The Ethics of Choosing the Hospital or Heaven

Last Fall a firestorm erupted with regard to a young child, Julianna, whose parents asked her if she wanted to go to the hospital or heaven. A two part CNN story delved into the life of Julianna Snow, a 5 year old child, who has a neurodegenerative condition called Charcot-Marie-Tooth syndrome. For unknown reasons, Julianna's condition is severe. Her mother, Michelle Moon is a neurologist, and wrote about her daughter on a blog she maintains. Link: https://juliannayuri.com Below is a passage that sparked the controversy:

Me: Julianna, if you get sick again, do you want to go to the hospital again or stay home?

J: not the hospital

M: Even if that means that you will go to heaven if you stay home?

J: Yes

M: And you know that mommy and daddy won’t come with you right away? You’ll go by yourself first.

J: Don’t worry. God will take care of me.

M: And if you go to the hospital, it may help you get better and let you come home again and spend more time with us. I need to make sure that you understand that. Hospital may let you have more time with mommy and daddy.

J: I understand.

M: (crying) – I’m sorry, Julianna. I know you don’t like it when I cry. It’s just that I will miss you so much.

J: That’s OK. God will take care of me. He’s in my heart.

Like many others, I found this discussion deeply disturbing. Can a 5 year old child understand death? Should the discussion have been presented in such a polarizing perspective? Essentially, the mother asked her daughter do you want to live or die. Predictably, CNN and other news outlets relied heavily on emotion. Link: http://edition.cnn.com/2015/10/27/health/girl-chooses-heaven-over-hospital-part-1/index.html Just as predictable, people with a disability, myself included, were taken aback at how Julianna's story was framed. A website was created, Dear Juliana, in which adults with comparable conditions wrote on line letters to Julianna. Link: http://dearjulianna.com I have not thought much about this case despite the fact I found it so disturbing last year. I was prompted to think about Julianna again as there was an excellent essay in MedPageToday by Christy Duan. Link: http://www.medpagetoday.com/PublicHealthPolicy/Ethics/57625  Duan is a fourth year medical student at Albert Einstein College of Medicine and an impressive writer. I think her essay about Julianna and the thorny issue of quality of life was spot on. Duan raised the issue of disability based bias when physicians address what constitutes a life worth living. As most people with a disability can tell you the general public and health care professions often grossly undervalue the quality of our lives. People with a disability routinely receive less care. The more significant the disability the less likely one is to receive appropriate pain management and aggressive life sustaining treatment. Duan wrote:

Instead of viewing disability as something to eliminate, we should appreciate it as a normal part of the human experience which adds valuable perspective. In doing so, we can focus on the real civil rights issue of accessibility and create a better world for everyone – regardless of disability.

Rather than view people with disabilities as defective, we should recognize our world as defective. Of noninstitutionalized adults, 12.6% reported a disability and 28.2% live below poverty. People with disabilities face significantly more obstacles in daily life. Over time, they've been withheld medical care, forced to live in state institutions with inhumane conditions, excluded from public education, denied jobs, prevented from voting, and involuntarily sterilized.

Given these inequities, the fight for assisted suicide is incomplete because it creates the illusion of choice. How can one truly choose death when one doesn't have access to existing resources that allow for a dignified life? The right to die and right to live are both important struggles for autonomy. But for people with disabilities, there can be no autonomy without the right to live with assistance. In Julianna's case, these biases could have fatal consequences.

It is the last sentence quoted above that keeps me up at night. Julianna is not an isolated case. Thanks to modern medical technology the number of people with a disability, children and adults alike, who are dependent upon medical technology is ever expanding. Our social response to those with severe disabilities dependent upon medical technology in the form of respirators, nutrition via g-tubes, power wheelchairs, synthesized voicing, etc. has been negative if not out right hostile. Life with a disability is perceived to be inherently less valuable. Hospital stays are tortuous. People who cannot walk are robbed of their abilities. Medical interventions are painful. The message is not subtle—people with a disability are a burden to their families and a costly drain on our health care system. Worse, people with a disability lives are devoid of value. They cannot work. They only exist. The idea of life with a significant cognitive and physical deficit is a fearful thing. I have heard the following for many years.

“I would rather die than be paralyzed”.

“I will die before I will let someone else wipe my ass”.

“If I lose my autonomy I will happily end my life”.

“If I get Alzheimers take me out the back door and shoot me”.    

To a degree, Julianna’s story is a red herring. We are not talking about one child. It is not possible nor is it advisable to pass judgment on her parents. Parents are given a wide latitude when making health care decisions for their child as they should. I for one would never put my son’s life in such a public spot light as Michelle Moon has. The same can be said for Ashley X parents who publicly support growth attenuation yet at the same time remain anonymous. The point here it’s never about the case in question. Avoid the emotion and hysteria. Think. We humans endure, adapt, and overcome. So exactly what are we people with a disability, a class of people, enduring, adapting and overcoming? In a word, ableism. We are adapting to a different body—a body that is too often deemed as nothing more than dysfunctional and defective. We are enduring class based oppression. We are overcoming a social system that is exclusive and hostile to our mere presence. Framing disability in this manner is rational and intensely unpopular. It is far easier to rely on emotion and pass judgment on others. This is why projects such as Alice Wong’s Disability Visibility Project and Dear Julianna are important. Beyond the wheelchair, beyond the imposing medical technology you will discover something essential—a human being just like yourself.  If you don’t believe me read a few virtual letters at Dear Julianna. There is nothing to fear.