Adam Tufts: The Legal Histories of End-of-Life Care
We lead heavily legislated existences because we crave order; we want to uphold our fundamental rights to liberty, the pursuit of happiness, and especially life. However, a great legal, medical, and philosophical quandary arises when one seeks to surrender this basic right to life which undergirds the entire legal framework of the United States. To what legal obligations is one still bound when on the verge of death? Or when they actively pursue death?
Multitudes of legislators and judiciaries have reckoned with these inquiries for decades over an extensive series of court cases. Looking at these legal and medical histories, a variety of semantic differentiations help to facilitate discussion on the broad topic that is end-of-life care. Firstly, a distinction must be drawn between the umbrella term “right-to-die” and the commonly confused procedures which are euthanasia and physician-assisted suicide (the former actively performed by a physician, the latter performed by the patient with a lethal drug prescribed by the physician). An individual may tout a right to death and simultaneously be barred from euthanasia. In other words, an individual might be able to refuse life-saving treatment, in which they are conscientiously accepting imminent death, but be unable to demand death-inducing “treatment.” This conditional freedom weaves its way throughout the United States’ legal landscape, where a stark contrast is drawn between an individual’s affirmative actions and their cessation of another action, even if both choices yield the same outcome. Consequently, matters of discontinuing life-saving treatment protocols and actively inflicting death on individuals not undergoing such treatments have been addressed distinctly throughout America’s legal history.
However, though somewhat divergent, these complex discussions involving end-of-life care, can both be traced back to a landmark court case in 1965 involving a woman by the name Karen Quinlan. After attending a party during which she consumed a staggering amount of alcohol and drugs, Quinlan passed out and was determined to be in a persistent vegetative state. Her parents determined that the chance she would awaken from this comatose slumber was small and requested that she be removed from ventilation. A local district attorney, hearing of these plans, threatened to prosecute the parents with conspiracy to commit murder if they took their child off the ventilator. With this dispute, courts were called to determine whether patients, especially those incapable of making decisions for themselves, held a right to death. For patients ruled as competent the judgment is simple: by reason of informed consent they can withdraw agreement to any treatment, even if it is life-saving, and the physician would be prohibited from saving the patient’s life. However, for those such as Quinlan, who are unconscious or lack competence by some other means, a right to death is more tenuous. The case, In re Quinlan, also lacked substantial precedent for how to determine whether an incompetent individual was capable of consenting to death. For this reason, the court invented a fiction wherein Karen was imagined conscious: the plaintiff’s counsel argued that if Karen saw herself she would not want to have remained in her barely responsive vegetative condition. They argued that this conscious “Karen” maintains a federal right to privacy which assures her prerogative to forgo life-sustaining medical treatment. The discussion concerning how far this privacy right extends will pervade discussions of end-of-life treatment following the Quinlan case’s resolution. Eventually, the court officially approved the Quinlan parents to remove their daughter from life-sustaining treatment, and, miraculously, Karen ended up surviving off of the ventilator. This reinforces the differentiation between the right-to-die and suicide: refusing life-saving treatment is not always a harbinger for death.
The foundations Quinlan laid in end-of-life care were nebulous at best. In fact, just years after Quinlan’s resolution (1985), another case involving a woman named Clare Conroy arose which challenges the logic that marks the Quinlan case. The large fault with the Quinlan ruling is that it hinges on fiction; Karen won’t magically wake up, and Karen won’t have the competency to decide whether or not her vegetative state is worth enduring. The court simply bases their ruling on the imagination that both of these impossibilities could in fact transpire. This is the precise reason why Conroy bears so much significance: it supplies the Quinlan ruling with a logic that is non-imaginative and, instead, steeped in legal precedence. Buried deep within dense legalese, the Conroy case presents a ladder of decisions that effectively replaces the fictions which the courts relied upon with In re Quinlan. Though the court leverages different logics, the Conroy case arrives at a similar conclusion to the Quinlan case: namely, by reading into the due process clause of the 14th Amendment, one can determine that Claire’s right to privacy outweighs the State’s interest in the preservation of life.
This then broaches the concept of fundamental rights extrapolated from the 14th Amendment. In order to earn the title of “fundamental,” rights must be entrenched in cultural and Common Law tradition—this provision first articulated in landmark reproductive rights cases such as Roe v. Wade and Griswold v. Connecticut. For this reason, both the Quinlan and Conroy cases footnote to Roe, referencing Roe’s usage of a “privacy” argument to affirm a woman’s right to abort an unwanted pregnancy (which, the court argues, is a deeply private affair). Thus, such a privacy right is in fact supported by historical precedent and may be deemed fundamental through the 14th Amendment. Although, it should be noted that with Roe’s overturning, the foundation of all cases, such as Conroy, which cite such a privacy right are called into question.
Although Conroy logically establishes an incompetent individual’s right-to-die (or reject life-sustaining treatment)–the mechanisms through which this right is exercised vary greatly and ensure that a cessation of life-saving procedures is not performed rashly. Such mechanisms include, but are not limited to, advanced directives, durable power of attorney for health care, MOLST (medical order on life sustaining treatment), and proxy decision-making. If none of these decision-making channels are viable, then medical personnel abide by a best-interest standard. Indeed, the decision-making protocols concerning end-of-life care following Conroy are comprehensive, yet disputes continue to ensue.
As evidence of this, consider the landmark case Cruzan v. Director, Missouri Department of Health. As a result of a traffic accident, Nancy Cruzan’s brain was deprived of oxygen and she had to be placed on ventilation. Family members of Nancy wanted to take her off the ventilator by declaring that they were her proxy decision-makers. State officials, however, objected, asserting that the family lacked sufficient evidence to confirm that their decision to remove her from the ventilator truly corresponds with Nancy’s wishes. In response, Nancy’s relatives claimed that state officials were interfering with their constitutional liberty to make private decisions about their end-of-life care. This conflict was eventually heard before the Supreme Court who, in turn, ruled in favor of the state, dictating that although there might exist a constitutional right to individual privacy, states have the authority to determine how much evidence is necessary to make a substitution of judgment. Evidently, even following Conroy, alterations and clarification were articulated surrounding how an incompetent individual may consent to removal from life support. Within Cruzan, the court never refutes the premise that an individual can refuse life-saving treatment, they merely highlight certain contingencies that must accompany such a decision. Put simply, throughout these distinct cases the judgment that there does exist a constitutional right to die has held, despite various nuances and exceptions the court has spotlighted.
However, this is not to imply that the right to die has been left uncontested since Cruzan or Quinlan. On the contrary, some of the nation’s most public cases have revolved around this debate—such as the predicament involving Terry Schiavo. This case arose following Terry Schiavo’s fall into a persistent vegetative state (similar to that of Quinlan) after mixing pills and alcohol. After incredible amounts of effort and consideration, the husband elected to take Terry off of life support as her proxy decision-maker. Terry’s parents, however, vehemently disagreed with this decision—arguing that the husband doesn’t truly know what Terry would have wanted and that she deserves to remain on life-sustaining treatment. In fact, this dispute became deeply intertwined with the abortion debate: pro-life supporters standing in support of the premise that all life (conscious or not) possesses some value. Given abortion’s hot-button relevance, large swaths of the national population who otherwise would not have devoted their attention to such a matter began to participate in the nascent conversation on whether unresponsive and incompetent patients retain a right to death. In fact, Terry Schiavo’s case gained the attention of notable politicians such as the Bushes and was covered in nearly every news publication. Despite all of this hubbub, the court finally ruled in favor of Terry’s husband, stating that Terry can, in fact, be removed from life-support given her right-to-death even in a vegetative state (by virtue of her having a reliable proxy decision-maker).
However, as aforementioned the dialogues surrounding a general right-to-die have not always coincided with those regarding physician-assisted suicide. In fact, it was until 1997 that Oregon passed the Death With Dignity Act (DWDA), which was the first instance of legalization of physician-assisted suicide. This legislation allowed physicians to prescribe their patients with a lethal drug so long as they have been diagnosed with a terminal illness (meaning they will die within 6 months) and they have consistently asked for the drug over a period of 2 weeks and in front of 2 eye witnesses. Evidently, this act was passed with the intent for physician-assisted suicide to be an option only possible after in-depth consideration and only in very specific cases. Indeed, physician-assisted suicide legislation is even more contentious than legislation involving a cessation of life support. For instance, George Bush attempted to block the Oregon program’s federal prescribing power (given that the lethal substance being prescribed was federally controlled). While this was struck down at federal court since doctors are able to use drugs for off-label purposes, it demonstrates the extent to which physician-assisted suicide was disputed on a legal and moral level. Other cases, such as Quill v. Vacco and Washington v. Glucksberg dealt with arguments in favor of physician-assisted suicide legalizations by reading into the 14th Amendment’s Equal Protection clause and the previously mentioned “privacy” right. However, in both of these cases, federal courts ruled against the legalization of physician-assisted suicide by pointing out the lack of traditional and legal precedent that would substantiate a “right” to physician-assisted suicide. Despite physician assisted suicide legalization not achieving success on the federal level, 10 different states did pass laws which allow for forms of physician suicide.
Put simply, the legal histories of end-of-life care in the United States have been marked by complex and often contentious debates. The right to die, whether through the withdrawal of life-sustaining treatment or physician-assisted suicide, has been a subject of significant legal and moral scrutiny. The right to death is upheld through intricate legal reasoning, relying on the right to privacy rooted in the 14th Amendment. Despite the challenges and disputes, end-of-life care remains a critical and evolving aspect of American jurisprudence, where individual autonomy, privacy, and fundamental rights intersect with evolving societal perspectives.
Adam Tufts is a Sophomore at Yale University in Berkeley College
Citations
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