In 1976 the New Jersey Supreme Court handed down its decision in the case of Karen Ann Quinlan, and in 1989 the U.S. Supreme Court ruled in the case of Nancy Beth Cruzan. The issue in both cases concerned whether the parents of these two women, who were both in a persistent vegetative state (PVS), could withdraw life-sustaining treatment when their daughters' preferences were unknown. Quinlan's treatment was a ventilator; and Cruzan's a feeding tube. The courts ultimately ruled the life-sustaining treatment could be withdrawn, although each court required a different process for doing so. It is these two court decisions that are considered America's landmark right-todie cases.
In 1976 Quinlan, who was twenty-one, suffered a respiratory arrest that resulted in a PVS. After it became evident that she would never recover, her parents decided to take her off the ventilator; however, the hospital and medical staff refused their request. Her parents asked the courts to grant them the power to authorize the ventilator's withdrawal. Almost a year later the New Jersey Supreme Court held that the state's interest in protecting Quinlan's life was outweighed by her right of privacy, given her poor prognosis and the invasion of her body that would be necessary to keep her alive.
In 1983 twenty-five-year-old Cruzan was found lying in a ditch after a car accident. This too resulted in a PVS, but without the need of a ventilator. As with the Quinlans, Cruzan's parents came to accept the fact that she would never recover. With this realization they asked her health care providers to withdraw her feeding tube; their request was also refused. The legal odyssey that ensued ended at the U.S. Supreme Court. The Supreme Court upheld the Missouri Supreme Court, which required "clear and convincing" evidence that Cruzan would forgo artificial nutrition and hydration given her current state before her parents could remove the feeding tube.
After the Supreme Court's decision was handed down several of Cruzan's friends came forward with recollections of statements she had made regarding patients who were in similar circumstances to hers. They said Cruzan had stated she would never want to live like that. These friends gave her parents the "clear and convincing" evidence they needed to have the feeding tube withdrawn.
Out of the Quinlan and Cruzan cases, particularly the latter, came the Federal Patient Self-Determination Act (PSDA). The PSDA went into effect on December 1, 1991, and requires all hospitals, nursing homes, hospices, and health maintenance organizations (HMOs) to provide patients with information on advance directives. The PSDA also requires these organizations to provide educational programs to their staff and community on advance directives.
An advance directive is a legal document that allows adults to state their preferences for end-of-life treatment. There are typically two kinds of advance directives: The first is a living will, which allows adults to state what treatments they would or would not want at the end-of-life such as cardiopulmonary resuscitation, a ventilator, or antibiotics. The second kind is a Durable Power of Attorney for Healthcare, which allows an adult to appoint someone, such as a friend or family member, to make health care decisions for him or her should he or she lose decision-making ability. It is through an advance directive that patients can meet the "clear and convincing" evidence standard as required by some states, such as Missouri. However, advance directives are of little help to endof-life patients who are not dependent on life-sustaining treatment. As a result, it was just a matter of time until the public demanded the next logical step after the right to refuse treatment—the right to end their lives with their physician's help.
In fact it took less than five years from the passage of the PSDA for the federal courts to hear arguments that patients ought to have the right to end their lives with the assistance of their physicians by way of an intentional overdose; in short, they wanted to legalize physician-assisted suicide. Pushing the courts was a newly passed voterapproved referendum that allowed just that.
The Oregon Death with Dignity Act was passed in 1994 by popular referendum with a 2 percent margin. The act allows adult residents of Oregon who are capable of making health care decisions and are terminally ill to request from their physician a prescription for a lethal dose of a medication. Immediately after its passage an injunction preventing its implementation was imposed. After three years of legal battles all hurdles were finally cleared, or so the general public believed. Oregon's legislators placed on the November 1997 ballot a measure calling for the repeal of the act. The measure was voted down by a 20 percent margin.
Following the second passage of the act another injunction was issued, pending court appeals. On March 6, 1996, the 9th Circuit Court of Appeals in Compassion in Dying v. Washington held that preventing a competent adult from seeking physician assistance in committing suicide interfered with an individual's liberty interest and, therefore, violates an individual's substantive due process rights. Less than a month later in a similar case, the 2nd Circuit Court of Appeals in Quill v. Vacco held that the New York statute criminalizing assisted suicide violated the equal protection clause of the Fourteenth Amendment. The court reasoned that the state has no rational or legitimate interest in preventing a mentally competent terminally ill patient in the final stage of his or her illness from taking a lethal dose of a physician-prescribed medication. Ultimately, the U.S. Supreme Court overturned both decisions; the Washington case became known as Washington v. Glucksberg.
On June 27, 1997, the Supreme Court ruled that a state's ban on suicide is rationally related to a legitimate government interest and therefore there is no constitutional right to physician-assisted suicide; however, states are free to decide for themselves whether to allow physician-assisted suicide. Currently, Oregon is the only state that allows physician-assisted suicide, as voter referendums that sought to legalize it have failed in Washington (1991), California (1992), Michigan (1998), and Maine (2000).
The Oregon Death with Dignity Act took effect on October 27, 1997. To date, ninety Oregon patients have died after the intentional overdose of medication that was prescribed by their physician for that exact purpose: 15 patients in 1998, 27 in 1999, 27 in 2000, and 21 in 2001.
See also: Cruzan, Nancy; Definitions of Death; Do Not Resuscitate; Euthanasia; Quinlan, Karen Ann; Suicide Types: Physician-Assisted Suicide
Battin, Margaret, Rosamond Rhodes, and Anita Silvers. Physician Assisted Suicide: Expanding the Debate. New York: Routledge, 1998.
Dubler, Nancy. "The Doctor-Proxy Relationship: The Neglected Connection." Kennedy Institute of Ethics Journal 5, no. 4 (1995):289–306.
Humphry, Derek. Final Exit: The Practicalities of Self-Deliverance and Assisted Suicide for the Dying. New York: Dell, 1996.
Kliever, Lonnie, ed. Dax's Case: Essays in Medical Ethics and Human Meaning. Dallas, TX: Southern Methodist University Press, 1989.
Schmitz, P. "The Process of Dying with and without Feeding and Fluids by Tube." Journal of Law, Medicine and Health Care 19, no. 1–2 (1991):23–26.