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. [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.]