Difficult Decisions for Courts and Society

SELDOM has the United States Supreme Court had a more difficult decision to make than in the so-called right-to-die case. The ruling in Cruzan v. Harmon, expected in the spring, will establish precedent nationwide for medical doctors and hospitals who are faced with using extraordinary means to sustain patients who are diagnosed to be in a ``persistent vegetative state.''

In the absence of a living will attested to be the patient's, many of these hospitals feel they have little choice but to use feeding tubes and other devices to provide life-support, even in the face of parental and family opposition.

The issues are complex. Basic is the question: Who makes the decision whether to continue such treatment - parents, doctors, or the state? And is the issue really the right-to-die or (as some suggest) the right to refuse medical treatment?

The Cruzan case illustrates these points. In January 1983, Nancy Cruzan, described as a vivacious and fun-loving young woman in her mid-20s, was involved in a serious automobile accident. Medical authorities were able to prevent her death, but Ms. Cruzan was diagnosed as having no feeling or recognition nor any sustaining life signs. She is not comotase but she is unresponsive and is fed through a gastrotomy tube. Some medical experts insist that since she has no functioning brain cells, she is technically dead.

Ms. Cruzan's family is very close and supportive. They have stayed by her bedside and determined - after much agonizing - that she would want to be ``turned loose.'' They say that her very nature made it clear that she would not wish to continue her present existence. However, these desires cannot be verified.

In 1988, a circuit court in Missouri, acting on a motion by the family, said that the parents could order the feeding tube removed. The state appealed, however, and won reversal in the Missouri Supreme Court, which said that the state, not her family, should decide what happens to Cruzan. The case was appealed to the US Supreme Court.

The medical prognosis for Cruzan is that she will not improve and could remain in her present state for 30 years or more. The cost for her care, borne by the state, would exceed $130,000 a year. The Cruzans argue that most states defer to medical doctors and families in allowing termination of extraordinary medical care in this type of situation.

Missouri law, however, upheld by that state's supreme court in their Cruzan ruling, calls for ``sustaining life'' at any cost, the justices said. The quality of life, the court stressed, is not an issue.

In hearing this case, the justices of the US Supreme Court seemed to be looking for a narrow issue on which to base their ruling.

Perhaps they will return Cruzan v. Harmon to a lower court to clarify whether Cruzan's ``expressed,'' but unwritten and unspecific, wishes to reject extraordinary medical treatment, were clear enough to constitute a legal mandate. If they find they were, the justices could accede to the family's wishes without nullifying Missouri law.

The broader issue of who makes the decision would remain, however. It affects public policy not only in this type of case but in matters involving children, the elderly, the sick, and the have-nots.

The result is basic to a free society. Government properly takes a role to prevent hunger, abuse, and neglect. It may also step in on occasion to fulfill the responsibilities of a negligent family. But the devotion and care of a loving family, like the Cruzans, must be seriously considered by the courts.

Families are an integral part of the fabric of society. Government must take care not to pull them apart.