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Death and Dying - The Right To Die: Individual Autonomy And State Interests

court cruzan quinlan patient

The first significant legal case to deal with the issue of termination of life-sustaining medical care was IN RE QUINLAN, 70 N.J. 10, 355 A. 2d 647. This 1976 case helped resolve the question of whether a person could be held liable for withdrawing a life-support system even if the patient's condition is irreversible. In 1975, Karen Ann Quinlan inexplainably became comatose and was put on a mechanical respirator. Her parents authorized physicians to use every possible means to revive her, but no treatment improved her condition. Although doctors agreed that the possibility of her recovering consciousness was remote, they would not pronounce her case hopeless. When her parents themselves lost all hope of Quinlan's recovery, they presented the hospital with an authorization for the removal of the respirator and an exemption of the hospital and doctors from responsibility for the result. However, the attending doctor refused to turn off the respirator on the grounds that doing so would violate his professional oath. Quinlan's parents then initiated a lawsuit asking the court to keep the doctors and the hospital from interfering with their decision to remove Quinlan's respirator.

In a unanimous decision, the New Jersey Supreme Court ruled that Quinlan had a constitutional right of privacy that could be safeguarded by her legal guardian; that the private decision of Quinlan's guardian and family should be honored; and that the hospital could be exempted from criminal liability for turning off a respirator if a hospital ethics committee agreed that the chance for recovery is remote. Quinlan was removed from the respirator, and she continued to live in a coma for ten years, nourished through a nasal feeding tube.

In cases following Quinlan, courts have ruled that life-sustaining procedures such as artificial feeding and hydration are the legal equivalent of mechanical respirators and may be removed using the same standards (Gray v. Romeo, 697 F. Supp. 580 [D.R.I. 1988]). Courts have also defined the right to die according to standards other than that of a constitutional right to privacy. The patient's legal right to refuse medical treatment has been grounded as well on the common-law right of bodily integrity, also called bodily self-determination, and on the liberty interest under the DUE PROCESS CLAUSE of the FOURTEENTH AMENDMENT. These concepts are often collected under the term individual autonomy, or patient autonomy.

Subsequent cases have also defined the limits of the right to die, particularly the state's interest in those limits. The state's interests in

Dr. Jack Kevorkian displays the machine he designed to allow a patient to self-administer lethal doses of poison.
AP/WIDE WORLD PHOTOS

cases concerning the termination of medical care are the preservation of life (including the prevention of suicide), the protection of dependent third parties such as children, and the protection of the standards of the medical profession. The interests of the state may, in some cases, outweigh those of the patient.

In 1990, the U.S. Supreme Court issued its first decision on the right-to-die issue, Cruzan v. Director of Missouri Department of Health, 497 U.S. 261, 110 S. Ct. 2841, 111 L. Ed. 2d 224. Cruzan illustrates the way in which individual and state interests are construed on this issue, but leaves many of the legal questions on the issue still unresolved. Nancy Cruzan was in a persistent vegetative state as a result of severe brain injuries suffered in an automobile accident in 1983. She had no chance of recovery, although with artificial nutrition and hydration could have lived another 30 years. Her parents' attempts to authorize removal of Cruzan's medical support were first approved by a trial court and then denied by the Missouri Supreme Court. Her parents then appealed the case to the U.S. Supreme Court.

The Court held that the guarantee of liberty contained in the Fourteenth Amendment to the Constitution does not prohibit Missouri from insisting that "evidence of the incompetent [patient's] wishes as to the withdrawal of treatment be proved by clear and convincing evidence." The Court left other states free to adopt this "clear-and-convincing evidence" standard but did not compel them to do so. Thus, existing state laws remained the same after the Cruzan decision. Although the Court affirmed that a competent patient has a constitutionally protected freedom to refuse unwanted medical treatment, it emphasized that an incompetent person is unable to make an informed choice to exercise that freedom.

The Court explained that the state has an interest in the preservation of human life and in safeguarding against potential abuses by surrogates and is therefore not required to accept the "substituted judgment" of the patient's family. The Court agreed with the Missouri Supreme Court ruling that statements made by Cruzan to a housemate a year before her accident did not amount to clear-and-convincing proof that she desired to have hydration and nutrition withdrawn. Cruzan had allegedly made statements to the effect that she would not want to live should she face life as a "vegetable." There was no testi mony that she had actually discussed withdrawal of medical treatment, hydration, or nutrition.

After the Court's decision, Cruzan's parents went back to the Missouri probate court with new evidence regarding their daughter's wishes. On December 14, 1990, a Missouri judge ruled that clear evidence of Cruzan's wishes existed, and permitted her parents to authorize withdrawing artificial nutrition and hydration. Cruzan died on December 27, 12 days after feeding tubes were removed.

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