high-dose morphine...But the pain is so severe because of the pressure" of the aneurysms. "If I gave you the same dose I'm giving her, you'd be knocked out completely."
To even have a chance at relieving her pain, "[W]e've got to take her to surgery and try to relieve the pressure [and] that has a ninety percent chance of killing her. That's what we're struggling with right now, whether that's something we want to do, or whether that's something we should do."
- How soon will she die?
"We don't know -- but I think if there were surgery tonight, she would die tonight." - Could she live a month?
"She could." - Two months?
"She could." - With that pain?
"She could."
Maybe I'm assuming that it's a no-brainer, that if she's screaming in agony all of the time, I assume she wouldn't choose that.
"That's an assumption... [T]he first thing you cannot do is bring personal value judgments to the bedside... For this little girl, just being alive and being able to see her mom once a day may be worth it to her to endure the pain."
Do you ask her?
"No. How do you ask a 6-year-old who is already compromised by severe pain?"
So, as we talk, Beyda and the staff struggle over this terrible decision: to operate to relieve the girl's pain, which would almost certainly kill her, or to simply make her as comfortable as possible.
"My sense is that we're not going to operate. That we're going to spend time with the family addressing the issues - trying to increase the pain medication, make her as comfortable as possible and see where we go. I don't think anybody is prepared to take her to the operating room tonight a watch her die on the table. At the same time, I'm prepared to give her as much medication as I need to relieve her pain, but also knowing that I will accelerate her death. Is that euthanasia?"
How much are you accelerating her death with the increased pain medication?
"That's the part I don't know."
Will you come to the point where taking her to the operating room will not be fatal?
"No, she will still be fatal. Even if I get to that point, it would still be - from my perspective as an ethicist - it would be best for her to be on high-dose morphin...with the family around her bedside, knowing that with the next flip of the [morphine-drip] switch, so to speak, with the next dose of morphine, she'll stop breathing. But she'll do so with her family around her rather than in an operating room table...with noboby around her."
So basically, pain control cannot be reached. She would just receive more and more pain medication.
"That's correct. And that'...why I asked the question about euthanasia. Am I killing her or am I allowing her to die? I would argue as a physician that I'm allowing her to die. I'm not killing her. My intent is not to actively kill her. I'm allowing her to die.
Unfortunately the amount of medication that I'm giving her, sooner or later will compromise her to the point where she will die. But that's not my intent. That's different than what Kevorkian's intent was with his patients, and that was, here's a bottle of carbon monoxide - the intent is to kill you. Do you see the difference? Now some people say it's subtle, and I disagree. It's not subtle. Even for me it's not subtle. Especially when you're practicing medicine at the bedside.
Do you feel a patient has a right to go to someone like Kevorkian if they choose?
"I think it's not an issue of right. I've had [adult] patients ask me to kill them. My comment to them has always been, 'Why do you want me, a physician, to kill you? Why don't you just do it yourself? Why do you want to place that burden on me? If you want to kill yourself, you can now to go any bookstore and buy a book written by the Hemlock Society that tells you exactly how to kill yourself. It tells you how to put a plastic bag over your head, tells you how to mix up arsenic, tells you how to mix up cyanide, tells you how many phenobarbitol pills to take. Ever seen that? We'll go to my office, I'll show you that book... [T]here's an appendix on how to kill yourself. You don't need me to do that. And so what I'm arguing even though I'm sounding facetious, is, don't put that on me. You want to kill yourself? Do it.
