Helga Wanglie is 87, comatose, and being kept alive by a feeding tube and a ventilator in the intensive care unit of Hennepin County Medical Center, a high-technology facility in Minneapolis.
The hospital wants to turn the life-support system off, on the ground that Wanglie has no hope of recovering from the extensive brain damage she sufferred after cardiac arrest in a nursing home. The hospital says her treatment is futile and has been seeking permission from the family for a year to take her off the ventilator.
Wanglie's husband, Oliver, 87, says she is a deeply religious woman who told him some time ago, "Only He who gave life has the right to take life." He has fought the hospital's efforts, and told doctors that he believes his wife of 53 years would want to live.
The case ended up in probate court this week, with the hospital asking the judge to appoint a guardian who could authorize removal of the ventilator. Oliver Wanglie has cross-petitioned to be appointed guardian.
The case is believed to be the first in which a hospital has gone to court for permission to terminate care against the wishes of the family. One of the unusual aspects of the case is that Helga Wanglie's care is being paid for by a private insurance company, Medica, a large Minnesota-based health maintenance organization. Her care has cost about $800,000 so far. Peter Fish, manager of Medica's public relations, says that Minnesota state law requires that there be no limit on HMO benefits. "We wait for a decision by the physician or the family."
What usually happens in these cases is that Medicare, the public medical program for the elderly, will pay for care as long as a person has a chance of improvement. When Medicare stops paying, the family has to spend its own resources until it is essentially impoverished. Then the indigent elderly person's care is financed through Medicaid, the public health program originally designed for poor families and children. Private insurers will often call the shots as to the level of care they will cover.
Arthur Caplin, director of the Center for Biomedical Ethics at the University of Minnesota, says "frequently third-party coverage would influence management of cases. In some ways, this is why this is the case that has gone to court. It provides a much cleaner case to examine the issue of medical benefit and medical futility.
"In most cases, what happens is the hospital and the doctors honor the desire of the family even though they know what is happening may be futile." He said the Wanglie family, which includes two grown sons, has agreed to a "do not resuscitate" order should Helga Wanglie's heart fail. "The family has drawn a line."
Steven Miles, a physician at Hennepin and the ethics consultant to the hospital on the case, says that of the 1.7 million people who die in nursing homes and hospitals each year, about 1.3 million of those deaths are preceded by decisions to withhold or withdraw life support.
Miles says he believes that informed consent entitles patients to refuse treatment or to choose among alternatives a doctor will prescribe. "But informed consent has never been understood as empowering patients to prescribe any medical technology they want to. In this case, we are willing to transfer her to another provider, but we are not aware of any provider who considers this appropriate care. The question then is can the patient oblige us to perform care we don't think is beneficial?
"If society wants to empower families of patients to do this, so be it. We have 35 million people without health care. If this family can command this, but a black pregnant woman can't command prenatal care, it doesn't make any sense to me. This woman is at the end of her life. We've done all we can.
"We're not proposing rationing beneficial care. We're proposing that this care is not beneficial."
Caplin says there is no benefit to Wanglie's being in an intensive care unit. He suggests that one way out of this situation now is for the judge to order a nursing home to take her, and have a different set of physicians work out a care plan with her family.
The ethical questions raised by the Wanglie case are not simple to resolve, and they will keep coming up as the health care system is swamped by more and more elderly patients being kept alive by medical advances. Caplin says 70 percent of Medicaid is now going to care for elderly nursing home patients rather than children. He believes it is time to ask the question publicly: "Are there limits to what people can request, knowing that the costs are enormous and that we are going to have to deny those resources to others, particularly children, in order to indulge our autonomy."