Another Terri Schiavo Muddle in the Making?

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Should authorities pull the plug on Janet Rivera, a woman who has been comatose for a couple of years in a Fresno, Calif. special care facility? In mid-July, Rivera's court-appointed conservator, on the advice of five physicians, asked that her respirator be removed and food and water be withheld. Some family members objected and the conservator reversed his request.

Rivera's situation differs in many respects from the Terri Schiavo case. First, Rivera is described as being comatose. Comatose by itself implies a possibly transient inability to respond to stimuli and temporary deep unconsciousness. On the other hand, the five physicians consulted by the conservator believe Rivera's unconsciousness is irreversible. Second, unlike the Schiavo case, Rivera's family members apparently all agree that she should receive artificial hydration and nutrition. And third, again unlike Schiavo's case, no one claims to know what Rivera would want to be done.

Although Rivera's court-appointed conservator says that expense played no role in his decision to have hydration and nutrition tubes withdrawn, there is an issue concerning how Rivera's care is being paid for. On July 28, the Chicago Tribune reported:

The cost of Rivera's care also has become part of the discussion.

Rivera's medical bills are being paid by Medi-Cal, the state-federal insurance program for low-income families.

Some bioethicists say that regardless of whether money is an issue in Rivera's case, her situation raises a question that's impossible to ignore in the end-of-life debate: How to decide whether it's worth spending limited resources to maintain life support in an apparently hopeless case.

"The stewardship of scarce resources does require us to take resources into account," said Ben Rich, a UC Davis bioethics professor. "But it has to be done carefully."

The cost issue and what is going to happen to Rivera in the immediate future was more or less resolved on July 29, when a California judge appointed one of Rivera's cousins as her conservator. The local Fox Television affiliate reported:

Rivera will likely spend the rest of her life in a hospital bed. Her family says they plan to keep her on life support until she is ready to die.

If Rivera's care were being paid for by a private insurance policy or out of her family's assets her case would not be a public issue. The weighing of benefits versus costs of care would have already been decided by the patient and/or her family in advance. However, decisions about rationing are inherent to government-financed medical care – bureaucrats, not patients, must weigh the benefts versus the costs on behalf of the taxpayers who are footing the bill. For now, a California court has ruled that Rivera's family can decide how much money California taxpayers must spend on her care.