Roanoke Times
Copyright (c) 1995, Landmark Communications, Inc.
DATE: TUESDAY, June 26, 1990 TAG: 9006260514
SECTION: NATIONAL/INTERNATIONAL PAGE: A/1 EDITION: EVENING
SOURCE: B.D. COLEN NEWSDAY
DATELINE: LENGTH: Long
The court said casual remarks made years ago by a Missouri woman, Nancy Cruzan - who has been in a vegetative state since an automobile accident six years ago - did not constitute "clear and convincing" evidence that she would have wanted to die. Her family had wanted their daughter's food and water tubes disconnected.
With about 80 percent of deaths each year occurring in hospitals and a large percentage involving some decision to withhold or withdraw treatment, a decision allowing states to set guidelines for how those decisions are made could eventually affect the way the majority of Americans die.
"It's very bad news," said Susan Wolf, associate for law at the Hastings Center, a bioethics think tank in Westchester County, N.Y. She pointed out that most people do not leave written instructions regarding the withdrawal of life supports.
"This means the state can just hook them up for years and years," she said. "This means that a lot of people are going to lose the right to refuse treatment if states take up the invitation."
Annette Mariano, co-chairwoman for the Roanoke chapter of the Virginia Society for Human Life, said Monday that the case was "actually a right-to-kill" question in which the court decided that a person "could not be starved to death."
She praised the court's decision as one that "extended the right to life to all regardless of the quality of life."
"It is dangerous to place a judgment on any human life," she said, noting that her organization opposes all forms of "abortion, infanticide and euthanasia."
Dr. Thomas Raffin, chief of respiratory medicine and program director for critical care at Stanford University Medical Center in Palo Alto, Calif., said the ruling could make it harder for physicians to base decisions regarding the care of the incompetent, terminally ill on purely medical issues.
The Cruzan decision does not require any changes in any state policies. Rather, it gives states the right to set their own standards for the termination of life-sustaining medical treatment. Thus, the Living Will laws in effect in 41 states, including Virginia, and the laws and court decisions governing policies in the other nine states are not immediately affected by the decision.
"I don't think it makes a big change," said Dr. Lawrence Scherr, chairman of the department of medicine at North Shore University Hospital in Manhasset, N.Y., and past chairman of the ethics committee of the American College of Physicians.
"I think this reinforces the right of the state to put into place a proper procedure whereby these decisions can be made, so I think it would renew interest in advance directives, with their limitations, and I think there are limitations."
But Raffin and some other experts interviewed Monday said the decision will affect the atmosphere in which critical-care medicine is practiced and may have a chilling effect on physician decision-making.
"Unfortunately, we fall into this pattern where doctors or other care-givers hear something about a decision and then put it into practice," Wolf said. "In the minds of clinicians, I think there's a serious risk this decision will make them think that they don't have to listen to families."
She pointed out that a study of all the deaths in a recent year in a major intensive care unit found that the vast majority of patients were incompetent by the time they died. And very few had advance directives.
According to Dr. Fred Plum, who along with a colleague in the mid-1970s, coined the term persistent vegetative state, no one is quite sure how many such patients there are.
Plum, who is an internationally recognized expert on the condition and is chief of neurology at New York Hospital, Cornell Medical Center, said, "We're trying at the moment to get accurate statistics. The little bit of almost anecdotal information we've been able to get suggests that there maybe almost twice" the usually quoted total of about 10,000 such patients alive at any given time.
"It's a major problem economically and its a major problem in terms of human suffering," Plum said. "The families of these people suffer unbelievably."
He said that once a patient survives the first 30 days in a persistent vegetative state, depending upon complications, he lives an average of about eight to 11 years. If, he said, care costs about $300 a day - and that is a low estimate - a year of care costs about $100,000, "so multiply that by 20,000 and see what you've got" - a national bill of as much as $2 billion a year.
Plum said that, regardless of Supreme Court decisions or state laws, in "large numbers of cases where physicians and families have known each other in what might be considered the old-fashioned style, physicians and families would both be aware of tacit indications of what people would want for themselves and would be guided by that understanding."
But "in circumstances where patients are under the care of impersonal medical care, probably what's going to happen is" the Cruzan decision is "going to require a re-examination of state law, so that's somewhat similar to some of the abortion issues. The place for what one might consider desirable and necessary action is going to have to occur at the state legislative level."
by CNB