On January 11, 1983, 25 year old Nancy Cruzan was involved in a one car automobile accident on Krummel Nursery Road in Carthage, Missouri. Still breathing but unresponsive, she was taken to a nearby hospital. She remained alive, but unresponsive and in a coma and a persistent vegetative state, until the early morning of December 26, 1990, when she died.
Nancy Cruzan was very close to her parents, her sister and her nieces, all of whom wanted the best for her, and each of whom became convinced that her condition was not going to change for the better. Although Nancy could breathe on her own and did not need a respirator, she could not eat on her own, even if fed by hand. So a feeding tube was inserted to provide her with nutrition. After much thought and discussion, her family decided that Nancy’s best interest lay in removing the feeding tube, and letter her die a natural death. They were convinced that the death would be painless and that Nancy would die comfortably. They were certain that this is what Nancy would have wanted.
The facility in which Nancy spent her final years did not agree. While they acknowledged that medical care could be eliminated in a case like this, they concluded that nutrition was not medical care and that removing the feeding tube could be determined to have been the first step in her murder. In addition to the potential criminal liability, hospital officials had moral or ethical objections to removing the feeding tube and it appeared that, even if a court determined that it was possible to disconnect Nancy from her food supply, they might not be willing to actually perform the act. They would, in such a circumstance, however, not object to Nancy being transferred to another facility where the ethical conclusions were different.
William Colby, a young lawyer with a large Kansas City firm, was asked by his firm’s pro bono committee if he would be willing to represent the family and bring litigation to get permission for Nancy’s feeding tube to be disconnected. He agreed, not knowing what he was getting himself into. In 2002, Colby published his account of this tragic situation, “Long Goodbye: The Deaths of Nancy Cruzan”. It is a fascinating book because of the underlying story and the many issues the story raises. It is a book I highly recommend also because Colby’s writing is so readable, so clear, and so compelling, and he writes both with the dispassion of a lawyer, and the passion of someone who became very close to his clients.
This was a case without bad guys. Everyone sympathized with the Cruzan family, even if their own personal ethical beliefs, or their interpretation of Missouri law, put them in opposition to the Cruzans in court. There were a number of issues involved – the Missouri law, whether a feeding tube is a medical instrument, how can one determine the intent of someone who cannot express intent, what – if any – constitutional rights of privacy against state intrusions into medical decisions exist. The state opposed the Cruzans in court. At the trial court level (actually probate court), the Curzans won. On appeal, they lost. They applied for a writ of certiorari to the United States Supreme Court. At the last minute, it was granted. The Supreme Court heard the case. On a 5-4 decision, they ruled against the Curzans, upholding the appellate court decision.
But the Supreme Court case contained a loophole. The court determined that there was insufficient evidence presented that would require a court to conclude that Nancy Curzan would have wanted her nutrition halted in these circumstances. If additional evidence ever turned up………..
And it did. Two new witnesses appeared – women who had worked with Curzan years before and had spoken with her about her end of life medical care beliefs. A new case was commenced in the state courts. The state determined this time not to intervene. The feeding tubes could be pulled and Nancy died, almost eight years after the accident.
The toll on her family was enormous. They never recovered from the ordeal. Her father, persistent in his attempts to do what was best for his daughter, persistent in the attention he paid to her and to her care, committed suicide six years after his daughter’s death. His wife died of cancer a few years after that. Her sister, after dealing with serious depression, apparently recovered – and devoted her time to running a foundation to help others deal with difficult end of life decisions.
There were, of course, other cases involving similar situations; Nancy Cruzan was not the only person to wind up in a persistent vegetative state. What should be society’s role in these decisions? What should be the role of the immediate family? What is the line between stopping life-saving processes and murder? These issues will come up again and again, particularly as medical care becomes technologically more advanced. Opinions – all well intentioned – run from pro-life, to pro-personal autonomy. The Living Will movement is meant to deal with this situation, as are the laws of all of the states (which of course differ from each other – why should this be?).