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Medical advances make decisions on life difficult
Few right-to-die cases end up in court; issues haven't changed much

By Michael Stroh and Janice D'Arcy
Sun Staff

March 19, 2005

As a long and bitter battle over the fate of a brain-damaged Florida woman dragged drearily on yesterday, legal scholars, ethicists and medical experts said it was unlikely the case would offer any new lessons to Americans who quietly face the same wrenching decisions every day.

Still, the case of Terri Schiavo, whose feeding tube was removed yesterday after she spent 15 years in a vegetative state, illustrates the end-of-life issues that advances in medical technology are making ever more difficult.

"We are facing the possibility that these kinds of choices are going to be in everybody's families in coming years," said Anita L. Allen, a University of Pennsylvania professor of law and philosophy. "I think we're all still trying to figure out the ethics of dying."

With a Florida judge brushing off a furious last-ditch effort by congressional Republicans to keep the tube from being removed, Schiavo is expected to die within the next few weeks.

For most of the past 15 years, Schiavo's husband, Michael, has battled her family over the right to remove the tube. Although she never made her wishes known in writing, Michael Schiavo said she told him she did not want to live indefinitely in a vegetative state. Her parents contested that view and said she might still be revived.

Steven H. Miles, a bioethicist at the University of Minnesota Medical School who tracks end-of-life disputes, says that such cases are extremely rare. Over the past 30 years, roughly 5,000 cases have gone to court across the country.

Sixty or so of those went to the appeals level, and one right-to-die case has made it to the Supreme Court.

"The Schiavo case is an exception to the rule - and it's an extreme exception," Miles said. "It's largely a political fight that has nothing to do with Ms. Schiavo."

Major cases

Despite the attention the Schiavo case has drawn, experts say the legal issues surrounding the right to die haven't changed much. The first major case arose in 1976, when the New Jersey Supreme Court granted the parents of 21-year-old Karen Ann Quinlan the right to shut off her life support equipment.

Quinlan, who had fallen into a vegetative state after consuming a tranquilizer and several cocktails, remained in a coma until 1985, when she died of pneumonia.

In 1990 the U.S. Supreme Court heard the case of Nancy Cruzan, a 32-year-old Missouri woman who had spent seven years in a coma after a car accident. Cruzan's parents wanted a state hospital to remove their daughter's feeding tube.

The court denied the parents' petition, ruling that it would require "clear and convincing" evidence that Cruzan would have wanted the tube withdrawn. Cruzan died in 1992.

Cases also go the other way. On Tuesday a Houston hospital disconnected a critically deformed 5-month-old boy from a mechanical ventilator over his mother's objections, acting under a 1999 Texas law that allows doctors to discontinue life support when a patient's survival is deemed hopeless.

A judge and the hospital's bioethics committee endorsed the decision after the boy's mother, Wanda Hudson, 33, contested it in court last fall. He died moments after life support was removed.

Patients' wishes

State right-to-die laws vary primarily on the burden of proof required to demonstrate the patient's wishes. Many states, including Maryland, have adopted the Supreme Court's language and now require "clear and convincing" evidence of the patient's wishes.

The most prominent case here involved Ronald W. Mack, an Essex man whose brain was irreparably damaged in a 1983 car accident and who never regained consciousness. Mack's wife and his family spent years battling over whether to remove his feeding tube and allow him to die. In 1993 the Court of Appeals turned down the wife's attempt to have the tube withdrawn.

"Fortunately, the bitter disagreement among family members is relatively rare," Schwartz says. "Most of these cases do not - thank God - go to court."

Living wills

One vexing element of the Schiavo case is that, like many people, she left no living will or other document to indicate her desires on medical intervention.

At Johns Hopkins Hospital, admission director Dan Wassilchalk oversees admissions and said that fewer than 10 percent of the 46,000 patients admitted annually present living wills. Even when they exist, they're typically written in such vague terms that they're of little help, Wassilchalk said.

Lawyers and individuals who write their own often employ terms such as "heroic measures" and "extraordinary care" that once had standard medical definitions. But advances in medical science have made such terms meaningless.

Dr. Jonathan D. Moreno, the director of the Center for Biomedical Ethics at the University of Virginia, said the care of a person in a permanent vegetative state was easier to define in the 1960s, when there was much less a doctor could do for a patient.

But now, what was once considered extraordinary - such as long-term use of feeding tubes - is relatively common.

Sun staff writer Gail Gibson contributed to this article.


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