High Court to Rule on Halting Treatment : Family’s Rights at Heart of ‘Right-to-Die’ Question

For more than six years, 32-year-old Nancy Cruzan has lain unconscious, kept alive by round-the-clock care and feedings through a tube surgically implanted in her stomach.

Since Cruzan nearly suffocated in an automobile accident, she has been in a “persistent vegetative state,” a form of permanent unconsciousness in which she is able to breathe on her own. Like thousands of other patients in this condition, she has no awareness of herself or her surroundings.

Her face is red and bloated; her arms and legs are severely contracted; when she is awake, her eyes move randomly in all directions. And she may remain this way well into the next century, unless the U.S. Supreme Court decides otherwise.

Although there is no hope for recovery, Cruzan has a normal life expectancy. Her care at a state rehabilitation hospital here costs about $130,000 a year.

Cruzan, like most young accident victims, had not left specific instructions about whether she would want to be kept alive indefinitely in a coma.

Her parents, however, armed with strong beliefs about what their daughter would want if she could realize her condition, have been fighting a legal battle to stop her tube feedings and let her die.

“Nancy would not want to live like this,” her father, Lester (Joe) Cruzan, said in a recent interview at the family’s home in Carterville, the small southwestern Missouri town where Nancy was born and reared. “The last thing that we could do for her is to set her free.”

“Twenty years ago, Nancy would have died that night, but medicine stepped in and pulled her back,” said her older sister, Christy White. “So now what we would like to see is medicine step out and let her go.”

When the Supreme Court announced earlier this month that it would review the Missouri Supreme Court decision that Cruzan’s feedings must be continued, it transformed the anguish of one family into one of the nation’s most important “right-to-die” cases.

It is the first time the high court, despite four previous requests, has agreed to rule on the circumstances in which medical treatment can be halted, a topic that is routinely debated and decided in state courts, state legislatures and in hospitals nationwide. The case, Cruzan vs. Director of Missouri Department of Health, will be argued this fall. A decision is expected early next year.

‘Most Significant Decision’

If the court makes a broad ruling one way or the other, it likely “will be the most significant decision on death and dying and overshadow even the Karen Ann Quinlan case,” said Alexander M. Capron of the USC Law Center in Los Angeles, an expert on medical ethics.

In that landmark 1976 case, the New Jersey Supreme Court granted a father’s request to remove his comatose daughter from a respirator. The decision--which the U.S. Supreme Court declined to review--set the stage for a gradual expansion of the rights of individuals to determine the course of their medical treatment, particularly at the end of life.

The Cruzan case raises anew some of the thorniest questions in medical ethics, as well as the role of the federal Constitution in shaping medical practice. These questions--some of which may be resolved by the Supreme Court--include:

- Do patients have a constitutionally protected right to refuse medical treatment? If there is such a right, what “right-to-die” issues are still subject to state regulation?

- When does the interest of society in preserving life outweigh the right of individuals to make decisions about their medical care?

- Do families and physicians have the right to make medical decisions for permanently unconscious patients whose wishes about medical treatment are not known?

- Can medical treatments be stopped for patients such as Cruzan, who are permanently unconscious, even if they are not terminally ill? If treatments are stopped, is the patient’s death the result of the condition that caused the unconsciousness, or a form of euthanasia?

- Are food and water administered through a stomach tube or a vein a type of medical treatment, similar to breathing machines or kidney dialysis, that can be stopped and started? Or are food and water more basic care that must always be given to patients?

At the heart of the Cruzan case is the interpretation of individual liberty as set forth in the Constitution. According to Laurence H. Tribe of Harvard Law School, the case centers on “the right to resist force-feeding in accord with one’s own previously expressed wishes” and on the right not to “force-feed or otherwise artificially sustain the life of an intimate relative.”

Tribe, author of the 1988 treatise, “American Constitutional Law,” said the case might allow the high court, outside of the bitter abortion controversy, to “address the fundamental question of how far the liberty clause of the 14th Amendment goes in protecting rights that are not explicitly stated in the Constitution.” The 14th Amendment says in part that no state shall “deprive any person of life, liberty, or property, without due process of law.” According to Tribe, the use of the term “liberty” in the 5th and 14th amendments is the basis of the widely discussed--and disputed--constitutional right of privacy.

Different Issues

On July 3, the day the Supreme Court announced that it would hear the Cruzan case, it also upheld a Missouri law restricting abortions and agreed to hear three new abortion cases. While some observers are struck by the parallels between abortion and death and dying cases, attorneys on both sides of the Cruzan case caution that many of the issues are quite different.

Abortion cases involve the competing rights of mother and fetus. The Cruzan case involves a woman who is permanently unconscious, has no dependents and, unlike a fetus, “has no potentiality ahead of her,” said William H. Colby, a Kansas City attorney representing the Cruzan family.

The Missouri case began in the early morning hours of Jan. 11, 1983, when Cruzan, then 25, was driving home from her job in a cheese-processing factory.

She lost control of her 1963 Rambler. It crashed and overturned. Cruzan, who was not wearing a seat belt, was thrown clear, landing face down in a field.

The state trooper who arrived first examined the young woman and believed she was dead. About 15 minutes after the accident, paramedics arrived. They quickly turned Cruzan over and resuscitated her, restoring her respiration and heartbeat.

Irreversible Brain Damage

Cruzan never regained consciousness after the accident. Her physicians concluded that she had suffered irreversible brain damage when her airway was obstructed during the time she had been face down. As a result of the lack of oxygen, her brain later atrophied and filled with fluid.

The part of the brain that controls voluntary behavior and consciousness was destroyed but the brain stem, which controls breathing and other reflex behaviors, was not. This differs from “brain death,” when the entire brain ceases to function.

In February, when the extent of permanent brain damage was still uncertain, Cruzan’s parents and her then-husband authorized her physicians to surgically implant a feeding tube into her stomach. Later, the probate court in nearby Carthage, Mo., approved a divorce and appointed her parents as her guardians.

On Oct. 19, 1983, Cruzan was moved here to the Missouri Rehabilitation Center, where she remains today.

No Awareness

A reporter recently visited the hospital with Thad C. McCanse, a Carthage attorney appointed by the probate court to represent Cruzan’s interests during the case. Her sunny private room was adorned with cards and stuffed animals from family members. Lying in bed wearing a bright floral nightgown, she made indistinct noises and moved her arms but appeared to have no awareness of either her nurse or her visitors.

Initially, the family had hopes for Cruzan’s recovery. They became active in a head injury support group. But gradually, in mid-1986, they realized that she was not going to get better.

Slowly, her parents reached a decision to seek the removal of her feeding tube. “I read everything I could get my hands on,” said Joe Cruzan, a sheet metal worker. “We began to focus on what would be her wishes. . . . She would be horrified at her existence now.”

Before the accident, Cruzan had several general conversations about death. According to court records, in one “somewhat serious conversation” with a friend she indicated that if sick or injured she would not want to go on living unless she could live at least “halfway normally.” But she never had specific discussions with her family covering her current situation. As a result, the family relied on its sense of her “values.”

Fiercely Independent

During a two-hour interview, her parents and older sister described Nancy Cruzan as a fiercely independent, upbeat young woman who was much loved by family and friends. They said she particularly enjoyed animals, children, holidays and the outdoors.

“So much of it stems from who she was before the accident. She was so vibrant, so vital, so alive,” her sister Christy explained.

The Cruzans anticipated that a court order would be necessary to discontinue the feeding tube.

According to the Society for the Right to Die, a New York-based advocacy group, Missouri and four other states have laws prohibiting the withholding of tube feedings. In contrast, 10 states have laws specifically authorizing physicians, in consultation with patients and their families, to withdraw food and water in certain circumstances.

In the fall of 1986, the Cruzans set in motion the protracted series of events leading to the court case. They contacted the Society for the Right to Die, which has assisted many other families in similar circumstances. Through the Kansas City chapter of the American Civil Liberties Union, they were put in touch with Colby, of the firm Shook, Hardy & Bacon, who is representing them without charge.

In the spring of 1987, the hospital denied their formal request to stop the feedings. In October, they asked their county probate court to intervene. In March, 1988, a three-day trial was held in the county courthouse at Carthage.

In July, Circuit Judge Charles E. Teel Jr. ruled for the family. He held that Missouri’s 1985 Life Support Declarations Act--which prohibits the withholding of artificial feedings--violated Cruzan’s federal constitutional rights to decline medical treatment, including nutrition and hydration.

The case was appealed directly to the state Supreme Court. In November, 1988, that court, in a 4-3 decision, reversed the trial court and upheld the state law.

The majority opinion expressed “grave doubts as to the applicability of privacy rights to decisions to terminate the provision of food and water to an incompetent patient.” It also discounted the significance of Cruzan’s general statements about death.

‘Err on Side of Life’

The Missouri court held that “the burden of continuing the provision of food and water” was “emotionally substantial for Nancy’s loved ones,” but not for her. In the face of “the uncertainty of Nancy’s wishes and her own right to life,” it concluded: “We chose to err on the side of life, respecting the rights of incompetent persons who may wish to live despite a severely diminished quality of life.”

Even before the U.S. Supreme Court agreed to hear the Cruzan case, it had captured the attention of “right-to-life” and “right-to-die” advocacy groups and leading medical organizations.

This is because the Missouri Supreme Court decision clashed with nearly all similar decisions by courts in other states, including Arizona, California, Connecticut, Florida, Massachusetts, New Jersey and Rhode Island. Many of these courts had upheld on constitutional grounds the withholding of various forms of medical treatment, including food and water, from patients in a persistent vegetative state.

These decisions likened tube and intravenous feedings to other medical interventions, not to the routine provision of nursing care or comfort. In a widely cited 1986 Florida case, an appellate court allowed the removal of a nasal feeding tube from a 75-year-old woman in a persistent vegetative state, ruling that her constitutional rights to decline treatment took precedence over a state law prohibiting the removal of such feedings.

California Case

California law does not specifically mention artificial feedings, although local and appellate courts have upheld the withdrawal of such feedings. For example, in a 1988 case similar to the Cruzan case, an appellate court authorized a relative to order disconnection of the nasal feeding tube that had sustained a 45-year-old San Jose man since a 1983 auto accident. Both the state Supreme Court and the U.S. Supreme Court declined to hear the case. The man, William Drabick, died after the tube was removed.

Against this legal backdrop, “right-to-life” organizations were thrilled by the Missouri Supreme Court’s decision. According to James Bopp Jr. of Terre Haute, Ind., general counsel for the National Right to Life Committee, the decision made clear that there is no constitutional right to “starve to death” the medically dependent and disabled, including vegetative-state patients.

But leading medical groups, such as the American Medical Assn., the American Academy of Neurology, and the Missouri State Medical Assn., were sharply critical. They said the Missouri court had rejected many clearly stated principles of medical ethics, such as shared decision-making for incompetent patients by physicians and families and the AMA’s widely accepted 1986 statement that “it is not unethical to discontinue all means of life-prolonging medical treatment” for patients in irreversible comas, including artificial feedings.

‘Family Has No Control’

Unless the person has left clear written directives, “We have a decision in Missouri that once you become unconscious . . . the family has no control over your medical treatment,” said Colby, who represents Cruzan’s family. “Your doctor has no control over your medical treatment and, if you read the opinion literally, you simply have to accept all medical treatment possible.”

Colby’s interpretation “is just wrong,” said Robert Presson, the Missouri assistant attorney general who has argued the case for the state. Presson said the Missouri court had issued a more limited and “flexible” opinion that does not “categorically rule out the withdrawal of food and water” from patients. But, in Cruzan’s circumstance, “they didn’t find it justified.”

Already, however, the impact of the state Supreme Court’s decision is being felt throughout Missouri, according to Gerald Sill, senior vice president of the Missouri Hospital Assn. Previously, there were “many instances” in the state where food and water were withdrawn from patients similar to Cruzan, Sill said. “Now, I feel confident that this has stopped.”

Legal scholars are uncertain how the U.S. Supreme Court is likely to approach the case.

Tribe, of the Harvard Law School, said that a “bare majority” of the court might come down on the side of individual liberties and set forth broad constitutional limits on the power of state and local officials to override medical decisions. But he added that it is “quite plausible and to some degree more likely” that the high court will use the case to further restrict constitutionally protected privacy rights.

“They might leave it to the states to remain 50 laboratories of competing approaches to this issue,” he said. “ . . . I certainly sympathize with both the individual and the family who say forcing us to keep this person alive is a profound intrusion, but it doesn’t follow from that that it violates the federal Constitution.”

USC’s Capron said it is possible to see a compromise decision or one “going either way.” For example, Capron said the court might affirm a constitutional right of Americans to make decisions about their personal health care, including the withdrawal of artificial feedings, while at the same time finding insufficient evidence to reverse the Missouri Supreme Court decision.

The Cruzans hope for a clear-cut decision that will let their daughter die. Visiting Nancy is “not that emotional, wrenching thing anymore that it used to be,” Joe Cruzan said. “It isn’t my daughter (at the hospital). My daughter’s been gone for over 6 1/2 years and that is just what is left of her.”