Yesterday's session in the first year Harvard Medical School "Medical Ethics and Professionalism" class was exceptionally powerful. The (required) course is taught in seminar, but yesterday was a plenary session, the second of two classes focused on end-of-life care. Dr. Rick Martinez, Director of Psychiatric Emergency and Forensic Services at Denver Health, the largest safety net program in Colorado, told the class about Mr. David Drummond, and showed a video of Mr. Drummond speaking. (This is his real name - Mr. Drummond's wish, supported by his family, was to be a teacher after his death. He asked Dr. Martinez to share his full story, including his name and details of his life.)
On May 3, 2007, David Drummond, who had been homeless for three years, fell off a wall while drunk and high on crack. He sustained a high cervical fracture and spinal cord injury, leaving him quadriplegic and ventilator dependent. As soon as he was able to communicate he requested that the ventilator be removed and that he be allowed to die. Dr. Martinez was called as a consultant to assess Mr. Drummond's competence to make a decision that Colorado and federal law clearly allowed him to make, assuming decisional capacity. He orchestrated a series of meetings - with Mr. Drummond alone, with Mr. Drummond and his family, with Mr. Drummond and his pastor, and, most remarkable, with Mr. Drummond and the entire clinical team, including hospital administrators.
The conclusion was that Mr. Drummond clearly understood his condition, the recommendations for rehabilitation, and the fact that most people with spinal cord injuries, including quadriplegia, ultimately adapt and experience a better quality of life than they predict for themselves shortly after the accident. He consistently expressed the wish for his life to end, emphasizing that being physically active was a central component of who he was as a person. Interestingly, once he was told that the decision about continuing or withdrawing the ventilator was in his hands he briefly asked "is my life's work done?" But once he had effected some reconciliations within his family he said he was ready. His family and pastor supported his decision. On September 24, surrounded by people who loved him, the ventilator was turned off, and he died.
I am writing about the class in this blog about organizational/health system ethics because of the way David Drummond, supported by Dr. Martinez, turned a personal tragedy into an opportunity for societal learning. The staff meetings at Denver Health - with more than 25 people (including Mr. Drummond) participating, were remarkable examples of collaborative deliberation. Organizations tend to fall into silos. Silos see issues from their own narrow perspective. The meetings Dr. Martinez orchestrated brought the partial perspectives of the multiple silos into thoughtful, deliberative exchange, leading to a decision that Mr. Drummond, his family, and most of the caretakers, felt at peace with. And, even those who saw the situation differently agreed that all points of view had been listened to respectfully.
The students focused on what it meant that if Mr. Drummond continued with the rehabilitation process, an imagined future self might look back and say "I sounded as if I knew what I was talking about then, but I wasn't ready or able to see what my life's mission turned out to be." Did that mean that the decision he made was not "autonomous," that it was not his "true self" speaking? The predominant view was that the possibility that a future self might disagree with the present self did not mean that the decision was not competent (autonomous).
Like the staff sessions at Denver Health, the Harvard Medical School class was very deliberative. Mr. Drummond's wish to be a teacher is being realized. In the videotape, when he was asked if he had any final advice to give, he thought for a moment, smiled, and said "remember to eat lots of ice cream and cookies."