The Cruzan decision disappointed those who had hoped that the Supreme Court
would find that families have a constitutional right to terminate a patient’s life
support. [AMA—Office of the General Counsel, Orentlicher D. The right to die
after Cruzan. JAMA. 1990;264:2444–2446.] The American Medical Association
has supported substituted decision making for termination of life support, both
because of concern with family suffering and because it is convenient for the
physicians. [AMA, Council on Ethical and Judicial Affairs, American Medical
Association. AMA ethical opinion 2.20: withholding or withdrawing life-
prolonging medical treatment. Curr Opin. 1989;13.] The dissent in
Cruzan
implied that without substituted decision making, physicians would be forced
to keep most patients in critical care alive forever.
Would that we were so effective at keeping patients alive as the dissent in
Cruzan implies. The dissent in
Cruzan profoundly misinterprets the nature of
most termination of life-support decisions. Cases like Nancy Cruzan’s are rare
rather than typical of termination of life-support situations. Most termination of
life-support decisions for incompetent patients are questions of a few hours or
days of extra care, not years or decades. Although not diminishing the familial
suffering that can be caused by unnecessary delays of even a few days in
terminating life support, this is not a problem that rises to constitutional
significance.
The right-to-die debate blinds the public to the real crisis in intensive care:
ensuring that every person who might benefit from medical care receives that
care. Peter Medawar put it best:
The tenacity of our hold on life and the sheer strength of our preference
for being alive whenever it is an option is far better evidence of a life
instinct than any element of human behavioral repertoire is evidence of
a death instinct. It is odd, then, that nothing in modern medicine has
aroused more criticism and resentment than the lengths to which the
medical profession will go to prolong the life of patients who need not
die if any artifice can keep them going.… Charity, common sense, and
humanity unite to describe intensive care as a method of preserving life
and not, as its critics have declared, of prolonging death. [Medawar, PB.
The threat and the glory: Reflections on science and scientists. Quoted
in Perutz, MF. High on Science. New York: Rev Books; August 16,
1990;37:12.]
