The Right To Die -- Legal, Ethical Issues Of The Cruzan Case Far From Resolved
To some, Nancy Cruzan was the symbol of the perils of modern medical technology, a shell of a person trapped between life and death. To others, she represented the need to protect the disabled and to preserve life, no matter what its quality.
When she died at 3 a.m. yesterday, the complex legal and ethical issues swirling around her case were far from resolved. But her family's ordeal had, if nothing else, helped to educate the public about the difficult decisions and emotional land mines that such a calamity involved.
Cruzan's father, Joe Cruzan of Carterville, Mo., said she left a legacy for thousands of people to be free ``from the fear of unwanted and useless medical treatment. I think this is quite an accomplishment for a 25-year-old kid, and I'm damned proud of her.''
On Jan. 11, 1983, Nancy Cruzan Davis worked a late shift at the Schreiber Foods cheese processing factory in Carthage, Mo. She drove east along Elm Road, still about a mile from her home. The weather was clear and the pavement dry as she headed up a slight hill in her 1963 Rambler Classic sedan. She may have fallen asleep. She apparently was driving too fast - a patrolman later estimated her speed at 60 mph. The speed limit was 55.
Whatever the reason, she lost control of her car. It ran off the left side of the road, struck some small trees and a mailbox, then swerved back across the road and ran off the right side. The car went through a fence and overturned several times, coming to rest on its top.
State Highway Patrol Trooper Dale Penn was the first to arrive at the accident scene, southeast of Carthage. He got there at 1 a.m. and found Cruzan lying face down in a ditch. She was not breathing; her heart had stopped. He did not administer cardiopulmonary resuscitation.
After looking through Cruzan's billfold and finding pictures of her two young nieces, Penn feared that a baby might have been thrown from the car. He began searching the area.
When paramedics arrived at 1:09 a.m., Cruzan was still face down in the ditch. They began CPR; a tube was placed down her windpipe and an IV introduced. By 1:13 a.m., the paramedics had shocked Cruzan's heart into beating; she had resumed breathing.
But her brain had been without oxygen for 12 to 14 minutes. Less than six minutes is the maximum time for the brain to be without oxygen without causing permanent damage. The longer the duration, the greater the damage.
Later, Cruzan's family told Thad McCanse, a lawyer appointed to represent her interests, that ``they wished the ambulance had gotten there either five minutes earlier or five minutes later.''
Cruzan remained in a coma for about three weeks. Then she opened her eyes. She was in what doctors call a persistent vegetative state.
Her lower brain, or brain stem, was working. It controls heartbeat, breathing and reflexes. But her upper brain, or the cerebral hemispheres, was too damaged to function. That part of the brain controls thinking and feeling, the ability to move purposefully.
In other words, although Cruzan had sleep and wake cycles and her eyes roamed about the room, doctors said she was oblivious to her environment. Her reactions were purely reflexive.
Cruzan's husband, Paul Davis, consented to surgical insertion of a gastronomy tube in her abdomen. The family held out hope that her condition would improve.
When Cruzan was discharged that spring, she was placed in her husband's grandmother's home in Oronogo, Mo., near Joplin, Mo. The grandmother, Ruth Troutman, made her dining room into a bedroom for Cruzan; she had full-time nursing care.
After a few months, Cruzan was moved to a hospital and then a nursing home, where she contracted an infection and had a temperature of 107. In October 1983, doctors transferred her to the Missouri Rehabilitation Center at Mount Vernon, Mo.
Cruzan's parents got court permission to replace her husband as Cruzan's guardians. At the parents' request, Cruzan's marriage to Paul Davis was dissolved by the court.
Davis declines to be interviewed. His grandmother says he talks little about the case.
In October 1987, Joe and Joyce Cruzan finally decided that their daughter's condition was hopeless and that the feeding tube should be removed. As Joe Cruzan put it, she was ``trapped in a ridiculous limbo between life and death.''
The family had sought medical advice and studied the cases of others in persistent vegetative states. Joe Cruzan told a reporter in December 1987, ``We've had five years to become informed on whether this is right.''
The family initially considered taking Cruzan home to die, but the judge overseeing their guardianship discouraged them. Jasper County Circuit Judge Charles Teel Jr. warned that someone could file criminal charges against the family for their daughter's death.
So the family filed a petition in Teel's court, asking him for permission to withdraw Cruzan's food and water. The family presented evidence that the woman would want to die. Her sister, Chris White, said Cruzan had told her that she would not want to live as a ``vegetable.''
In July 1988, Teel, known as a conservative country judge, granted the family's request to withdraw the feeding tube.
But the Cruzans' legal roller-coaster ride had just begun. Then-Missouri Attorney General William Webster appealed to the Missouri Supreme Court. That court overturned Teel's ruling.
The court noted that many states had allowed people in Nancy Cruzan's situation to die. But Missouri, the court said, had a strong policy favoring life, as expressed in the state's anti-abortion and ``living will'' laws.
The anti-abortion law gave the right of life to all humans, born and unborn. The living-will law specifically prohibited people from specifying that they would want food and water withdrawn if they were incapacitated.
The last chance for the family lay with the U.S. Supreme Court. The high court, which never had heard a ``right to die'' case, decided the Cruzan case last summer.
Cruzan did have a constitutional right to refuse food and water as part of unwanted medical treatment, the court said. But the state could require the family to present ``clear and convincing'' evidence Cruzan would want to die.
That sent the family back to Jasper County Circuit Court. In November, the family presented the testimony of three new witnesses - co-workers who had heard Cruzan say she would never want to live as a vegetable. McCanse recommended the tube be removed.
Once again, Teel found the evidence ``clear and convincing.'' The attorney general had dropped out of the case three months earlier; Webster said the state had no interest in the outcome of the case because the U.S. Supreme Court had established a ``standard of proof'' for such cases.
So, no party to the case disagreed.
On Teel's order, Cruzan's feeding tube was removed Dec. 14. She died 12 days later. She was 33 years old.