Background Information
Cruzan v. Director, Missouri Department of Health , 497 U.S. 261 (1991), was a momentous United States Supreme Court case that involved a young incompetent lady, Nancy Cruzan. This was the first case ever heard by the court with regards to ‘right to die’. The case was first argued in the court on December 6, 1989, and was later decided on June 25, 1990. It all started on January 11, 1983 when Nancy Cruzan lost control of her vehicle as she was driving during the night near Carthage, Missouri. The fatal accident saw her thrown out of the vehicle and she fell her face down in a ditch filled with water. Having found with no any signs, the medics however, resuscitated her, she was in a coma for three weeks, and after that, feeding tube became the only way for her survive.
In 1988, her parents instructed her doctors to remove her feeding tube. However, the hospital refused to do so without a court order, the removal of that feeding tube would cause Cruzan's death, as that was her means of survival. The parents further filed a court order which directed the medics to remove the feeding tube. The court order ruled that constitutionally, there exists “a fundamental natural right, to refuse or direct the withholding or withdrawal of artificial death prolonging procedures when the person has no more cognitive brain function, and there is no hope for further recovery.” This was also backed up by the fact that Nancy had earlier stated to a friend that incase she obtains an injury and be put under support machine, she would not wish her life to continue like that, only if she could live at least halfway normally.
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The state of Missouri and Nancy's parents both appealed this decision. The Supreme Court of Missouri however, reversed the trial court's decision, by ruling that no one should in either way refuse a treatment of another person. Nancy’s family later on appealed the case and in 1989, the Supreme Court of the United States heard the case.
Relevance of Cruzan
Gaudin (1991) argues that the development of medical technology to a point where now the ability to keep patients who on the other hand would have died-alive on various machines and treatments has brought about explosion of cases on the patients’ right to die. She further argues that such cases are in most cases brought by a guardian or a relative who has a proper knowledge that even though the biological features of the body are still functioning, there is absolutely no sense of joy or fear, thoughtfulness or gratefulness, pain or desire, love or hate, touch, taste or smell or anything to do with life experiences, and with no genuine possibility of responsive life.
These patients are put under care on machines that are so frightening, and this could be the reason why some relatives choose death over life for their patients. One major alarming effect of the technological advancements in the field of medicine is that they are used on patients whom they were not originally intended. For instance, in Nancy’s case, cardiopulmonary resuscitation (CPR) and artificial nourishment, were set to sustain her life. However, the initial use of CPR or the reason why it was first developed was to help those people that seemed healthy, but their hearts had stopped beating after a surgical process, or during any traumaticevent, to revitalize them time to time.
In a 5-4 decision by the court, it apprehended that while people appreciated the right to refuse medical treatment under the ‘Due Process Clause,’ incompetent individuals were not in a position to apply such rights. Vague "clear and convincing" evidence that Cruzan wanted treatment to be withdrawn, the Court established the State of Missouri's actions premeditated to preserve human life to be constitutional. Since there existed no guarantee that relatives of incompetent patients would at all times act in their best interests, and because invalid decisions to take away treatment were irrevocable, the Court thus advocated for the state's intensified
Nancy's parents had appealed in court that “Nancy had a Fourteenth Amendment due process right not to be kept alive by unwanted medical procedures, and that before her accident she had told friends that she would not want to be kept alive in such a comatose condition evidentiary requirements.”Cruzan established two major issues: Any competent adult has a constitutionally-protected Fourteenth Amendment sovereignty interest to refuse undesirable medical procedures; and; in a case whereby a patient is incompetent, the state has the responsibility of constitutionally refusing to allow these medical procedures to be dismissed except in a case where there is "clear and convincing evidence" showing exactly what the patient would have wanted.
According to the law, the due process clause defends an interest in life, and also an interest of refusal of life-sustaining medical treatment. However, a state may legally seek to protect the personal element of such a choice for those considered to be incompetent persons through the obligation of intensified evidentiary requirements. The state may affirm an unreserved interest to preserve human life, (Student Case Briefs, 2010).
Nancy in her state did not have any cognitive ability; she was ultimately lacking all consciousness. While some people would view this condition as life, others would view it as life not worth living. For instance, in the American Association Poll (1988), eighty percent of the people interviewed would withdrawthe life supporting machines from desperately ill patients, or the permanently comatose patients, incase the patients or their families made such kind of a request. In another poll conducted by the Colorado University Graduate School of Public Affairs (1998), eighty five percent of those questioned stated that they would not love to see their own lives being supported by artificial nutrition and hydration at a point in time when they become hopelessly unconscious.
Justice Handler of the New Jersey Supreme Court while summarizing his feelings on the same subject stated;
“ Eventually, pervasive bodily intrusions, even for the best motives,will arouse feelings akin to humiliation and mortification for the helpless patient. When cherished values of human dignity and personal privacy, which belong to every person living or dying, are sufficiently transgressed by what is being done to theindividual, we should be ready to say: enough.”
In Cruzan, the Supreme Court inferred that the right to refusal of medical treatment comprised the right to refuse life-sustaining nutrition and hydration. The court had assumed for the sake of this particular case that the U.S Constitution would allow a competent person a constitutionally protected right to refuse lifesaving hydration and nutrition.
According to Gaudin (1991), the Court’s acknowledgment of nutrition and hydration as medical treatment is not convincing at the first stance since they used an ambivalent language. She argues that the Court ought to have used the nutrition and hydration question so as to dodge the decision at all the real issues such as whether there exists a right to die-anywhere in the constitution, or whether Missouri would be in need of a clear and convincing evidence. She claims that since the Court aborted their focus on the hydration/nutrition issue in resolving the case tells that the fairness of the majority have got their confidence in, if not vehemently, that the use of life-sustaining nutrition and hydration is a medical treatment.
In the rulings by the Supreme Court, an adult who is in conscious mind, is allowed to refuse medical treatment or willingly decide not to take medical treatment to embrace death in a natural way.This is referred to as Passive euthanasia. According to the Supreme Court, passive euthanasia is a decision made by a competent patient to do away with life-saving treatment, and this is considered lawful and legal, and is acceptable within the State. A state is also concerned with preventing suicide. The Courts have unswervingly stated that refusal of life-sustaining medical treatment has got nothing to do with suicide, Dabas (2018).
According to Gaudin (1991), when a patient refuses medical treatment, that would basically allow the disease to take its natural course, and if death were to occur, it would be the end result, thus the disease would be the cause of that particular death, and not any injury inflicted by the patient. Various states will hold that refusal of medical treatment is not suicide, and the courts maintain that it is seen as euthanasia, living will, suicide the individual has the right to die with dignity. Article 21 states “Right to life and liberty is meaningless unless it encompasses within its sphere the individual dignity.”
L iving will is a written order through which an individual provides or indicates the withdrawal of life-sustaining measures in advance, if at any point they would be necessary. It is a criterion used by any incompetent patient to exercise the right to refuse a life- sustaining medical processes. With the living will, a patient’s best interest are secured and automatically becomes respected as long as the living will meets all the legal requirements.
The main problem with the living will is that even though quite a big number of people have already achieved one, it represents just a very small fraction of the population, and even with that, there is no assurance that the patients who find themselves into a tireless vegetative state will be those that executed the living wills. (Dabas, 2018). Another problem that comes with the living wills which in one way or another could bind their application even after their execution is meeting the legal requirements. For instance, some states eliminated nutrition and hydration from the types of medical treatments which can be excluded with regards to particular directives. So, even if the living will has been executed within those particular states, nutrition and hydration can surely not be eliminated, unless the patient meets what is called ‘a test’ adopted by those particular states, which can be applied in cases where the living will does not exist. Furthermore, the states that have adopted the living will statute, the patient somehow, is still required to be in a terminal condition. This, according to them, is because the patients in a constant vegetative state might live in that particular condition for such a very long time, and probably they are not terminal, thus execution of a living will might be irrelevant.
A health care directive is a document outlining treatment decisions made by a patient that the patient has proposed tobe followed in case they become unable to talk or make any decisions for themselves. This kind of document is also referred to as living will or advance care plan . Health care directives look as simple as a handwritten note, but they must be signed and dated. For one to make a health care directive, he or she must be at least 18 years. However, the health care directive also allows one to name an agent- one who can decide for them in case they want someone to decide for them. In some states, there is a requirement that health care directives be witnessed, while in other states, as long as one has what it takes to make a decision, they can make for themselves health directives (Absolon, 2010).
Some of the advantages of health care directives is that; it gives family members the relief of not making tough decisions, since the decision is made by an individual, thus they become confident that their actions are as per the particular individual’s will; it reduces conflict that would probably occur between the decision makers since the treatment decisions are already made by the person in question; people get relieved knowing that what they wish for will be respected at that point when they cannot decide themselves.
However, on the other hand, the healthcare directives also have limitations surrounding it; the potential situations cannot be predicted in advance; as a patient becomes increasingly ill, he or she may want to change the treatment feelings options, but this could not be possible as soon as expected because, the directives will have to be updated, and this may take a few processes; in some cases, the health care directive might ask for care that is not medically probable. For instance, if a heart eventually stops because the body systems have shut down at the end of an incurable disease, the doctors cannot be asked to restart the heart. The health care team can basically not be asked to do what is virtually impossible.
Samantha (2016) argues that when one dies without a living will, the doctors and the family might not know the person’s plans, so the healthcare delegation will ensure that someone has the authority to make medical decisions on the person’s behalf. It’s quite traumatizing to a family, especially to the children if the parent did not clearly state how his properties would be handled or who would take care of the children left behind. In a bid to divide equally the properties left behind, disagreements might ensue.
The fundamental distinctions between recuperative medical care and palliative care is the acute and post-acute medical care for the destitute people who are either too ill or in poor health, and might not recover from a physical illness or an injury on the streets but are not ill enough to be hospitalized. However, the decision to modify care from recuperative to palliative is that of the patient. But in a case where the patient is not able to make the decision, family members should be responsible or another person should take the place of the patient as the decision maker. It is the right to refuse all medical care appropriate when such virtually ensure the death of the patient is when the patient makes the decision themselves. If the patient is incompetent the right lies with the healthcare provider.
Dying individuals might have to make selections on the anticipated degree of family involvement in caregiving and decision-making. They in most cases, make lawful decisions about wills, advanced directives, and sturdy supremacies of attorney. There is no tangible difference between euthanasia and cessation of treatment; this is because, even though the actions might be different, they both cause the same result in taking the life of another. The only noticeable thin difference is in action or practice. In active euthanasia, the medical doctor actively brings about the death of the patient while in passive euthanasia the medical doctor just allows it to happen.
Lastly, the measures that can be taken to ensure the quality of ongoing family and social relationship, individually and as a group, to end of life patients is to include the family in the entire process. For example, there must be the patient-family understanding of, and coping with illness and grief. Furthermore, there should be support for the patient-family decision making. The pitfall that should be avoided in ensuring maintenance of these relationships is failure to understand the patient needs, failing to ensure the patient and family both have access to spiritual guidance, and failure to ensure the patient has access to pain relievers. The actions that may be taken to ensure the spiritual and existential dimensions of the process are respected and integrated is by having a spiritual evaluation process, which includes an entire spiritual assessment.
References
Gaudin, A. (1991). Cruzan v. Director, Missouri Department of Health: To Die or Not to Die: That is the Question- But Who Decides? Louisiana Law Review.
Student Case Briefs. (2010). Cruzan v. Director, Missouri Department of Health. StudentJD
American Association Poll. (1988).American Medical News.
Colorado University of Graduate School of Public Affairs. (1988). New York Times.
Dabas M. (2018). Right to Refuse Treatment is Different from Suicide.
Absolon M. (2010). Health Care Directives. Minnesota Department of Health.
Carrese, J., & Rhodes, L. (1995). Western bioethics on the Navajo reservation. JAMA.
