Fall, 2005
Review by David Goldblatt, MD
Professor Emeritus of Neurology and the Medical
Humanities University of Rochester School of Medicine and Dentistry
Million Dollar Baby, a movie based on a short story
by a former boxer and cut man, won four 2005 Academy Awards, including best
picture, actress, supporting actor and director (Clint Eastwood). I will
discuss the ethical dilemma presented in the film. If you don't know the plot,
you should decide whether you want to read on.
Maggie, a boxer, has been sucker punched in a title fight.
She has high cervical, ventilator-dependent quadriplegia. She transfers to a
rehabilitation facility, all expenses paid by the Boxing Commission. Despite
competent care, she loses a leg to infection. With her career at an end and no
other interest in life (she has at last rid herself of her cartoonish
trailer-trash family, and she has no desire to pursue an education), she asks
her devoted manager and trainer Frankie, played by Eastwood, to help her to
die. She does not have
that discussion with her doctor, whom we see only briefly.
When Frankie tells Maggie he can't do what she wants him to,
she tries, twice, to kill herself by biting deeply into her own tongue. Her
doctors respond by keeping her under sedation.
Frankie, a questioning Catholic, goes to his priest, who
says that if Frankie does help Maggie to die, he will be irredeemably "lost."
Nevertheless (in a strategy that works on the screen but would cause a patient
suffering in real life), Frankie, in secret, first disconnects the ventilator,
then administers a large dose of epinephrine through the IV.
This depiction of mercy killing has evoked much discussion,
from persons partisan to the sanctity-of-life concept and from advocates for
the disabled, some of whom believe that the able bodied are plotting to do away
with the disabled by discounting their lives, failing to acknowledge that it's
"all right" to be that way. Both factions appear to have accepted the film's
tacit assumption: Maggie's doctor, who has kept her alive even at the cost of a
leg, and has kept her from taking her own life even at the cost of her
alertness, would, if he were to abandon the fight and let her have her wish, be
no different from Frankie. He would be killing his patient. Because he can't do
that, it's up to Maggie and Frankie.
Because I don't buy the story's premise, I don't - how else
can I say it? - buy the punch line.
Euthanasia, suicide and assisted suicide remain choices,
legal or not, for persons who have the capacity to decide whether or not to
live with either disability or illness. As a person who has undergone chemotherapy,
I think about decisions I may or may not act on if my illness progresses
despite treatment. These choices are important, but, in Maggie's situation, they
should be irrelevant.
Persons who retain the capacity to make decisions on their
own behalf and who are receiving any form of treatment have the right to refuse
it. That remains true even when foregoing treatment will surely result in
death. When a person who is receiving life-sustaining treatment (usually,
artificially administered hydration and nutrition, hemodialysis or mechanical
ventilation) has firmly made the decision not to "live this way," euthanasia or
suicide, assisted or not, is neither appropriate nor required.
As a clinical ethicist, I have talked with competent,
ventilator-dependent patients who had traumatic quadriplegia or amyotrophic
lateral sclerosis, to help them decide about foregoing life-sustaining treatment.
As an attending physician, I have withdrawn ventilatory support. Those
experiences were difficult and deeply moving. My skills in both roles improved
with experience. I do not regret my participation.
Maggie, as she was portrayed, had the capacity to make a
valid refusal of treatment. Once she had made her decision, her doctor should
have been the one to stop the ventilator, in accordance with a tested protocol.
No physical suffering. No horrible self-mutilation. No clandestine, illegal
mercy killing.
Whether or not good ethics and attention to established
legal precedent could have made a good short story or a good movie is a
question I shouldn't try to answer. Nevertheless, the movie had the opportunity
to inform the public that, when a treatment is life-sustaining, another choice
exists. Passing up that opportunity was a booboo.
As we were about to get into our cars outside the theater
where we had just watched Million
Dollar Baby, a man who recognized me and knew I am a doctor remarked
on the ending. I gave him the 30-second version of this article. "That's good
to know," he said.
Additional reading
Bernat JL, Cranford RE, Kittredge FI Jr, Rosenberg RN.
Competent patients with advanced states of permanent paralysis have the right
to forego lifesustaining therapy. Neurology
1993;43:224-225.
in collaboration with
Dartmouth-Hitchcock Medical Center
The opinions expressed in the journal, Lahey Clinic Medical Ethics,
belong to the individual contributors and do not represent the institutional position
of Lahey Clinic on any subject matters discussed.
