Whose Right to Die?

By Alain L. Sanders

The nightmare began nearly seven years ago. In the early-morning hours of Jan. 11, 1983, Nancy Cruzan's car swerved on an icy and deserted Missouri country road. The car flipped and crashed. The 25-year-old woman tumbled out and landed facedown in a ditch. Medical help arrived promptly enough to save her life but not fast enough to save her oxygen-deprived brain.

Nancy Cruzan never regained consciousness after that accident, and doctors say she never will. Now 32, she lies in a condition known as a persistent vegetative state, awake but totally unaware, at the Missouri Rehabilitation Center at Mount Vernon. Her body is stiff and severely contracted, her knees and arms drawn into a fetal position, her fingers dug into her wrists. Some nurses report that Cruzan can turn toward persons who speak to her and that she has cried on several occasions, once when a valentine card was read to her. But doctors say she is oblivious to the environment except for reflexive responses to sound and painful stimuli. "We have literally cried over Nancy's body, and we've never seen anything," says her anguished father Joe Cruzan. "Sometimes you swear she is looking right at you, but then you move three or four steps. She has no awareness of herself."

A tube to Cruzan's stomach provides all the food and water that keep her on this side of existence. The cost of her care, $130,000 annually, is borne by the state (since she is not a minor, her parents are not held responsible for her debts). Doctors say her heart could beat and her lungs could breathe for 30 more years, but her parents want the feeding stopped so that she can die in peace now.

This week the family will direct its plea to the U.S. Supreme Court, and for the first time draw the nation's highest court into the murky legal and ethical seas that surround the notion of a right to die. What the Justices decide will directly affect Cruzan. It will also set some legal boundaries for addressing the plight of the 10,000 other people in the U.S. lingering in a persistent vegetative state. Ultimately, the ruling could have an impact on the 7 out of 10 Americans who can someday expect to confront questions of life-sustaining medical care for themselves or their loved ones.

The Cruzan case dramatically evokes many of the primal emotions and fundamental uncertainties of life, death and love. Even the simple question at the heart of the Cruzan case -- who is to decide on ending a life -- defies an easy answer. The Missouri Supreme Court ruled last year that the state must decide. And in Cruzan's case, the court concluded, the state's interest in preserving life was not offset by any clear or convincing evidence of Nancy Cruzan's own wishes or by any demonstration that the feeding tube was "heroically invasive" or burdensome. "We choose to err on the side of life," declared the court.

Cruzan's parents believe the decision to end her life, painful as it is, should rest with them, based on their intimate knowledge of Nancy's personality, views and preferences. "My daughter would say, 'Help, get me out of this,' " insists Joe Cruzan. The Cruzans' lawyers argue that the guarantee of liberty in the Constitution's due process clause protects individuals -- including helpless patients -- against unwarranted bodily intrusions by the state, and that a loving family is the best surrogate to decide what medical course an incompetent relative would choose. In 1983 a presidential medical- ethics commission endorsed the principle of family surrogate decision making, and so have many state courts since the 1976 landmark Karen Ann Quinlan case, in which the New Jersey Supreme Court permitted the Quinlan family to remove her from a respirator. Although who decides and what proof is required have differed, most state courts have found a way to accommodate those who seek to let a death proceed.

Right-to-die questions generate powerful sparks of moral friction. They clash against two basic values, says Daniel Callahan, director of the Hastings Center, an ethics think tank. "One is the sanctity of life, with its religious roots; the other is the technological imperative to do everything possible to save a life. Put together they are like a locomotive running at 100 miles an hour." The sweep of that force troubles many experts. Says George Annas of Boston University's School of Medicine: "The technological imperative obliterates the person altogether. It acts as if the person doesn't exist -- that she has no personality, no family, and that no one who loves her can make decisions about her." But other experts believe that advocates of self-determination often skip over a basic question in incompetent-patient cases. Asks University of Michigan law professor Yale Kamisar: "Whose rights are being fought for, Nancy Cruzan's or her parents? Whose preferences are being advanced?"

Cases that involve the withdrawal of a feeding tube, as opposed to a respirator or heavy mechanical support, pose particular problems. The American Medical Association and many ethicists believe even artificial nutrition and hydration is a medical treatment that may be withdrawn from terminally ill or irreversibly comatose patients. But others disagree; to them, food and water, even through a tube, represents the necessities of life and constitutes basic care. Some experts also debate whether there is a clear or a blurred line between withholding nourishment and the next step, injecting death-inducing drugs. Many worry about a slippery slope that could lead to legalized euthanasia and suicide, and a general devaluation of life, particularly of those who are incompetent or elderly.

The issues in the Cruzan case are ultimately both profound and perplexing. "If only the ambulance had arrived five minutes earlier," muses Joe Cruzan, "or five minutes later." But even as he muses, and as the Supreme Court ponders, other ambulances are reaching other patients at that same fateful juncture of too late and too soon.

With reporting by Jerome Cramer/Washington and Elizabeth Taylor/Chicago