Legal and Ethical Issues in Health Services: The Nancy Cruzan v. Director, Missouri Department of Health Case Study

 Survey of USA Legal System- Analysis Of A Legal Decision Module 01 Written Assignment Week Three

Nancy Cruzan, resident of Missouri state was involved in a severe car accident on January 11, 1983. While lying in the hospital she was at vegetate state due to severe brain damage caused by accident.  She lived as a being without recognition, thinking, or feeling. She could not swallow or eat; rather she had a feeding tube inserted in her stomach for food and water. Also she was incontinent and had to wear diapers. According to Barton (1991), Nancy did not respond to stimuli or recognize her family, and diagnostic tests, such as electroencephalograms (EEGs) detected no brain waves due to her persistent vegetative state since January of 1983. {Barton, 1991 #3} 


Nancy's parents joined by family members and friends asked the Missouri State Hospital to stop administering food and fluids to Nancy after professionals’ after  determination that she  has no and would never recover cognitive ability {Barton, 1991 #3}. According to Morrison (2009) Nancy did not have an advance directive or medical proxy whatsoever. She did not have any will or any written document that could prove her parents claim or could indicate how medical institutions can treat her in case of incapacitation {Morrison, 2009 p127}.

After the local probate judge ruled in favor of Nancy’s family and friends,  the Attorney General of Missouri appealed the Nancy ruling to the Supreme Court of Missouri However, eventually Nancy’s family worn the appeal on December 14^th 1990, but after the battle that took many years {Morrison, 2009 127}. The matter that was brought in the Missouri Supreme Court on the Cruzan v. Director, Missouri Department of Health made history as “the first time that court had considered the issue of  the right to die” {Morrison, 2009 127}. The question was could the state of Missouri necessitate clear convincing evidence of Nancy’s wishes by conceding permission to her parents? {Morrison, 2009 127}.

Legal Issues that raises ethical matters in this case are such as, could Nancy, presently unable to make decisions for herself, choose to live in this vegetate state?  was there a family right of sovereignty that overrides the State's interest in preserving  her vegetate state life? Nancy did not leave specific instructions to terminate her life support if she were ever in a persistent, vegetate state. Who, then, should decide to withhold medical treatment? The family? A doctor? A court? To me I see that it depend who is facing either of these sides, a family member or friends, a doctor, or a judge and DA. What they believe about life and what they value in life sometimes directly influence their decision making. It can be ethical or unethical, perceived well or condemned by the public. But to close family members, vegetate sate to the love one, it can be trauma and disappointing seen someone you always see responsive and communicative laying helpless and cannot talk or show any sign. It is even worse if family members are put in this scenario because of hand of government or politicians.

Put in mind that the removing of feeding tube would result in Nancy's death from dehydration, it sounds inhumane, but her parents and friend had confident that she would not have wanted to live her life as a vegetable, neither one of us wouldn’t, as far as I know. Ethical maters in this case are not like “life is precious” on the issues of random abortions or suicides. To me it is ethical to not consider the general ramifications of the decision on this case, in stead to decide the Nancy’s case on its own merits {Leschensky, 1991 #4}.

Nevertheless, the state of Missouri standing on regardless of the condition of the patient, the overt action of removing feeding tubes constitutes murder under Missouri law; therefore to permit any life-threatening action by a medical caregiver is to violate Missouri criminal law. This was not killing or life threatening by anyone by any means. It was the wish of the Nancy’s family and friend not live the pain of seen their loved one laying in the state rehab helpless at vegetate state with no hope to recover; due to some outsiders who never even met Nancy. It is traumatic and cause more pain than rewards for the family members and friends {Leschensky, 1991 #4}.

Term that was used to analyze and prove this case in this case in the Missouri Supreme Court is “clear and convincing” that Nancy would want the feeding tube to be removed, or on the other words to die. Supreme Court ruled that state are permitted to set the standard at high level even though such a high level of proof, “clear and convincing”,   is not required in Nancy’s case. This case was returned to the trial court.

For example, Justice O'Connor settled with the result reached by the Supreme Court majority, and furthered, specifically distinguishing a patient's independence interest in refusing the "artificial delivery of food and water." troubled that “there be means available to protect an individual's liberty interest to refuse medical treatment, she pointed out that the Court had decided "only that one state's practice does not violate the Constitution" and that the ruling "does not preclude a future determination that the Constitution requires states to implement the decisions of a patient's duly appointed surrogate." {Leschensky, 1991 #4}

On 12/14/1990 the judge ruled in favor of Nancy’s parents after more witness who testified that Nancy told them that she would not want to live in the persistent vegetative state. This evidence satisfied the “clear and convincing” standard {Morrison, 2009 127-8}. This case illustrates how important it is for every one to preplan and complete advance directive or proxy or will contracts, as a concept recognized by state laws and supported by most Americans. However, PSDA act of 1991 gives federal government mandate to call upon states and healthcare providers to educate professionals and the public about local laws concerning healthcare decision making rights and advance directives. PSDA don’t provide universal acknowledged advance directive, even though majority suggests that PSDA universality would some how smooth the improvement of public information and awareness {Morrison, 2009 124}.

Cruzan v. Director, Missouri Department of Health case has expedite to put in place Patient Self-Determination Act (PSDA) that was introduced in the U.S. senate by Missouri senator John C Danforth (R) and New York Senator Daniel Patrick Moynihan (D) in October 1989. This bill died, but six months later Representative Sander M. Levin (D) from Michigan sponsored to the U.S. House of Representatives a considerable revised version of the original bill that died in the senate.  On December 1990 President H.W. Bush signed the PSDA bill as part of OBRA, and on December 1, 1991 the bill became effective {Morrison, 2009 124}.

To put laws or legislatives in place such as PSDA Act is to avoid future legal conflicts like this is the way forward, but to cause others to suffer because of divisive common sense then that is not liberty.  I do value life dearly, such as reduction of crimes, road accidents, and practices that cost innocent lives. Nancy’s case is unique and needs its own merit because it causes more pain to family members and community, I have been there, and don’t want to resurrect pain every time you visit the hospital or rehab. Barton (1991) said that “we are constitutionally protected right to refuse life-sustaining treatment”. It can be ethical to some and to some can be unethical. 

By Desdery J. Masao January 2009

Bibliography:

1.                              {Barton, 1991 #3} Barton, R. S. (1991). "Cruzan v. Director, Missouri Dept. of Health." Issues in Law & Medicine 6(4): 409-413.

2.                              {Morrison, 2009 #2} Morrison, E. E. and J. F. Monagle (2009). Health care ethics : critical issues for the 21st century. Sudbury, Mass., Jones and Bartlett Publishers.

3.                              {Leschensky, 1991 #4}Leschensky, W. L. (1991). "Constitutional protection of the `refusal-of-treatment': Cruzan v. Director, Missouri Department." Harvard Journal of Law & Public Policy 14(1): 248.

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