New Case - Arthur Johnson III v. Charlotte Regional Medical Center

On Thursday, 19-year old Florida resident Arthur Johnson III was shot in the head.  He was declared dead and Charlotte Regional Medical Center prepared to harvest his organs consistent with his prior consent.  (Herald Tribune)  But Arthur's parents protested.  They wanted a "second opinion on whether he was actually brain-dead or if he could have recovered."  But the parents were unable to obtain a second opinion and, this afternoon, consented to stopping life support.  Arthur’s parents also objected to the organ procurement.  

As if the case were not sad enough, the Herald-Tribune reports that "Lifelink, the group that handles organ donations in Southwest Florida, typically does not proceed with harvesting if surviving family members object."  Lifelink apparently followed that policy in this case.  Apparently, Arthur had consented to organ donation.  Under Florida law and the law in almost every other state, his parents' consent was not required.  Moreover, the OPO should not allow the parents to "modify, deny, or prevent a donor's wish or intent to make an anatomical gift after the donor's death."  Fla. Stat. Ann. 765.512.

Autonomy at the End of Life - Classic Quote

"Making someone die in a way that others approve, but he believes a horrifying contradiction of his life, is a devastating, odious form of tyranny."

          --  Ronald Dworkin, Life’s Dominion

Addressing Inappropriate Care Provision at the End-of-Life: A Policy Proposal for Hospitals

Carolyn Standley and Brian Liang at California Western School of Law have published "ADDRESSING INAPPROPRIATE CARE PROVISION AT THE END-OF-LIFE: A POLICY PROPOSAL FOR HOSPITALS" in the Michigan State University Journal of Law and Medicine 15 (2010): 137-176.  

This article reviews many of the open issues, though it has two limitations.  First, it appears the article was written over a year ago, making its March 2011 publication a little dated.  Second, it does not grapple with the open issues in a sufficiently detailed manner.  For example, the end of the article offers a model institutional futility policy.  But the final step recommends that "if the disagreement persists after the ethics committee meeting" then the patient should be transferred.  Since such transfers are incredibly hard to find and effect, it seems a model policy really must address that situation.

Winnipeg Health Region Issues Reports on End-of-LIfe Conflict

Yesterday, the Winnipeg Health Region released two reports that examine how achieving consensus between patients (their families and representatives) and health care providers over end-of-life issues can be better supported.  Both reports are available here. 

"End-of-life decisions are personal and difficult," Dr. Brock Wright, WRHA Senior Vice President and Chair of the Regional Working Group, said. "But the vast majority are resolved through consensus. What we're trying to do here is put in place the necessary supports so that everything possible is done to facilitate agreement between families and care providers in the very small number of more complex and contentious situations."

The report produced by the Working Group chaired by Dr. Wright recognizes the College of Physicians and Surgeons of Manitoba's Statement on the topic is binding on all Manitoba physicians, but that broader WRHA policies and procedures that do not conflict with the College Statement, can be established that apply to all WRHA staff, including physicians. (The CPSM's statement is available on the College's website.)

Both reports raise the issue of whether there should be a legislated or internal review process to resolve end-of-life care issues between patients, families and health providers as an alternative to, or intervening step before, pursuing legal action through the justice system.

Minister of Health Theresa Oswald said she considered the suggestion, but thought it more appropriate for the region to put in place the support and resources to avoid disagreements between patients, their families and health professionals.

"Decisions about end of life care are sensitive, personal and best left to patients, their families and their doctors. We believe efforts should be directed to the resources and education that can support those decisions and prevent or resolve disputes between patients, families and health care teams rather than creating an additional legislated panel for patients or families to navigate in what would already be an extremely difficult situation," Minister Oswald said. "Patients' wishes about end-of-life-care should be identified as early as possible, and initiatives currently being implemented by the WRHA will help to clarify and honour those wishes."

Rasouli v. Sunnybrook - Ontario Physicians Must Use CCB to Resolve Futility Disputes

A couple of weeks ago, the Ontario Court of Justice issued its opinion in Rasouli v. Sunnybrook Health Sciences.  I posted a copy of the opinion here.  Some earlier Canadian cases (outside Ontario) held that physicians need not seek patient or surrogate consent to refuse life-sustaining treatment that they deem inappropriate.  The Ontario court rejected this proposition.  Instead, it ruled that Ontario physicians must use the CCB to resolve medical futility disputes.  

Advance Care Planning - Free Video

Loving Conversations: One Family's Story About the Importance of Advance Healthcare Planning 

The American Health Lawyers Association's Loving Conversations video follows a fictional family through the difficult process of making healthcare decisions for a loved one who did not execute an advance directive. Each dramatization is followed by a didactic session where health lawyers answer some of the questions raised in the video. This video will be helpful in facilitating conversations between you and your client or the healthcare provider and her patient.

National Healthcare Decisions Day in Delaware (April 15, 2011)

Designed for healthcare professionals.  (Public program is on April 16th)

National Healthcare Decisions Day in Delaware (April 16, 2011)

Designed for and open to the public.

Peter Singer on Joseph Maraachli - Which Lives to Save

Peter Singer argues that what has happened to Joseph Maraachli should teach us what to do - and what not to do - if we are really serious about saving human lives.

If Priests for Life were really serious about saving lives, instead of "rescuing" Joseph so he can live another few months lying in bed, unable to experience the normal joys of childhood, let alone become an adult, they could have used the money they have raised to save 150 lives - most of them children who would have gone on to live healthy, happy lives for 50 years or more. . . .  We can obsess over Joseph and Terri - or we can make an honest effort to save the lives of countless children whose names we may never know. It is our choice.

CCB Rules for Surrogate in Desmond Watson Case

After 14 months of treating him for dementia, pneumonia, bed sores and other ailments, Desmond Watson’s medical team at Oakville Trafalgar Memorial Hospital determined that he had noncommunicative and irreversible dementia and that no improvement can be expected.  (Toronto Star)  The medical team sought permission from Desmond's wife Maria to remove heroic measures from their treatment plan and care for him as a palliative patient.

Desmond’s wife and two of his daughters firmly opposed that approach, insisting the devout Catholic patient would have wanted to be given every chance at life despite any suffering he may be enduring.

The CCB panel found that the wishes of Maria, Desmond’s substitute decision maker, must be respected.   As super-CCB-lawyer Mark Handelman stated, "This was a case that basically pitted a person’s values and beliefs against his objective medical condition."  In such cases, the surrogate often prevails. 

Pediatric Futility Controversies: Ethical and Legal Considerations

In May 2011, at the Pediatric Academic Societies meeting in Denver:  “Futility Controversies: Ethical and Legal Considerations”  Here is the program description:

In pediatric clinical ethics today, the most common and intractable controversy is about medically futile therapy. Doctors and nurses get frustrated when they believe that further medical treatment is futile, but family members insist that treatment be continued. For professionals, such demands create a clash between their own personal moral beliefs and perceived legal or institutional constraints that force them to act in ways that violate those beliefs. Bioethicists are divided about the appropriate response to such dilemmas. Many professional societies, some hospitals, and some states have policies or laws to deal with these controversies. In this session, we will discuss the legal and philosophic basis for the conflict, review laws, legal cases, and statutes that are designed to address the issues, and will suggest ways that clinicians can respond to futility conflicts. Dr. Truog, an Anesthesiologist, Intensivist, and Bioethicist, will discuss the ways in which futile care might be symbolically important to family members. Dr. Feudtner, a general pediatrician, pallliative care physician, and bioethicist will discuss the ways in which discussions with families about hope can help redirect the goals of care from life-prolongation toward the circumstances of dying. Dr. Meadow, a neonatologist and bioethicist, will present cases from the NICU in which futility controversies were successfully resolved. He will present conversational strategies to help clinicians reach agreements with parents about appropriate care.

1:00 PM -	Background of the Futility Controversy John  D. Lantos Professor of Pediatrics, University of Missouri - Kansas City, Director, Children's Mercy Bioethics Center, Children's Mercy Hospital, Kansas City, MO
1:10 PM -	Why It is Sometimes Appropriate to Provide Futile Care Robert  D. Truog Childrens Hospital Boston, Boston, MA
1:40 PM -	Discussions with Families About Hope Can Help Redirect the Goals of Care from Life-prolongation Toward the Circumstances of Dying Chris   Feudtner The Children's Hospital of Philadelphia, Philadephia, PA
2:10 PM -	Conversational Strategies to Help Clinicians Reach Agreements with Parents about Appropriate Care William  L. Meadow University of Chicago, Chicago, IL
2:40 PM -	Discussion Discussion

Non-Medical Goals of Treatment

Surgeon Richard Thompson has a brief article in the February 2011 British Journal of Hospital Medicine titled "Medical Futility: A Commonly Used and Potentially Abused Idea in Medical Ethics."  It is an elementary overview of the concept using a narrow range of dated sources.  But Thompson does helpfully remind us that patients have treatment goals other than the "obvious biological goals of most treatments."  These include:

• Aesthetic (e.g. cosmetic surgery)


• Hedonic (e.g. analgesia)


• Personal (e.g. birth control)


• Psychological (e.g. antidepressants)


• Spiritual

If the treatment can achieve any one or more of these goals for the patient, is it futile?

Wilkinson & Savulescu on Medical Futility

Last month, I blogged about the early publication of "Knowing When to Stop: Futility in the ICU" by Dominic Wilkinson and Julian Savulescu.  The final article has been published and is (apparently because of its funding source) freely available on the Journal site.  This is primarily a review article.  As such, it is first-rate.  It succinctly summarizes the history and core issues surrounding medical futility (as well as citing several articles by Professor Pope).  



Still, I have one concern.  The authors write that there are two basic justifications for unilateral refusal:  (1) when further treatment is not in the patient's interests, and (2) when further treatment is harmful to others.  With respect to the first reason, the authors repeatedly refer to this as a "paternalistic judgment" about the value of treatment and life.  Yes, futility seems analogous to paternalism because empowering physicians to unilaterally refuse life-sustaining treatment brings us back to the strong-physician, weak-patient model of the 1950s.  But I do not think that providers hardly ever make a "paternalistic judgment" in refusing treatment either because it is unwanted by the patient or because it is not in her best interests.   



Calling the unilateral refusal a "paternalistic judgment" seems inaccurate on three levels.  First, unilateral refusals do not necessarily involve any paternalism.  Second, they actually do not usually  involve paternalism.  It is not the autonomy of the patient that is overridden but rather the decision of the surrogate.  The surrogate is often not an accurate spokesperson for the patient.  Therefore, overriding the surrogate actually promotes, not undermines, the patient's autonomy.  Third, the authors themselves do not advocate overriding patient autonomy.  If the patient herself really wants the treatment, the authors (following Truog) argue that physicians should provide it (unless the harm-to-others rationale obtains).  Ultimately, the patient's autonomy is respected.  Rarely do we have robust evidence of the patient's preferences applicable to her present circumstances and decide to override those.

Surrogates Replaced with Guardians Fight Back

In the United States as in Canada, surrogate decision makers who demand treatment that healthcare providers judge medically inappropriate are sometimes replaced with court-appointed guardians.  Interestingly, in the past weeks, some of those displaced surrogates have been turning around to challenge the decisions of the guardians, just as their own decisions were earlier challenged.  One case is the long-running Gary Harvey case in New York.  Another is the Rachel Nyirahabiyambere case outside Washington, DC.

New Case - Oakville Trafalgar Memorial Hospital v. Desmond Watson

The Toronto Star reports that "over the past two weeks, a provincial panel has been adjudicating an agonizing dispute over the life of 87-year-old Desmond Watson.  Doctors at Oakville Trafalgar Memorial Hospital, where Watson has been for more than year, have asked to cease aggressive, life-saving medical intervention."  





But Maria, his wife of 69 years, has steadfastly insisted he be given every chance at life. “How could I accept what they want to do?” she says. “I can’t. It’s against my religion and against his wishes. I would be murdering my own husband.”

New Report from Massachusetts Expert Panel On End-Of-Life Care

This week, the blue ribbon Massachusetts Expert Panel on End-Of-Life Care issued its report.  It found three core principles on which there is consensus:

1. From the time of diagnosis, as early as possible, every patient with a serious illness that may be fatal should be fully informed of the range of ways they might be taken care of. 


2. If the patient has preferences among that range, either for efforts to prolong life or for, say, as much time at home as possible, whatever those preferences are should be known, documented, and always available when decisions are going to be made.


3. Those preferences should always be respected when a person receives care.

To achieve these ends, the Panel makes several specific proposals which would be equally beneficial in any other state too:

1. A public awareness campaign to educate people about their options and encourage them to plan for their own end-stages.


2. Spread MOLST statewide.


3. Require institutions that care for patients with “life-limiting” conditions to systematically identify patients who could benefit from hospice or palliative care and help them get it.


4. Increase training in palliative care, and training in other forms of end-of-life care.


5. Require all health insurers to cover hospice care.


6. The creation of an “entity” to oversee and evaluate the state’s efforts at improving end-of-life care. 

Congress Investigating Agency Advance Care Planning Coverage Circumvention

This week, the House Energy and Commerce Committee sent this letter to HHS Secretary Sebelius questioning her short-lived attempt to expand now-available Medicare coverage for advance care planning.  

The Committee charges that "the secrecy surrounding their inclusion in the final rule indicates that this was a political maneuver designed to avoid public scrutiny and comment."  The committee further charges that "if a regulation based on a proposal that could not be enacted through the legislative process can be inserted into a final rule without a chance for any public comment, then there appear to be no limits to the power delegated to you as Secretary under the PPACA."  There will be a hearing next week exploring this further.

Ethical Choices: When Medicine Can't Save Your Life

Texas Treat Til Transfer Bill -- Patient and Family Treatment Choice Rights Act of 2011

Texas Representative Bryan Hughes has introduced H.B. 3520 which would materially amend the medical futility provisions in the Texas Advance Directives Act.  

The purpose of the Patient and Family Treatment Choice Rights Act of 2011 is “to protect the right of patients and their families to decide whether and under what circumstances to choose or reject life-sustaining treatment.”  The amendments proposed in the bill are aimed at ensuring that “when an attending physician is unwilling to respect a patient's advance directive or a patient's or family's decision to choose the treatment necessary to prevent the patient's death, life-sustaining medical treatment will be provided until the patient can be transferred to a health care provider willing to honor the directive or treatment decision.”

Specifically, the bill proposes to require that life-sustaining treatment be provided to the patient until the patient is actually transferred to another physician or health care facility willing to comply with the directive or treatment decision – unless the surrogate refuses such transfer.

National Healthcare Decisions Day in Delaware

Here is the schedule for an event open to the public on Saturday, April 16th, for National Healthcare Decisions Day.  

Registration 9:00 – 9:30 AM

Advance Directive Basics – Legal perspective

Timothy J. Snyder, Esq. Estate Planning Attorney Young Conaway Stargatt & Taylor, LLP

9:30 – 10:15 AM

Advance Directive Basics – Medical perspective

John Goodill, MD, Director; Jo Melson, RN, NP Pain & Palliative Care Service Christiana Care Health System

10:15-11:00 AM

Break 11:00-11:15 AM   

Community Resources

Chris Johnson, Social Worker Christiana Care Health System

11:15-12 noon

Lunch

Sponsor & Info Tables staffed

12:00 – 1:00 PM

Delaware Next of Kin

Thaddeus Mason Pope, J.D., Ph.D. Law Professor Widener University

1:00-1:45 PM

5 Wishes

Pat Singleton, Chaplain  Christiana Care Health System

1:45-2:30 PM

Break

Sponsor & Info Tables staffed

2:30-3:00 PM

AD – why it’s so important to get it right – a case study

Ereana Gogola, PCC  Christiana Care Health System

3:00-3:45 PM

Resources:  Sponsor & Info Tables staffed

3:45-5:00 PM

Do Courts Favor Families in Futility Disputes?

A hospital ethicist sent me this quote by Rebecca Dresser in a story on the Joseph Maraachli case.  She asked: Do you know if this statement is based on actual "legal cases"?

Rebecca Dresser, a professor of law and medical ethics at Washington University in St. Louis, said U.S. courts generally side with families in such cases that want to continue treatment for loved ones even in seemingly hopeless medical cases.

This was the heart of my response:  I think that is true in only a very limited sense.  Courts will order TEMPORARY injunctions to continue care until there can be a fuller development of the facts and experts.  Often the patient dies in the meantime, so the TEMPORARY injunction often ends up being dispositive.  But on the merits, courts have not generally sided with families.  Healthcare providers are overwhelmingly successful in these cases.

End-of-Life Disputes Go To Court

The Philadelphia NPR station ran this story, yesterday, titled "End-of-Life Disputes Go To Court."  It uses the Betancourt case as a vehicle to explore some of the public policy issues concerning conflict over end-of-life treatment.  The reporter effectively uses clips from interviews with physicians and with several lawyers involved in the Betancourt case, including myself.

Joseph Maraachli Transferred to St. Louis

Surrogate decision makers are almost never able to find a transfer facility in intractable futility disputes.  But the parents of Joseph Maraachli have.  (Toronto Sun)  Against the "strongest possible medical advice" from experts in Canada, the U.S. and Europe, London Health Sciences Centre said, Baby Joseph's parents accepted an offer to transport him by air to the faith-based Cardinal Glennon Children's Hospital in St. Louis, Missouri.  

Thirteen-month-old Joseph was flown out of London, Ontario at 10:20 p.m. Sunday on a private plane.  For pictures of the transfer see the Priests for Life site. Director Father Frank Pavone stated: "He needs to be in a hospital that cherishes life over the bottom line."  I am not sure this comment is fair, given the lack of evidence that the Canadian treatment and legal decisions were motivated by anything other than the best interests of Joseph.

Guardian Replaces Surrogate. Will Guardian-2 Replace Guardian?

The New York Times reports that the the children of Rachel Nyirahabiyambere have challenged the decision of a court-appointed guardian to remove their mother's feeding tube.  An Alexandria, Virginia Circuit Court ordered her feeding tube reinstated while the legal issues were weighed.  





It does not look like this latest court action is a direct attack on Georgetown University Hospital's November 2010 decision to remove the family as decision maker.  Rather, the inquiry will probably focus on the articulated rationale of the appointed guardian.  It seems that she did not act, as required, as a fiduciary to the patient.  The decision might very well be the same after this review.  But it seems that the guardian failed to appropriately consider the expressed desires and personal values of the patient and/or her best interest.

Palliative Medicine: Care versus Cure? (Diane Meier video)

While it was taped last September and just aired a couple weeks ago, this 28-minute interview with Diane Meier is, as one would expect, an excellent primer and overview of what is going on in palliative care.

Watch the full episode. See more The Open Mind.

Maraachli to Appeal Once Again

The Maraachlis lost before the Consent and Capacity Board in January 2011.  They appealed that ruling to the Ontario Superior Court of Justice.  In March 2011, that court affirmed the ruling of the CCB.  

Now, with their new attorney Claudio Martini, the Maraachlis plan to appeal the Superior Court ruling to Court of Appeal for Ontario. (Toronto Sun)  Even if the appeal fails, a stay would mean the parents get several more months.

Defying the Odds: Kimberly McNeill

In December 2010,   

New Zealand teenager Kimberly McNeill was in a very serious car accident on her way to a music festival.  Physicians determined that she would never recover.  After 15 days, they withdrew life support against her family's wishes.  

But, defying the odds, Kimberly pulled through and was transferred to a regional hospital and then, this week, to her parents' home.  (Hawkes Bay Today)

There really are limits to prognostication.  That fact and cases like this will continue to prevent some surrogates from accepting recommendations to move to comfort care only.  There is often a remote chance of error, a chance that there will be a "miracle."

Medical Futility Conference - Abstracts DUE March 25

The Australasian Association of Bioethics and Health Law Conference, "Expectations, Hope and Futility: Law and Bioethics in Contemporary Healthcare" (July 7-11, 2011),  has extended the abstract submission deadline to March 25th.

Ethics Committee Rejects Physician Request for Unilateral Refusal

Ethics committees usually agree with physicians who bring futility cases for review.  But a new physician blog, The American Doctor, describes a case in which the ethics committee disagreed with the physician.

Perception of Law vs. Reality of Law

What matters to practice is not what the law "is" but what the "perception" of the law is.  While the actual legal risks surrounding unilateral refusals are remote, the perception is that the risk is material.  I suspect this is due to cognitive features like salience.  Baby K had such a high profile, that while distinct (since most futility cases involve ICU and other inpatients not subject to EMTALA), it is thought to “control” these situations.

People's behavior is guided (1) by what they think the law is, (2) by what they think the chances of enforcement are, and (3) by what the sanctions are.  Less important are (a) what the law actually is, (b) what the chances of enforcement actually are, and (3) what the sanctions actually are.  

At some level, I am hoping to change the perception of risk both through education and through establishing safe harbors like regional ethics committees.

Surrogate Selection in Another Futility Dispute: Rachel Nyirahabiyambere

In April 2010, Rwandan immigrant Rachel Nyirahabiyambere suffered a devastating brain hemorrhage.  She never regained awareness.  After several weeks, Georgetown University Medical Center tried, unsuccessfully, to discharge her.  (NY Times)  Then, in November, the hospital filed a court petition in Alexandria, Va., seeking to have a guardian appointed.  The hospital explained: “We only take this somewhat unusual step when there is a concern that the family members are legally appropriate decision makers.”  A brief hearing took place December 28.  The sons pleaded for the family to retain the power to decide their mother’s fate.  But the judge appointed Andrea Sloan, a lawyer and nurse, as Ms. Nyirahabiyambere’s guardian.  Ms. Sloan transferred Ms. Nyirahabiyambere to a nursing home.  Ms. Sloan then directed that Ms. Nyirahabiyambere’s feeding tube be removed.  

So far, this is not terribly different than other surrogate selection cases.  But there are two disturbing aspects of this case.  First, there is some evidence that the patient would have wanted at least the feeding tube.  Her six adult children vehemently opposed the removal decision.  “Ending someone’s life by hunger is morally wrong and unrecognized in the culture of the people of Rwanda.”  But the guardian said that she would disconnect the patient unless her sons could demonstrate that she wished to live out her life “with a feeding tube, in diapers, with no communication with anyone.  In other words, the guardian appears to have made decisions on a pure best interest standard unless the family produced clear and convincing evidence of patient wishes otherwise.  This flips the presumption in favor of life, requiring evidence that the patient wanted to live rather than the typical requirement that the patient did not want to live under the circumstances.  It also demands more specific evidence than is typically demanded.

Second, money appears to have played a larger role in this case than in some others.  Ms. Nyirahabiyambere was uninsured.  The guardian wrote:  “Hospitals cannot afford to allow families the time to work through their grieving process by allowing the relatives to remain hospitalized until the family reaches the acceptance stage, if that ever happens . . . .  Generically speaking, what gives any one family or person the right to control so many scarce health care resources in a situation where the prognosis is poor, and to the detriment of others who may actually benefit from them?”

Causation in withholding and withdrawing life-sustaining measures

Andrew McGee, a law professor at Queensland University of Technology, has just published "Ending the life of the act/omission dispute: causation in withholding and withdrawing life-sustaining measures" in Legal Studies.  Here is the abstract:

The aim in this paper is to challenge the increasingly common view in the literature that the law on end-of life decision making is in disarray and is in need of urgent reform. The argument is that this assessment of the law is based on assumptions about the relationship between the identity of the defendant and their conduct, and about the nature of causation, which, on examination, prove to be indefensible. A clarification of the relationship between causation and omissions is provided which proves that the current legal position does not need modification, at least on the grounds that are commonly advanced for the converse view. This paves the way for a clarification, in conclusion, of important conceptual and moral differences between withholding, refusing and withdrawing life-sustaining measures, on the one hand, and assisted suicide and euthanasia, on the other.

Get Your Certificate of Thanatology Online

End-of-Life issues impact the practice of all healthcare professionals, counselors, clergy, hospice staff, social workers and many others. In order to provide appropriate, compassionate care, one must have a sound understanding of all aspects of grief – from anticipatory grief to post death grief.  Special Topics in Thanatology: Dying, Death and Bereavement is a three part distance learning program incorporating both video (DVD-ROM) and on-line instructions components provided on a password protected website. The program divisions are:

• The Grief Primer


• Issues and Interventions Related to Complicated and Disenfranchised Grief


• Capstone Experience

The two content DVD-ROMs contain from five to seven topic areas with multiple modules addressing each area. The Capstone Experience DVD-ROM contains an overview of the experiential component of the program.

This program is offered in educational partnership with University of Delaware.  For additional information or to register now, visit the information website at www.udel.edu/dsp/thanatology or call (302) 831-8370

Maraachlis to Make a "Run for the Border"

The Maraachlis are apparently planning to make a run for the U.S. border.  This sounds like a bad plan.  But at least one thing going for them is that the closest state is Michigan.  Michigan is in the Sixth Circuit which does not recognize an inpatient exception to EMTALA.  Consequently, regardless of the standard of care or the appropriateness of continuing treatment, a Michigan hospital could arguably be obligated to continue treatment indefinitely if Joseph reached its front door.  





This reminds me of the scene in First Do No Harm in which Meryl Streep's character tries to take her son out the hospital contrary to medical advice.  Hospital security stops her and the hospital then files to terminate her parental rights for not acting in her son's best interest.

London Health Sciences Center Publishes Account of Baby Joseph Case

As Baylor Hospital did a few years ago in the face of intense negative press regarding the Tirhas Habtegiris medical futility dispute, with respect to the ongoing Baby Joseph case, London Health Sciences Center has published "key facts about the situation to correct the record."  The hospital explains: "the public does indeed have a “right to know” the truth about this matter so that people can form informed opinions based on fact, not innuendo, speculation or untruths."

Baylor had to secure court permission to release confidential information.  LHCS, on the other hand, is able to merely summarize information already made public.  The Baby Joseph case, in contrast to the Habtegiris case, has been litigated through two levels of judicial review and the family has released a great deal of information to the media.