Cruzan and Caring for Others

Abstract

Cruzan and Caring For Others How can one be a health care professional in Missouri today? What does one say to the family of a very sick elderly person? Does one actually acknowledge that every life-sustaining treatment must be provided unless the person left very specific, formal advance directives declining specific life-extending interventions? Or does the responsible health care provider just continue to serve patients well and ignore the potential adverse force of the law? Must one try so hard to avoid being trapped in the cycle of treatment that long-shot treatments are simply not offered? Health care professionals can hardly be expected to pretend that following the Supreme Court's Cruzan analysis will not hurt patients and families. If they generally simply refuse to follow Cruzan, instead relying on good sense and family wishes, they place themselves at substantial risk. The Court's Cruzan opinion, to be sure, did some helpful things. Just in case there was ever any doubt, competent persons will apparently be allowed to decide whether to accept life-sustaining health care, probably even if the decisions are made by way of advance directives. Artificial nutrition and hydration will be considered "medical treatment." Nothing important was made to turn on whether a patientis near death or is in persistent vegetative state. Since these gains seem to be largely dependent upon the need of the majority to secure Justice O'Connor's concurrence, however, one shudders to realize that, the wake of Justice Brennan's recent resignation, this troubling opinion is probably the high water mark for federal jurisprudence in this area for a long time to come. The grand tradition of personal rights guarantees in the federal Constitution ought to have given some protections against the seriously wrongheaded actiosn of states. Although the decision of the Missouri Supreme Court is potentially ambiguous on some points, clearly the intention was to make it virtually impossible for a postponable death to occur early, at least for incompetent persons. The suffering of the patient and family, the costs, the kind of life that can be gained, all are to count for nothing. If life can be prolonged, then it will have to be. It is hard to say what one should do if confronted with a family member in PVS. Most people queried in public opinion polls think they would want to be allowed to die, though some think even think sort of life should be sustained. The discord yields quickly when the question is changed to that of whether persons would want their families to be authorized to make this decision: Virtually everyone trusts their families to make the decision, and they also would rather have families risk error than have the decisions to be dictated by some other authority. Society runs real risks of damaging the social institution of families by mistrusting them, by ignoring that they will have to live with and make sense of the decisions made, and by abrogating long traditions of family responsibility in favor of state decisionmaking. The U.S. Supreme Court has tried to remove the Constitution from resolution of questions about decisionmaking for incompetent patients, and returned these issues almost entirely to the states. Undoubtedly, many more people will execute advance directives, some of which will help shap optimal decisionmaking and many of which will be inadequate due to incomplete advance understanding of the clinical situation, incompetence or death of the designated surrogate, and other shortcomings. …