Activity 12.1: Cases on Termination of Treatment The facts about several individual patients are set forth here. Each of these patients was the subject of a judicial decision by the court of a particular state. In some cases, the court permitted the withholding or withdrawal of treatment, which presumably resulted in the patient’s death. However, in three of these cases, the court held that treatment should be continued, and therefore, the patient was not allowed to die. For each case, the decision of the court is also provided. The goal of this activity is to determine whether the court’s decision in each case was reasonable in light of the specific facts of the case. Read the description of each case and record the details in Exhibit 12.1. With regard to the patients for whom treatment was continued, explain in writing any ways in which those cases were factually distin-guishable from the cases in which treatment was terminated. Case 1: Cruzan v. Director, Missouri Department of Health 29 After Nancy Beth Cruzan was injured in a car accident, she was in a persistent vegetative state and had virtually no chance of regaining her cognitive function. However, she was not terminally ill and was breath-ing on her own. Her parents asked hospital employees to terminate the artificial nutrition and hydration, but they refused to do so without court order. Cruzan had never executed an advance directive, and the only evidence of her desires was a somewhat casual statement to a friend. Specifically, Cruzan had indicated that she would not want to continue living if she were ever in a severely impaired condition.Cruzan’s parents sought an order from a Missouri state court to ter-minate the artificial nutrition and hydration. The Missouri court refused to order the termination of treatment on the grounds that there was no clear and convincing evidence of the patient’s desire to terminate artificial nutrition and hydration. As discussed in Chapter 2, this case became the subject of a famous decision by the U.S. Supreme Court. However, because of the limited role of the federal courts, the U.S. Supreme Court did not consider the broad question of whether Cruzan should be allowed to die. Rather, the U.S. Supreme Court merely deter-mined that the state law of Missouri, which required clear and convinc-ing evidence of the patient’s intent, did not violate the U.S. Constitution. Therefore, the Missouri court was entitled to apply its requirement of clear and convincing evidence. Case 2: Bouvia v. Superior Court of Los Angeles County 30 Elizabeth Bouvia was a 28-year-old quadriplegic with cerebral palsy. She was almost completely immobile and in continual pain. Her condi-tion was irreversible and although she needed medication for pain, she was mentally competent. Bouvia had to be spoon-fed, and eating sometimes caused nausea and vomiting. If she were fed through an NG tube, she could be kept alive for another 15 to 20 years. However, Bouvia dictated instructions to her lawyers that she did not want an NG tube and signed the docu-ment with a pen that she held in her mouth. Nevertheless, the hospital’s medical staff inserted an NG tube against her will to prevent her from starving herself to death. Bouvia asked the California state court to order the hospital and physicians to remove the NG tube. In response, the hospital and physi-cians argued that the state has legitimate interests in preserving life, preventing suicide, and maintaining the ethical standards of the medi-cal profession. Eventually, the California Court of Appeals held that the hospital and physicians must remove the NG tube, which was inserted against her will. As the court of appeals explained, “It is incongruous, if not monstrous, for medical practitioners to assert their right to preserve a life that someone else must live, or, more accurately, endure, for ‘15 to 20 years.’” 31 Moreover, the court held that the physicians had a duty to relieve her pain and suffering while she starved herself to death. Case 3: Satz v. Perlmutter 32 Abe Perlmutter was a 73-year-old man who was paralyzed by Lou Geh-rig’s disease. He was terminally ill and needed a respirator to breathe. However, he was competent and could communicate with the judge. He had previously pulled out his respirator, but hospital employees recon-nected it. Now he wanted to stop the hospital employees from interfer-ing with the removal of his respirator, which would result in his death within an hour. Perlmutter told the judge, “It can’t be worse than what I’m going through now.” 33 In that case, the Florida court ordered the hospital not to interfere with removal of the respirator. Case 4: Brophy v. New England Sinai Hospital 34 Paul Brophy was permanently comatose as a result of a ruptured aneu-rysm. Although he was unable to swallow, he could survive for several more years with a tube for nutrition and hydration. Previously, he had made some oral statements that he would not want artificial life support and that under those circumstances he might as well be dead. At the request of the patient’s family, the Massachusetts court allowed the withdrawal of the tube. Case 5: In re Eichner 35 Brother Joseph Fox was a member of a Catholic religious order. He was in a vegetative state, was on a respirator, and had no reasonable chance of recovery. s superior, Father Eichner, wanted the hospital staff to remove the respirator from Brother Fox.In formal philosophical and religious discussions, Brother Fox had expressed his desire that he not receive any extraordinary means of life support, and he reiterated that view shortly before his final hospitaliza-tion. Therefore, the New York Court allowed the removal of the respira-tor on the grounds that there was clear and convincing evidence of the patient’s desires. Case 6: In re Mary O’Connor 36 Mary O’Connor, 77 years old, had suffered several strokes but was not in pain. Although she was incompetent as a result of the strokes, she was not in a coma or persistent vegetative state. Rather, she was conscious and might become more alert in the future.The hospital wanted to insert an NG tube for nutrition and hydration to avoid a potentially painful death by starvation and thirst. However, the patient’s two adult daughters objected to the use of the NG tube. The only evidence of the patient’s desires was in conversations with her daughters and coworkers to the effect that she would not want artificial life support. However, she had never discussed the specific issue of nutrition and hydration and had not discussed the possibility of a pain-ful death. In this case, the New York court refused to stop the insertion of the NG tube on the grounds that there was no clear and convincing evidence of the patient’s desires. Some people have compared this case to the decision in Eichner , in which the New York court allowed termination of treatment for Brother Joseph Fox. Specifically, critics have charged that the New York court is unfair to ordinary people like Mary O’Connor, who express their desires in conversations with family and friends and do not have the opportunity to participate in formal philosophical discussions as Brother Fox did. Case 7: Superintendent of Belchertown State School v. Saikewicz 37 Joseph Saikewicz was profoundly retarded, but he was conscious. Although he was 67 years old, he had a mental age of two years and eight months and had never learned to speak. He had leukemia, and the issue was whether he should be given chemotherapy. Most competent patients with leukemia choose to undergo chemotherapy, which can be successful. However, Saikewicz would not have cooperated with the chemotherapy and would not have understood the reason for the treat-ment. In this case, the Massachusetts court ruled that chemotherapy should be withheld. Case 8: In re Storar 38 John Storar was profoundly retarded and conscious. Although he was 52 years old, he had a mental age of only 18 months. He was terminally ill with bladder cancer and on drugs for the pain. Regardless of any treat-ment, Storar would die within three to six months. However, he was los-ing blood in his urine and would die within weeks if he did not receive blood transfusions. The facility wanted to give blood transfusions to Storar, but his mother objected. Although the patient disliked the trans-fusions, he could be sedated. In this case, the New York court held that the facility should be allowed to give blood transfusions to the patient over the objections of his mother.
