The patient was brain dead, and had been for several days. His head had been crushed in an automobile accident, and it was apparent to all concerned - the physicians, the patient's family and the hospital administration - that the only thing keeping him "alive" was a mechanical respirator.
But the hospital administrator, after consulting with the institution's attorney, refused to allow the physicians to declare the patient dead and disconnect the machine. Such a course of action, the attorney advised, might cause civil or criminal problems for the hospital.
At that point a police officer, who felt the family was being "knocked around" by the hospital, told Dr. Ron Wright, deputy chief medical examiner for Dade County, what was going on, and Wright did what he has now done several times - formally ordered the hospital to turn the body over to him for an autopsy, and warned that failure to comply with the order could result in a fine and a jail sentence.
In an era when the lines between "life" and death have become blurred, and many physicians, and particularly hospital administrators, are frozen into inaction by conflicting legal advice and fear of lawsuits. Ron Wright has become a unique figure, using the power of his office to provide a simple solution to what others see as a complex problem.
Wright described his order to the hospital in the young man's case as "a little love note." It read:
"I have been advised by Det. Mondo of the death of Michale McNichols following a motor vehicle collision. The body shall forthwith be sent to the medical examiner's office pursuant to Chapter 406.12 and 406.13."
Attached to the order was a memorandum signed by the next of kin and witnessed, reading: "I have been advised that my son, Michael E. McNichols, has irreversible brain death. I do not desire to have the body of my son continued on a respirator. I understand that the body will be taken to the medical examiner's office."
Did the hospital attorney resist the order? Wright was asked.
"Hell, he loved it! He was being a good attorney and wanted to limit his client's liability and he looked at it as an area of liability. I told him, 'you're out of your mind. However, if that's the way you feel about it, and you being one of those fellas who's supposed to know about those things, I'll tell you what I'm going to do: I'll issue the order and then I'll put anybody in jail who interferes with that, because I have that authority, and there's no way you can be liable for that because criminal penalties attach and I can put anybody in jail who fails to comply."
"We don't have any statutory language" defining death, said Wright during a recent interview" . . . so you can do whatever you want. Under those circumstances, I'm not very enthusiastic about them passing a statue. My general overall philosophy is that statutes primarily are licenses to sue and serve little other function."
About a dozen states, including Maryland and Virginia, now have laws defining death in terms of the permanent cessation of all activity in the brain, so-called "brain death."
The "brain death" definition is designed to be used when a patient has been placed on artificial life supports, and could, in theory, be kept "alive" indefinitely.
Wright said that, ironically, before the much publicized case of Karen Ann Quinlan, in 1975-76, he had little trouble over the applicaton of the brain death definition.
The Quinlan case, which got national and international news media attention, involved a comatose New Jersey woman whose father asked for a court order authorizing his turning off a respirator thought to be sustaining her life.
A lower court judge refused the request, but the New Jersey Supreme Court ruled in favor of the Quinlans, despite the fact that Karen Ann's brain was not completely dead. She was removed from the respirator, and is still "alive" today, in a Morris County, N.J. nursing home, comatose and weighing about 70 pounds.
After that decision, despite the latitude it seemed to give physicians, Wright said, the publicity began to make hospital administrators extremely leery of allowing the withdrawal of artifical life support.
In order to make things easier for the physicians involved in such cases, as well as to make things easier for the relatives of the patients. Wright is more than willing to take upon himself the burden of ordering the machines shut off.
Actually, it's not so much that he is ordering the machines shut off as he is ordering that the body be turned over to him for an autopsy, and since he isn't asking that the machines come with it, the effectively takes the heat off everyone involved.
Wright said that his last major confrontation with a hospital administration involved the case of a man in his 50s, who collapsed early one Sunday morning after a blood vessel in his brain burst.
By bending the rules a bit, he was able to get a judge to hold a special Sunday morning hearing at the hospital - with reporters and photographers in attendance - at which he successfully argued that the family was being forced to pay $2,000 a day to keep a dead body in the intensive care unit.
"I haven't had any more trouble with hospital adminstrators since they has about five television crews camped in their front yard. That type of publicity is not the type of [thing] they like to put up with," said Wright. "That took care of my hospital administrator problem."
Because of the publicity given a few of the cases he was involved with, Wright gets about three or four calls a week from physicians in the Miami area who want to consult with him before turning off respirators sustaining brain dead paitents.
He attributes the fact that he has yet to be sued to his acting only in cases where the family and physician are in agreement, and only the hospital administration is against disconnection.
The medical examiner said that he advises physicians that they are more open to suit if they don't turn off a machine than they are if they leave it on.
"Basically . . . liability has four elements," he explained: duty;: negligence in that duty; causality, that the damage you're talking about was caused by the negligence; and damages, which are fixed by thins flowing out of the negligence.
"Well, as to duty, obviously you've got a duty to your patient - they're paying the way and they came to you. Negligence? To measure negligence in malpractice you look to see . . . what national standards are for the care of patients. In 1968 and 1969 there were these articles in the Journal of the American Medical Association that talk about what you're suposed to do when you have somebody who's got irreversible brain death," said Wright, whose countryboy manner obscures his being one of only about 100 presently practicing, board certified, forensic pathologists in the country.
"It says, a) how to diagnose brain death, and, b) what to do when you got it. Them be standards. Now, when you don't do what the standards say, you is negligent. Now we're up to the causality part: Did your not doing that cause anything? Yes, damages! It runs about two grand a day. Now, when you've got money damages in our system of law you've got something called pain and suffering . . . and there's a lot of pain and suffering involved when you're making people not quite know whether their loved ones are dead or alive."
And using that reasoning, Wright says, he can usually convince physicians to turn off the machines themselves.