University Daily Kansan / Friday, March 23, 1990
Medicine
11
Story by Julie Browman Illustration by Bart Vivian
Joe and Joyce Cruzan sat by their daughter Nancy's bedside during one of their weekly visits to the Missouri Rehabilitation Center.
Missouri Hospice Organization
Nancy had no idea they were there. She was not even aware of her own existence.
But her parents were painfully aware that the body lying on the bed was no longer their daughter.
Once vibrant, she now lies in a fetal position, her face red and bloated. Her arms are curled up to her chest, where cloths keep her fingernails from digging into her wrists. A tube surgically implanted in her stomach keeps her alive because she is unable to swallow on her own.
Gruzan's parents treat their daughter with tender love. During their visits, they tell Nancy what is happening around her. They explain that instead of letting her wear hospital gowns,
The Cruzans said they wanted what was best for their daughter, who has been lying in a coma for seven years after a car accident that left her brain damaged.
They believe the best thing for their daughter is to let her die.
"We're not trying to work our will on her," Joe Cruzan said. "We're trying to do what we think Nancy would tell us."
Nancy is one of the 10,000 individuals that are maintained by artificial feeding, according to the American Medical Association. She is in a persistent vegetative state, with no brain activity beyond what keeps the body functioning.
Relatives of some of these 10,000 people have tried to stop treatment that keeps these people from dying. But the U.S. Supreme Court has refused to consider the four right-to-die cases it has received in the past 16 years. The Cruzans' plea to remove their daughter's feeding tube is the first such case the Court has agreed to decide, and it could set a precedent for other families that want to end their relative's life support.
The case began in fall 1986 when the Cruzans asked the Missouri Rehabilitation
Center to remove Nancy's feeding tube. The hospital denied their request in spring 1987.
One year later, a county probate court overruled the hospital. The court said that Missouri's Life Support Declaration Act, which does not allow the withholding of artificial feeding, was unconstitutional. According to the court, the act violated Nancy's federal constitutional right to refuse medical treatment.
The Missouri Supreme Court reversed the lower court's decision. The justices contended that they had been asked to kill Nancy by allowing her to die from starvation and dehydration. They said that Nancy was not terminally ill and could live up to 30 more years.
The Cruzans contend that the chemical substances she is receiving are unnecessarily prolonging the slow, inevitable deterioration of her body.
The Cruzans and their lawyer said force-feeding Nancy was an invasion of her 14th Amendment rights, including the right to liberty. They argued that her right to die was protected under the common law right to be free from bodily intrusions. They see their choice as letting nature take its course, not killing their daughter.
All cases like these take on the sensational label of the right to die, but it is actually just a case of plain rights, said Shannon M. Davis, an associate professor at the University of Kansas Medical Center.
"The right to die is sort of a sexy public relations term." Bartholome said.
He said that any person had the right to autonomy and the right to refuse medical treatment. These rights exist as long as he is able to do so, and capacity to know what he or she is doing.
"The Cruzan case is complicated," Bartholomei said. "Although Nancy is an adult, she is not here to tell us what she wants done. She never selected her parents to designate her life. But we do know that she's not getting better. So why not accept the fact that her parents are acting in her best interest and that this would be what she wanted?"
If the court's ruling is limited to the specifics of this case, it will not have a direct impact on the Med Center, he said.
because the Kansas laws on withholding medical treatment are different than those in Missouri.
That would change if the Supreme Court decides that states have the power to make laws concerning the right to die, Bartholome said.
"This could serve as a precedent of how cases like this will be decided in the future," he said. "That's the direct impact."
But even if the Supreme Court rules in favor of the Cruzans, physicians would not have more freedom to make these decisions. Bartholme said.
"I don't think that it will give doctors a new kind of right," he said. "What it would do is clarify that guardians could, with the aid of doctors, make decisions about things like withholding life-sustaining treatment."
Bartholme said that a decision against the Cruzans would have strong implications.
"What a refusal would do is say to society that we shouldn't trust health-care professionals, health-care institutions and guardians," he said.
By deciding this case, the court could affect the role government plays in medical treatment.
"It would be saying that we should have some kind of judicial review or law that says there are certain decisions that these people can't make, like the decision to remove a feeding tube," Bartholme said. "That would be the danger. It would be the rejection of what a lot of people see as a very important mechanism for delegation of responsibility for making health care decisions for people like Nancy."
Bartheloe said the decision should be delegated to the doctors and the family, and possibly an ethics committee if a problem arose, but not to one group unilaterally.
He said one reason doctors at the Med Center and in Kansas hadn't found themselves in the middle of a battle like this was that Kansas had a silent law regarding cases like these. If the parents or guardians and the doctors agree that it is best for the patient to be disconnected from the artificial feeding tube, then the state government does not intervene in the process.
Nancy's state had the right to allow themselves to die. If they cannot communicate their wishes, then the decision should be up to the people that know them best, not a court.
Missouri contends that Nancy is a ward of the state and that they are acting in her best interest. The state said it was not clear that Nancy would have rejected the artificial feeding. But, most importantly, the state said it had an unqualified interest in preserving human life, which outweighs the patient's right to privacy. As the Missouri Supreme Court stated in its decision, "Life is precious and worthy of preservation without regard to its quality."
best, but a lot of the
"We should all have the right to choose how to live and the quality of life we prefer," he said.
"No one, including the people of Missouri, wants the preservation of life at all cost," Bartolheme said. "The people know that everyone must die."
This doctrine of unqualified interest in preserving life has outraged Bartholome
Because a comatose person can't make that choice, writing a living will — a document specifying a person's wishes under these circumstances — is essential, Sterling said. A living will would bar any misconceptions about what the state should do in a case of irreversible coma.
KANSAN Graphic
Stanley Sterling, associate professor of social welfare, teaches a Death and Dying class at the University. He said people in
able has told us that Nancy is not aware of anything, so she won't suffer anything," Joe Cruzan said.
In addition to the high emotional cost, there is a high economic cost to Nancy's suffering. The Cruzans' insurance ran out in 1986, and since then the state has been paying $130,000 a year to keep Nancy alive.
Missouri, however, will not allow a patient to refuse food or water through the use of a living will. So even if Nancy had written one, it would not have helped her.
Joe Cruzan said that by keeping the feeding tube in his daughter's stomach and not allowing her to die, the state was invading Nancv's rights.
The Cruzans' case cites the 14th Amendment, which prohibits a state from depriving a person of life, liberty, or property without due process of law. They said this protected Nancy's right to refuse medical treatment. They argue that it is not being cruel to her.
Everyone that is medically knowledg-
William Colby, the lawyer representing the Cruzans, said he was not trying to decide the whole right to privacy issue. He only wants a decision on Nancy's fate.
Nancy's fate would have been different had she been treated in another state. Arkansas, for example, allows the withdrawal of artificial feeding.
All the questions may be answered in May or June, when the U.S. Supreme Court is expected to make its decision. Colby said one key might lead the court to decide in the Cruzans' favor. He doesn't think the court will exclude the family altogether from such an intimate family decision.
Joe Cruzan thinks the family is the only group that can really know what a person would want.
"Nancy would say, 'I don't want to live like this,'" he said. "And there's no one out there that can make this decision better than we can."
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The Chancellor's Student Awards Committee is accepting nominations for the following awards:
The Rusty Leffel Concerned Student Award
The Agnes Wright Strickland Award
The Donald K. Alderson Memorial Award
The Class of 1913 Award
Nomination forms are available in the Organizations & Activities Center, 400 Kansas Union Nomination Deadline, Monday, April 2, 1990