A Life in the Balance

"Take her from the machine and let her pass into the hands of the Lord...If he wants her to live in a natural state, he'll create a miracle and she'll live, if he wants her to die, she will be off all the artificial means and she'll die whenever he calls her. "

Joseph Quinlan, a modest drug-company section supervisor, loves his adopted daughter, Karen Anne. That is why the squarely built man with the short graying hair found himself in court last week, pleading for permission to let her die. Karen, 21, has been in a coma since the early morning of April 15, her breathing maintained by a machine called a respirator. By all accounts she has shriveled into something scarcely human. She weighs only 60 Ibs., and she is unable to move a muscle, to speak or to think. One doctor testified last week that she had become an "anencephalic monster." Another described her simply as "grotesque." Yet she is undeniably alive. Which is why her parents' efforts to end her stunted existence reached a court of law.

Now Superior Court Judge Robert Muir Jr., 43, a relative newcomer to the bench but a man with a reputation for doing his legal homework, confronts the most difficult kind of decision any judge can face, a decision with a life in the balance. Because it deals with some of the most fundamental aspects of human existence, the Quinlan case has become the focus of increasing attention from doctors, lawyers and moral thinkers (TIME, Sept. 29 and Oct. 27), but it is up to Muir alone to rule whether there is a point beyond which life need no longer be preserved. He must rule whether it is legally permissible to remove the artificial devices that are keeping another human being in the twilight zone between life and death.

In the midst of its new notoriety, New Jersey's Morris County Courthouse remains a quiet, old-fashioned sort of place. George Washington wintered his troops in Morristown in 1777, and handsome 19th century houses still stand near the village green. The courthouse is a three-story Georgian building shaded by yellowing oaks, and the pew-like benches in Courtroom No. 1 have room for only about 110 spectators, with space for another 30 in the white-paneled balcony. The seats are packed every day, mostly with reporters from as far away as Tokyo and London; there are a few students, and one white-bearded eccentric called Prophet Dan, who claims he could cure the stricken girl. Dominating the courtroom, just behind the witness stand, is a huge (3 ft. by 5 ft.) diagram of the human brain, with all the parts clearly labeled--cerebellum, brain stem, pons, medulla ...

The trial that has attracted so much attention is an adversary proceeding in which there are no enemies. Neither the doctors who refused the Quinlans' request to remove Karen from her respirator nor the guardian appointed by the court to represent her nor the attorneys who represent the legal rights of the county and the state--none of these rival authorities can avoid a sense of uneasiness at prolonging the anguish of Joseph Quinlan and his wife Julia Ann. Their court argument is really a search for answers to questions for which there are no clear legal precedents.

Nor are there any satisfactory explanations for how Karen got into her appalling situation. She was born of unknown parents in Pennsylvania and adopted by the Quinlans when she was four weeks old. The Quinlans still think of her as a friendly, outgoing girl, a fine skier and swimmer, who occasionally picked up a few extra dollars by singing in church. Friends from Morris Catholic High School, from which Karen graduated in 1972, describe her as quiet, but popular with the boys. Her employer at a ceramics company in Ledgewood, N.J., where she was a production worker until she was laid off in a company cutback in August 1974, remembers her as a good, hard worker.

Those who knew Karen in the last few months of her active life paint a different picture. Shortly after losing her job, she moved out of her parents' home and into a world of casual employment and even more casual friendships. For a while, she shared a house on a lake with two young men; somewhere along the line, she began experimenting with drugs. Several friends describe her as an occasional marijuana user and frequent pill-popper, who took "uppers" and "downers" to suit her moods.

Drugs were probably responsible for her current condition. On April 14, apparently depressed over personal problems, she took some tranquilizers, then went to a bar to celebrate a friend's birthday. After drinking gin and tonic, she began, as one friend put it, "to nod out." Thomas French, 22, helped Karen out of the tavern, then the group took her home and put her to bed, where she passed out. When French looked in on her a few moments later, he realized that she was more than drunk. "I just looked at her and I realized she wasn't breathing," he remembers. While he attempted to revive her with mouth-to-mouth resuscitation, another friend called an ambulance. But even though French and the emergency crew that rushed her to the hospital were able to get Karen breathing again, she never regained consciousness.

For a while, Karen's parents kept hoping that she would recover. As their testimony in court revealed, Mrs. Quinlan was the first to accept the inevitable, followed shortly after that by her two natural children, Mary Ellen, 19, and John, 17. But Joseph Quinlan kept talking about a miracle. His own parish priest, the Rev. Thomas Trapasso, said, "I was beginning to fear that Joe was not in touch with reality." The priest had to persuade him that Catholic theology does not require that life be preserved indefinitely by artificial and extraordinary means (see box, page 58). In early September, Quinlan testified, he gave up. "In my own mind, I had already resolved this spiritually through my prayers, and I had placed Karen's body and soul into the gentle, loving hands of the Lord...It was resolved that we would turn the machine off."

The Quinlans signed a statement authorizing Drs. Robert Morse and Arshad Javed to shut off the respirator. Unsure of the legal and moral implications of such an act and unwilling to risk a charge of malpractice, the physicians refused. Quinlan then turned to the law and asked Judge Muir to name him Karen's guardian so that he could authorize her removal from the machine. Muir responded by asking the county prosecutor to show cause why he should not be prevented from prosecuting if the machine were stopped. Muir also appointed a public defender to protect the unconscious Karen's legal rights.

As the key witness last week, Quinlan spoke in a voice so low that he could barely be understood by those at the rear of the courtroom. He denied that he wanted to end his daughter's life, arguing that her life would go on after death. "Terminate is a word that I don't particularly like," he said. "I want to put her back into a natural state. This is the Lord's will."

Next day Quinlan 's wife Julia Ann took the stand and testified that if her daughter were able to make a choice, she would surely not want survival as a subhuman being. "Life was very important to her and very dear to her," said Mrs. Quinlan. "But the way that she could live her life was also very important to her." Mrs. Quinlan said that she and her daughter had seen what incurable cases of cancer could do to people and their families, and she insisted that Karen was against the artificial prolongation of life. "Mommy, please don't ever let them keep me alive with any extraordinary means," Mrs. Quinlan quoted Karen as saying. She added: "I cannot say that those were her exact words...but to her life was very dear and she wanted to enjoy life. And that's why when I see her in this condition, I know in my heart as her mother it is not what Karen would want to be."

Lori Gaffney, 18, a longtime friend, had also discussed the cancer of another acquaintance's mother with Karen. "Karen stated that if it was her, she would not want to be kept alive by machines under any circumstances."

Several doctors were called to the witness stand to testify on Karen's disastrous condition. Dr. Fred Plum, a professor of neurology at the New York Hospital-Cornell Medical Center in Manhattan, described her condition as a "persistent vegetative state." After apologizing to the family for the pain his words would cause, Dr. Sidney Diamond, a neurologist at New York's Mount Sinai Hospital, explained Plum's diagnosis in graphic terms. Said Diamond: "She was lying in bed, emaciated, curled up; every joint was bent into a flexion posture making a tight fetal position. Her eyes, which were open at the time moved together ... they darted about." During the five minutes he observed Karen, Diamond said, "she had five paroxysms during which she would tighten even more; there would be a forced expulsion of air, some of which escaped through the cuff around the trachea and produced a sound. Nothing external provoked it."

None of the medical experts held out any hope that Karen could ever recover. Dr. Julius Korein, a neurologist at Bellevue Hospital in Manhattan, said it most dramatically when he likened Karen to a child without a brain. Karen, he made clear, is not in a "locked-in" syndrome--i.e., a state in which she sees, hears or understands but cannot communicate. She is, said Korein, a vegetable. His description was so disturbing that Mrs. Quinlan, who had maintained her composure throughout the proceedings, slipped quietly from the room.

And yet Diamond insisted that the machine could not be turned off, for "no physician will ever interrupt a device that is performing lifesaving functions." The experts agreed that despite the seriousness of Karen's condition, she meets none of the accepted criteria for determining death. She has not suffered "brain death," the legal measure of death in eight states--though not New Jersey. An electroencephalograph shows that there is still brain activity. She has, on occasion, breathed spontaneously, for up to half an hour, though most experts doubt that she could do so much longer without the aid of the respirator.

The lawyers in the case have already set forth their widely divergent arguments. Paul Armstrong, the attorney who represents the Quinlans, acknowledges that there is no question about Karen's being alive. But he insists that her parents as guardians have a responsibility to look after her best interests. They also have a constitutional right to end her medical treatment on the basis of guarantees of religious freedom, protection against cruel and unusual punishment and the right to privacy as spelled out in the First, Eighth and Fourteenth Amendments. "The court," said Armstrong, "certainly can determine, given the form of existence for Karen, that it would be for her best interest to remove the respirator."

Daniel Coburn, a part-time public defender who represents Karen, disagrees. Although he has retreated slightly from his earlier claim that Karen could recover, he still insists that the court must protect her constitutional "right to life." New Jersey Deputy Attorney General David S. Baime takes a similar stand. Says he: "Although one has the right to hold religious beliefs, one does not have the right to practice them to the detriment of the state, society or the particular person."

Attorneys representing the hospital and the doctors involved in the case take yet another tack. The hospital's lawyer, Theodore Einhorn, urges the court to leave the patient to her doctors, who are best qualified to decide how to treat her. Ralph Porzio, counsel for Morse and Javed, agrees. If the court authorizes an action that may end Karen's life, he says, "hundreds of thousands of people who are confined to institutions for the chronically ill" will be affected. They "may be in a condition similar to Karen's and you can terminate their lives."

Outsiders who have followed the case are similarly divided. Doctors acknowledge that they occasionally practice "judicious neglect," deciding, for example, against reviving a terminal cancer patient who has just gone into cardiac arrest or performing corrective surgery on a hopelessly retarded infant with a serious heart condition as well. Indeed, many doctors admit that the withholding of extraordinary medical care is a not uncommon practice at both ends of the life spectrum. Dr. Raymond Duff, for instance, revealed in the New England Journal of Medicine in 1974 that of 299 infants who died over a 2 1/2-year period at Yale-New Haven Hospital, 43 had been allowed to die, after consultation with their parents, because of hereditary or congenital abnormalities.

Doctors defend such decisions as a part of the practice of medicine. "What is the point," asks one Manhattan physician, "of restarting a terminal cancer patient's stopped heart so that he can survive in agony for a few more weeks?" But almost all doctors are decidedly uneasy about terminating treatment once it has been started, especially if doing so will mean the certain death of a patient. Many doctors, after all, are taught to regard death as an enemy and to do all they can to defeat it--or at least to keep it at bay for a while. Many regard "pulling the plug" as an act akin to euthanasia, which is forbidden by both law and the medical code.

Still several surgeons sympathize with the Quinlans. "At this point in the process of dying, it is the survivors who count," says the University of Chicago's Dr. Chase P. Kimball. "I personally feel that individuals do not have a right over their body after a certain point in the life-death phase. It becomes the responsibility of those closest to them."

Exercising this responsibility would be easier if the courts were not involved, says Kimball. "A physician's task is to aid the patient, not to make the patient suffer unduly, and to use his judgment when to prolong and when not to prolong life. A court cannot decide in total detail what a physician is to do."

Doctors are not alone in their disapproval of a court's involvement in the case. "Some decisions are beyond the law's competence to make with any rigor or confidence in being right," says University of Chicago Law Professor Franklin Zimring. Questions of this kind are often decided outside the courtroom, according to Stanley Price, an attorney who also lectures at the University of California at Los Angeles School of Public Health. Price believes that the Quinlan case has become a cause celebre mainly because of doctors' growing concern over malpractice suits, which have increased significantly during the past decade. Says Dr. Laurens White of San Francisco: "Karen's luck ran out when the doctor put her on the respirator...Maybe, if she's lucky, she'll have a cardiac arrest."

Some people who share the Quintans' view have signed documents called "living wills" directing their families and physicians not to use extraordinary methods to keep them alive if they become seriously ill and have no reasonable hope of recovery. But a great many others admit that, when faced with death, the natural reaction is to cling to life. Robert Cleath, 47, a speech professor at California Polytechnic State University and a part-time Presbyterian minister in Cambria, Calif., has watched in anguish while his son Rob, now 23, has vegetated in a coma since an auto accident five years ago. Even though Rob shows no signs of recovery, his father has no intention of letting him die. "Why? Because I love my son. God is the author of life and no one has the right to take a life, not even his own."

The law provides little guidance in such cases. The courts have yet to establish that there is any constitutional "right to die." The New Jersey Supreme Court has held that a member of Jehovah's Witnesses did not have the right to refuse a blood transfusion on religious grounds. On several occasions, courts have named doctors as guardians in order to assure that children will be given treatments that parents, for whatever personal or religious reasons, are unwilling to provide.

Nor have the courts always acted consistently in other, related cases. Though euthanasia, or deliberate mercy killing, is still regarded as murder, the courts have generally dealt lightly with those accused of it. Juries in such cases have shown a reluctance to convict; even when they do, judges have usually been lenient in their sentencing. In a 1968 case in Illinois, for example, a 69-year-old man admitted to suffocating his crippled wife and then attempting to take his own life. The judge, on his own initiative, withdrew the man's guilty plea, entered a judgment of not guilty and sent him home with his son.

There is also a growing feeling that people do have the right to refuse treatment that might painfully prolong lives. A Florida court ruled in 1971 that a terminally ill woman had a right to decline treatment that would, at best, provide her with a short, painful extension of her life. Said the court: "It is not in the interest of justice for this court of equity to order that she be kept alive against her will."

In the midst of all these uncertainties, Judge Muir gave only the barest hint of how he would rule. Asked by the Quinlans' attorney to visit Karen in the hospital, Muir declined. "I don't think it's appropriate for me to go see her," he replied. "I'm an ordinary human being with ordinary thoughts and ordinary emotions. My position in this case is to decide on the basis of the evidence presented. Emotion is an aspect that I cannot decide a case on."

If Muir decides to grant the Quinlans' request, and if he is upheld on appeal, he will have set a precedent that could have enormous implications. For although the Quinlan case concerns mainly the maintenance of life by artificial means, it could, if carried to its logical conclusion, be applied in state hospitals, institutions for the mentally retarded and for the elderly. Such places currently house thousands of people who have neither hope nor prospects of a life that even approaches normality. A decision to remove Karen's life-support system could prompt new suits by parents seeking to end the agony of incurably afflicted children, or by children seeking to shorten the suffering of aged and terminally ill parents. If Muir insists that Karen must be maintained on the machine, the impact of his decision will be equally important. Medical resources are in short supply at even the best-equipped of hospitals, and doctors, whether they admit it or not, must perform some sort of triage, or sorting, deciding which patients can be helped and which cannot. If they are forbidden to make any decision to shorten a life, they may be forced to maintain with machines many patients who have no hope of true survival.

The outcome of the case of Karen Quinlan will thus be historic. However he decides, Judge Muir will not merely be interpreting the law. He will be making it.

This file is automatically generated by a robot program, so viewer discretion is required.