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A hostage to technology.

A Hostage to Technology

In one respect, the U.S. Supreme Court decision in Cruzan makes sense. There is simply not enough national consensus at the present time to establish uniform, national standards for terminating treatment (especially on the controversial issues before the court in Cruzan). Some states ne.g., Missouri, Oklahoma) are so vitalist, absolutist, and fearful of slippery slopes that they have severaly limited patients' rights to decline medical treatment. Others (e.g., Colorado, Minnesota), less concerned about vitalism and abuses, have more confidence in physicians and families to make the right decisions. Judicial decisions and legislation in these latter states are substantially different from those of the former (contrast Torresin Minnesota with O'Connor in New York or Cruzan in Missouri). Given this current lack of national consensus, it seems unwise to impose one state's values on all.

In other respect, though, Cruzan is terribly wrong, even in its most narrow holding, and its thinking (dicta) is contrary to almost every higher court decision, medical/ethical standard (President's Commission for the Study of Ethical Problems in Medicine, The Hastings Center's Guidleines on terminating treatment, American Medical Association, American Academy of Neurology) and current medical practice. To hold that Nancy's liberty interest in declining unwanted and nonbeneficial medical treatment as expressed by her loving, caring parents is outweighed by the state's interest in preserving life and minimizing abuses in other cases where no loving family exists is just wrong. But given its conservative nature, this Court was psychologically and constitutionally incapable of holding any other way than it did. The decision is thus disappointing but not unexpected.

While recognizing that states' rights prevail for now, we should realize what the law is in Missouri, as articulated by the Missouri Supreme Court in Cruzan, and how it applies to patients like Nancy. Missouri law says that once medical treatment is started (at least for artificial nutrition and hydration), it can't be stopped. I think there are few physicians in the country who would have initiated treatment had he or she known for sure Nancy would have ended up in a persistent vegetative state; nor is there a family as loving and caring as Joe and Joyce Cruzan who would have consented to starting any form of treatment had they known the final outcome, what it really means to be in PVS, and what a terrible burden this is on the family and others. But, once consent is given, it cannot be withdrawn--at least in Missouri.

In my opinion, when the diagnosis of PVS has been well established, and there are loving, caring parents who know the patient well, the presumption (without knowing any explicit wishes of the patient) should be to follow the views of the family--providing there is no conflict of interest among the family members. To do otherwise is to imprison thousands of patients who are vegetative or otherwise severely brain-damaged as hostages of medical technology. To hold to a clear and convincing evidence standard in the most devastating of neurologic conditions and where there is a loving, caring family is unworkable, unfair, and cruel to so many families who will experience the utter helplessness of the Cruzans. It will place an enormous burden on society, which will spend hundreds of millions of dollars each year for a condition that no one in their right mind would ever want to be in.

No matter what the Court says about preservation of life, potential for abuse, and states' rights, I am convinced that Nancy Cruzan would cry out in horror if she were ever made aware of her mindless, dehumanizing existence. She would be even more appealled (as well would be) if she knew the ordeal her parents have been through trying to do what Nancy would have wanted.

The long-term effect of decisions of the Missouri Supreme Court and the U.S. Supreme Court may well be the very opposite of what was intended . . . and what was most feared . . . namely, to drive people more toward active euthanasia as the public fully recognizes how much they have lost control of their own lives and the lives of their loved ones.

At least the Court found no difference between artificial nutrition and hydration and other forms of medical treatment. Justice Brennanhs well-reasoned, compelling arguments on why artificial nutrition is a form of medical treatment are one of the highights of the decision.

What are the implications and recommendations for health care professionals? First, the decision does not prevent health care professionals from following current standards and practices in the individual states. It doesn't force physicians to act in any way contrary to their own moral beliefs or professional standards (except in Missouri). Doctors are still free to continue focusing on patient autonomy and best interests as the two overriding goals in medicine. Second, health care providers should strongly support the movement toward advance directives, both living wills and surrogate decisionmakers. Finally, health care providers should continue to develop written policies and guidelines for procedural safeguards at the institutional, state, and national level.

Ronald E. Cramford is a neurologist at the Hennepin County Medical Center, Minneapolis, MN, and a consultant to the Cruzan family.
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Title Annotation:"Cruzan v. Director, Missouri Department of Health" right to die case
Author:Cranford, Ronald E.
Publication:The Hastings Center Report
Date:Sep 1, 1990
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