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THE IMPACT OF CRUZAN

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.[81] 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.[82] The dissent in Cruzan implied that without substituted decision making, physicians would be forced to keep most patient 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. While 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. Current trends in health care finance have already begun to make controversies over a patient's right to die an anachronism.

In the 1970s and early 1980s, the confluence of effective new technologies and reimbursement schemes that encouraged doing everything for that patient created the popular illusion of critical care physicians as technovampires who would never let patients die. Those days are gone. Third-party payers pressure physicians to admit fewer patients to intensive care units and discharge admitted patients sooner. Increased copayments and medical insurance policies with high stop-loss provisions put most families of critically or terminally ill patients in an intense financial conflict of interest. In this environment, the risks of substituted consent far outweigh its administrative convenience.

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.[83]

[81]AMA(2); Office of the General Counsel, Orentlicher D: The right to die after Cruzan. JAMA 1990; 264:2444-46.

[82]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.

[83]Medawar PB: The threat and the glory: Reflections on science and scientists. Quoted in Perutz MF: High on science, NY Rev Books, 1990 Aug 16; 37(13):12.

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