Pulling the Plug: Ethicists Debate Ramirez Case

June 28, 2007 — -- Two short weeks after the culmination of a legal battle between his wife and family over whether to maintain his life support, Jesse Ramirez of Arizona appears to be on the road to recovery.

According to local reports, Ramirez, 36, suffered traumatic brain injury in a May 30 car accident, which put him in a coma. He had been in this minimally-conscious state for a little more than a week when doctors informed his wife that he may never recover -- and she made the decision to have his feeding and water tubes removed.

Ramirez's family made a legal appeal and won, and his feeding tubes were reconnected. Now, Ramirez has regained consciousness and recovered to the extent that he can interact with visitors.

It is an episode that some are already suggesting echoes the 2005 case of Terri Schiavo, a woman whose brain injury led to a persistent vegetative state. In her case, a protracted legal battle between her husband and Schiavo's family ended in the removal of her feeding tube and her subsequent death.

But ethicists debate the extent to which this comparison is valid.

"This guy was not hopeless and in a persistent vegetative state by any means," says Dr. Steven Miles, professor of internal medicine and bioethics at the University of Minnesota Center for Bioethics. "It has no impact on the bigger debate of life support."

'Miracle' May Be Misnomer

If there is one point of accord among both ethicists and neurologists, it is that Ramirez's recovery falls far short of a medical miracle.

"This is by no means a miracle of any kind," Miles says. "Traumatic comas are notorious for late wake-ups."

Dr. Ausim Azizi, chairman of neurology at the Temple University School of Medicine, agrees.

"There is actually a physical basis for those who recover," he says. "The reason they call it a miracle is because they're so rare."

The doctors said much of the reason that Ramirez recovered from his minimally-conscious state -- while so many others with brain damage do not -- has to do with the nature of his injury.

The injuries Ramirez sustained in his accident were traumatic in nature, meaning that the shock of impact likely ripped apart some of the fragile connections in his brain, leading to his coma.

These injuries, on occasion, can heal to a certain extent, allowing the patient to recover functionality. This is far different from the damage caused by anoxia, in which a lack of oxygen to the brain causes irreparable brain damage. Those who suffer this type of damage, including Schiavo, have a much slimmer chance of ever regaining consciousness.

When to Pull the Plug

But the fact that the nature of Ramirez's injury meant that he still had a chance to recover raises a natural question: Was the decision to discontinue his life support premature?

Azizi says the decision to cut off life support usually takes weeks, or even longer. In the Schiavo case, for example, the decision to remove her feeding tube occurred 15 years after the heart episode that brought about her persistent vegetative state.

In this case, however, Ramirez's wife asked doctors to remove her husband's feeding and water tubes nine days after the accident.

"That's a little soon, because there are so many factors involved," Azizi says.

He adds, however, that every case is unique.

"I wasn't at his bedside," he says. "Each person has a different situation; it's important to talk to the physicians working with the patient."

"In general, I would not want anyone to hear this story and be critical of his wife," says Jeffrey Spike, associate professor at the Florida State University department of medical humanities and social sciences.

"In general, we trust spouses to make good decisions for us, because in general spouses know the most about us."

Whether Ramirez's wife's decision was a good decision is open for debate, of course. But Spike says the case raises the question of whether people should trust spouses or parents to make these life or death decisions, Spike says.

"When you have these tough decisions to make, this kind of parental love makes the decisions very difficult. And that's why we tend to trust the spouses more in these situations. Parents tend to make decisions based on what they can live with, rather than what the patient would want."

Still, Miles says Ramirez's wife may have been acting on incomplete information from the doctors about her husband's chances of survival.

"This case is about a hasty clinical decision which should have never been made," he says. "In terms of the process itself, stopping the feeding tube this close in time to the injury is actually pretty unusual.

"This is about malpractice, not about a persistent vegetative state."

Social Impact Questionable

While much about the Ramirez case remains a mystery, speculation still swirls as to whether this case could have an impact on life support laws.

Part of the reason that brain death is such a contentious subject could stem from the fact that the way it is determined varies from country to country -- and even state to state.

Azizi notes that in Virginia, a battery of seven neurological tests is needed to make such a declaration. On the other end of the spectrum lies Pennsylvania, where no neurologist is required when declaring a patient brain dead.

"The idea of who is brain dead has become sort of a lawyer-y thing," he says.

But as to whether the Ramirez case will influence laws, ethicist Miles says any real policy change based on this case is highly unlikely.

"Everyone said the Schiavo case would result in all sorts of new state laws," he says. "In fact, every one of those laws subsequently went down in the state legislature.

"I think the role of the press is to emphasize that he was not hopelessly ill. This is about a guy heading to rehab after a car accident."

Kate Gammon and Joseph Brownstein contributed to this report.