Treating Dax Cowart

The Dax Cowart case involves many ethical questions and issues ranging from what role physicians should play, to whether or not in this case the physicians made the right decision in treating Dax, even though it was against his decision. It is the goal of this paper to show that the physicians did, in fact, make the right decision in treating Dax against his decision. This will be done by examining the morally relevant features of the case, showing why the physicians made the right decision, bringing up the strongest objection and replying to it, and finally, how this view fits with another case.

The Dax case began in the summer of 1973 when a propane explosion killed his father and severely burned more than two-thirds of his body leaving him blind and unable to use his hands.[1] He was rushed to a hospital where treatment to save and restore his life began. Even though he was found competent twice, and repeatedly stated that he did not want to be treated, the doctors continued regardless.[2] After switching hospitals once and going through extremely painful disinfectant treatments for a year, Dax was released. It was only after seven years of severe depression and three failed suicide attempts did he manage to start living what he felt was a meaningful and happy life.[3] Currently, he feels as though he is living a happy life and is taking karate, writing poetry, practicing law, and has even scaled a 50-foot utility pole.[4]

The morally relevant facts of this case are that Dax was found competent when making his request for the doctors to stop treatment, that in the end, Dax is happy, and that all throughout his treatment there was a severe lack of information provided to Dax which hindered his decision-making ability. The fact that Dax was found competent is morally relevant because it raises the question of whether or not someone should go against the wishes of a competent person when it only involves the person making the decision. It is safe to say that most people feel that they should have the right to decide what is and is not done to themselves, so long that it does not involve anyone else. This would make it seem like the physicians made the wrong decision, but as it will be shown later, it is possible to agree with this and at the same time agree with the decisions the physicians made.

The second morally relevant issue is that of Dax being happy in the end although it is after seven years of depression. This is relevant because for a paternalist it would, to some degree, show that the physicians made the right decision because it is fringing on fulfilling the thank you test. The thank you test is simply a test that justifies the actions of the physicians based on whether or not the patient is thankful afterward. This, however, will not be used in support for defending the physicians’ actions for two reasons. The first being that Dax, although being very happy currently, states that he would make the same decision again if he was in the same situation which would negate the test.[5] Secondly, it is not the purpose of this paper to defend a hard paternalism. Each case should be looked at as a unique and dynamic case. It would not only be wrong to assume one model of patient-physician relationship should always be used but potentially harmful as well.

The final morally relevant issue in the case was the lack of information provided to Dax. Dax’s decision to have treatment stopped on him, so that he could die, was based on incomplete information and so it may have been the case that he would have chosen to continue with the treatment if he had more information. The crucial element of communication in a patient-physician relationship was missing in this case which was the fault of the physicians, and they were wrong for not providing enough information to him, but it is also due to this communication block that the physicians were justified in treating him. This will now be explained in further detail.

It is important for physicians and patients to have an open line of communication so that any decisions made can be unbiased and a well informed one. In the Dax case, however, there was far too little conversation and not enough effort to give Dax all the relevant information, which was a horrible mistake, that the physicians were guilty of. They were not wrong however in treating a man which was making a clearly biased, uninformed decision. The reason why it is not appropriate to follow the decisions made under such conditions is that it cannot be seen as what a person truly wishes to do. Dax’s unbiased, informed decision, in this case, was actually to proceed with the treatment. When Burt asks Dax if it would be appropriate to say to a patient in the same situation as he was that “You know, the seven years time, it was a hard time. Looked at from the other side, it now feels to be worth it, and it might feel like that to you, too.”[6] Dax agrees and says “That would be the honest way to do it.”[7] What this shows is that Dax feels that the best decision to make in this instance is to proceed with the treatment. The problem here though is that this is all after the fact and unless someone is placed in the same situation twice it would seem that it could be said they are never fully informed which would allow physicians to do what they felt is right. This is not correct, however. So much information to the level of actually going through it once should not be needed to be considered an informed decision. Somewhere in between the total lack of information that was provided to Dax, and a complete understanding of a possible outcome should be sufficient. It could be the case that Dax once going through it once, and is put in the same situation again, would choose not to go through it again, which in fact he also, contradictorily states as well. If Dax was properly informed and unbiased then the doctors should have discontinued treatment, and let him die. Dax, however, was neither, and so the physicians had a duty to continue treating him.

Dax was biased from two factors. The first being the amount of physical pain he was in and secondly the shock he must have been in, from going from a healthy physically able person to the state he was in from the explosion. He states “The immediate issue, the urgent issue, was that my pain was not being taken care of. That was why I wanted to die.”[8] This shows that the most important thing on his mind was the immense pain he was in and trying to have it go away. So it was not the case that he did not want the treatment, he just did not want the pain that went with it. Why is this not enough of a reason to let him die it might be asked? The pain may have been a part of the treatment. A nurse who used to work there would cause pain to the patients and treat them poorly so they had a reason to keep on living, that being to kill her in the end.[9] It seemed to work which may have been what they were trying to do in the Dax case. Eliminating the pain however at the time would not have been enough for Dax to agree with treatment because of his second bias of becoming blind and a cripple. Dax in an initial conversation with Dr. White says “I know that there’s no way that I want to go on as a blind and a cripple.”[10] This shows that before any significant information has been given he already has the view that he does not want to lead the life of a disabled person. Dax later agrees that at the time he was biased and was wrong in thinking that way.[11] This shows that at the time he was making decisions under bias which he willingly admits were wrong decisions.

Not only was Dax making biased decisions at the time but he was making uninformed ones. The physicians did not put enough effort into supplying Dax with information on what is possible after the treatments. This lack of information had a large role in his decision not to accept treatment. “If I felt that I could be rehabilitated to where I could walk and do other things normally, I might have a different feeling about it.”[12] Had the physicians sat down with Dax and talked with him more, they may have gotten him to feel as though he could be fully rehabilitated which, as can be seen from what actually happened, was possible in the end. Dax himself, in fact, agrees that a request to die, without a physician, first fulfilling his duty to inform the patient as best he can, should not be blindly followed.[13] So the question of when the process of informing a patient is done then arises. How long should the patient and physicians discuss possibilities? Dax believes that under severe pain and any other such issue of immediacy the time period for discussion should be short, while if there is no such issue it can be a longer time period.[14] Should it not be the exact opposite though? If someone is under severe pain their thought process should not be considered rational, for the only thing they are really thinking about is the pain itself. If on the other hand, a person is free of such a bias they can easily absorb and evaluate all relevant information in as short as a day or two perhaps. It is clear that whichever time period is taken to be the one that should be used, that some form of time period should exist. It was exactly this time period of discussion and understanding that was missing from the Dax case, and it is because of this that the physicians were correct in their decision to go against Dax’s will and treat him.

The main objection to this view of the case is probably the following. Whether or not a person’s decision is bias or uninformed is irrelevant when the decision only affects the person making the decision. According to Dax true freedom allows us to make wrong choices.[15] Dax also states that there is nothing legal or otherwise that can take the right to control your own body, from a mentally competent person, and give it to another person.[16] Although this objection is the strongest one and is most likely used to defend the position that what the physicians did was wrong, it has problems. To begin with, the idea that nothing can or has taken away the right that people have to do whatever they wish to themselves is just wrong. Many laws exist that state a person does not have the right to do such things as take drugs or drink under a certain age, even though the only person involved is the one making the decision. It could be said that the consumption of drugs is illegal because it is usually bought from someone and therefore does not just affect yourself. This is very true but it would still be illegal for someone to grow or make a drug themselves and then consume it. This would still be illegal and the only person involved is your self. Are there truly any decisions made that do not affect someone else in some form? It is hard to think of one because, in order for it to truly effect only you, you would have to live isolated from all of society and be totally independent. Even if this were the case, it would be irrelevant since no one would be there to disagree with any choice you make.

The hardest case to square the position that, unless a person is unbiased and informed it is up to the physicians to do what they feel is in the best interest of the patient, would be the Paul Brophy case. The reason why it would be the hardest is that of the persistent vegetative state that he is in, which would prohibit him from making any decision at all.[17]  In such cases, it should be those who have been closest to him and knew him the best throughout his life, that make the decision and take on the role of discussing possibilities with the physicians.

[1] “Confronting Death: Who Chooses, Who Controls? A Dialogue between Dax Cowart and Robert Burt,” Hastings Center Report 28, no 1 (1998):14-24. pg. 14

[2] Ibid. pg. 14

[3] Ibid. pg. 17,21

[4] Ibid. pg. 17

[5] Ibid. pg. 18

[6] Ibid. pg. 19

[7] Ibid. pg. 19

[8] Ibid. pg. 17

[9] Ibid. pg. 21-22

[10] Ibid. pg. 15

[11] Ibid. pg. 17

[12] Ibid. pg. 15

[13] Ibid. pg. 18

[14] Ibid. pg. 24

[15] Ibid. pg. 17

[16] Ibid. pg. 16

[17] George J. Annas, “Transferring the Ethical Hot Potato,” Hastings Center Report, February (1987) pg. 20