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Student Name

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Date

The Wanglie Case

August 15, 1991

Informed Demand for Non-Beneficial Medical Treatment

By STEPHEN H. MILES
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An eighty-five-year-old Mrs. Hegla Wanglie, a nursing home resident was on January 1,

1990, taken to Hennepin County Medical Center. She was taken to the facility so that she could

be given treatment for dyspnea that she had, a condition that was a result of chronic

bronchiectasis. She was provided with emergency intubation by being placed on a respirator. She

could not properly communicate following her placement on the respirator. However, she was

able to identify and recognize visiting family members and could acknowledge the discomfort,

though occasionally. In May, she was transferred to a chronic care hospital as weaning her from

the respirator by the staff became impossible.

Her heart stopped a week later during another attempt aimed at weaning her from the

respirator. This necessitated more care and she was taken to the intensive care unit in another

hospital after being resuscitated. After failing to regain consciousness, it was indicated to the

family by a physician that a consideration to withdraw her from the life-support systems would

be appropriate. However, the family's response was initiating her transfer on May 31 to the

Hennepin County Medical Center. Two weeks later, the medical staff was convinced by tests that

she had gotten into a Persistent Vegetative State (PVS) due to severe anoxic encephalopathy.

Maintenance on the respirator with repeated antibiotics courses, airway suctioning frequently, an

air floatation bed, biochemical monitoring as well as tube feedings constituted her care.

During the year 1990’s months of June and July, the physicians indicated that the family

withdrew from life-sustaining treatment because she was not benefiting from it. According to

the report by Dr. Steven Miles, the family said, "physicians should not play God, that the patient

would not be better off dead, that removing her life support showed moral decay in our

civilization, and that a miracle could occur. . . .” Never had Mrs. Wanglie showed that she

preferred life-sustaining treatment. This was according to her husband. The family, however,
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reluctantly never accepted a do-not-resuscitate (DNR) order due to the improbability of

providing that she would survive a cardiac arrest. The family declined the recommended

counseling by a consultant from the committee on ethics. In late July, the family went ahead to

ask that removal of the respirator should never be a question to be raised ever again.

Continued life support was not appropriate. This was the consensus view in August by

the nurses who were involved in the care of Mrs. Wanglie. A new physician in October 1990,

after consulting with other specialists, a new physician confirmed that both the pulmonary and

cerebral conditions were permanent. The new attending physician concluded that the patient

(Mrs. Wanglie) was “at the end of her life and that the respirator was 'non-beneficial,' in that it

could not heal her lungs, palliate her suffering, or enable this unconscious and permanently

respirator-dependent woman to experience the benefit of the life afforded by respirator support.”

Since the respirator could not extend her life, he didn’t term it as “futile.”

In concurrence with both the hospital’s ethics consultant since August as well as Steven

Miles, the physician in November informed the family that he wasn’t willing to continue the

respirator. Mrs. Wanglie’s husband rejected this information. He also refused to seek an order or

determination from a court of law to demand such an exceptional treatment or transferring her to

another health facility. Because of this action by the patient’s husband, the court decided that it

would seek a court's determination regarding the obligations it has to continue with the

treatment. After two weeks, the indication provided by a follow-up conference was that both

parties had not budged. The family hired an attorney. The husband said that consistently, the

patient under such conditions indicated that she desired respiratory support.

The hospital was authorized to seek a court determination in resolving the dispute. The

authorization came through a 4-to-3 vote by the medical center's board of directors, who could
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also be referred to as the Hennepin County Board of Commissioners. The family was unable to

find a different health facility that would take in Mr. Wanglie despite the several efforts the

family made to locate one during the initial months of the year 1991. Due to her poor prognosis

for rehabilitation, even the facilities with space decided to decline.

The hospital’s request was to have a conservator appointed by the court. The conservator

would conduct a determination if the patient was benefiting from the respirator. The hospital

intended to request another hearing. It would be determined if it had an obligation to continue

with the treatment should the conservator hold that the respirator was not benefiting the patient.

In late May and July 1, 1991, Mr. Wanglie was appointed the conservator following a trial court

hearing. He had requested to be appointed as the conservator based on the fact that he was best

placed to represent his sick wife's interests. However, the court's speculation on whether the

court could grant the request to have treatment stopped was not addressed. This is because no

request of such nature had been made. Additionally, the hospital had decided to continue with

the respirator due to the uncertainty associated with the hospitals' legal obligations to give it.

On July 4, however, due to multisystem organ failure orchestrated by septicemia, the

patient died. The family indicated that excellent care was given to the patient, and an autopsy

wasn't an option for them. The daughter said, ‘‘we just disagreed on ethics.'' Mr. Wanglie on his

side said, "We felt that when she was ready to go that the good Lord would call her, and I would

say that's what happened.'' The county as well as the hospital didn’t have any interest financially

to withdraw the treatment and leave the patient to die. For the first hospitalization, a major part

of the entire bill of $200,000 was paid by Medicare, while for the second hospitalization, the bill

of $500,000 was paid by a private insurer.

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Life support systems comprise the equipment as well as medication utilized to sustain

people’s lives and keep them alive in various medical conditions (Graeme et al. 210). One or

more organs or organ systems of these people could be failing and as a result, they cannot

function without assistance. In the event of severe injuries or illness, the problem becomes severe

to the extent that a machine must be employed to keep the person alive. This was the case with

Mrs. Wanglie, which necessitated her placement on a respirator to remain alive. However, even

with these life support systems, the patient could get even worse to a point when the respirator is

not helping out and the patient dies, as is the case with Mrs. Wanglie.

Ethical Analysis of the Case of Wanglie

In a bid to keep her alive, the family of Mrs. Wanglie took her to a medical facility and

had placed her on a respirator due to the state of her illness at that point. They went on transfer to

her to another facility that could offer chronic care. With efforts to wean her from a respirator,

her heart stopped and she had to be transferred to yet another facility for intensive care, where

the physician advised that life-support systems be withdrawn. The family could not agree to the

physician's conclusion that she was in her last days and could even accept to go for a court

hearing for their patient to remain supported by the systems. The patient was not able to say if

she wanted to continue being supported by the systems or be withdrawn. But due to the failure of

multiple organs, Mrs. Wanglie died.

A Deontological Perspective

Deontological ethical theories emphasize duty. According to some non-consequentialist

ethical theories, consequences are not directly related to actions, whether the actions are wrong
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or right. Rather, evaluation of the action is done on whether or not they conform with one's duty

(conformity to a rule).

According to the Kantian perspective, it is critical to propose a rule first. The proposed

rule for this case could be: “It is ethically permissible to continue to have a patient on a life

support system even when the system is not benefiting the patient.” This proposed question has

covered all relevant features within this case

The universalization principle will first test this rule. "There is, therefore but one

categorical imperative; namely this: Act only on that maxim whereby thou canst at the same time

will that it should become a universal law." Considering the proposed maxim, most people,

including me would be willing to allow such a rule to be universally applied since it is not

ethically required but ethically permissible. Therefore, this rule will pass the universalization

rule. In as much as the patient was not in a position to give his consent to continue being

supported by the support systems, anyone would want a family member or a relative to be on a

life-support system for as long as possible with the hope of recovery. This is due to the lack of

any guarantee that she would become well if the system were withdrawn. Even the patient

herself would not want to be removed from the only thing that is supporting her life. This means

that her autonomy was not substantially violated, although it was formally violated.

Moreover, we shall consider the categorical imperative's second version called humanity-

as-ends version that says, "So act as to treat humanity, whether in own person or in that of any

other, in every case as an end withal, never as means only." On this consideration, the family

treated Mrs. Wanglie with respect and insisted on having her continue being supported by the

life-support system or machine, all in her best interest. They did not want to believe that she

would die and the support-system was not going to save her. They still wanted to hold on to the
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little hope they had that she would survive because she had not died yet. There was no slight risk

in having her in the support system since there was no guarantee that maybe she could have

survived had the support system been withdrawn. This indicates the family did not use her as a

mere means to their convenience or pleasure. Therefore, both of Kant’s categorical imperative

can be used in supporting that the decision taken by the family was right.

A utilitarian Perspective

Utilitarianism is the most widely utilized consequentialist theory. This theory's core idea

is that the evaluation of possible actions should be based on the utility principle. This means that

the consequences should be the happiness of the majority of the greatest number. The absence of

pain or pleasure is what constitutes happiness, according to utilitarian’s.

Since the utilitarianism rule demands the formulation of a rule or even rules, the same

rule used in Kant’s theory will be used here. The proposed rule is, "It is ethically permissible to

continue to have a patient on a life support system even when the system is not benefiting the

patient." The proposed question passes this test yet again because considering what the family

wanted to happen; they wished that their patient continue to be put on the life-support system.

There is no doubt in saying that the system supports their patient's continued stay gave them

peace of mind as it gave them hope that at least she had not yet died. This amounts to their

happiness. This is why it is felt that the action by the family passes the test of the utilitarianism

rule.
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Moral Principles Perspective

If for any reason, the moral theories of consequentialist and deontological varieties are

ignored and the case is subjected to examination based on moral principles, for instance,

autonomy, justice, beneficence, and non-maleficence, similar outcomes will be achieved.

In terms of the autonomy principle, the problem encountered was continuing to have Mrs.

Wanglie on life-support systems without her formal consent. However, it has already been

highlighted in this paper, her presumed consent solves this problem. Based on the justice

principle, the actions of the family were not for their pleasure but in the best interest of the

patient, although the patient eventually died.

Based on beneficence, the patient benefited from the support-systems until her condition

became permanent. Additionally, the family members benefited from the peace of mind that they

had while having her on the support-systems as this at least gave them some hope. Based on the

principle of non-maleficence, medical ethics' first rule is not to harm. According to this case, this

rule was followed as none was injured. This is affirmed by the fact that neither of the facility's

intention to withdraw the support-system nor the family's intention to continue having her on the

support-system would harm the patient.

Conclusion

The three approaches have tested the case of Mrs. Wanglie and the approaches have

supported the decision by the family as expressed in the proposed question. From all three

perspectives to the very least, the family's action was found to be ethically permissible.
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Work Cited

MacLaren, Graeme, Alain Combes, and Robert H. Bartlett. "Contemporary extracorporeal

membrane oxygenation for adult respiratory failure: life support in the new era." Intensive care

medicine 38.2 (2012): 210-220.