A Missouri court ruled yesterday that Nancy Beth Cruzan has the right to die, ending a legal battle that has kept the comatose woman on a feeding tube for eight years and focused national attention on the plight of the hopelessly ill.
In a written order released yesterday, Jasper County Probate Judge Charles Teel said Cruzan's parents had presented "clear and convincing evidence" that their daughter would not want to "continue her present existence, hopeless as it is, and slowly progressively worsening."
Missouri officials, who had opposed the efforts of Cruzan's parents, said they would comply with the decision.
Food and water will be withdrawn almost immediately from Cruzan, 33, and, according to medical experts, she is likely to starve to death within two weeks.
The decision is considered a triumph for the growing right-to-die movement, which has argued that in cases of irreversible coma or terminal illness the wishes of the patient or, if the patient is unconscious, the patient's family can be used to justify removal of life-sustaining measures.
"Because of Nancy, I suspect hundreds of thousands of people can rest free, knowing that when death beckons they can meet it face-to-face with dignity, free from the fear of unwanted and useless medical treatment," her parents said in a statement read by their attorney at a news conference yesterday.
But many bioethicists and legal experts said resolution of the Cruzan case did little to clarify the confusing legal picture surrounding the termination of life-support measures, and was too narrowly drawn to serve as a precedent for other right-to-die cases.
"This is a bitter victory," said Arthur Caplan, director of the Center for Biomedical Ethics at the University of Minnesota.
"The family was put through seven years of bureaucracy, courtrooms, hearings, second-guessing and media exposure for a decision that I always felt they should have had the ability to make privately and with dignity," he said.
"Legally this is not all that important," said Daniel Callahan of the Hastings Center, an ethics think tank in New York. "But it is of educative and symbolic value. It signals the fact that there are a significant number of people in a persistent vegetative state.
"It signals the fact that laws on this issue differ from state to state, and it has called to attention the anguish that families have when they are faced with a confusing legal situation," he added.
Lester and Joyce Cruzan first asked for a court order to discontinue feeding of their daughter in 1987, four years after she became irreversibly brain damaged in an auto accident.
The local court ruled in favor of the Cruzans. But the Missouri attorney general appealed successfully to the state Supreme Court, which ruled in November 1988 that no one, not even family members, could make choices for an incompetent patient in the absence of "clear and convincing" evidence of the patient's wishes.
The Cruzans then appealed to the U.S. Supreme Court, which, in a landmark judgment last June, upheld the ruling of the state Supreme Court, saying Missouri had the right to set a "clear and convincing" evidence standard.
In August, however, the Cruzans asked a local state court for a new hearing. Three friends of Nancy Cruzan's, they said, had come forward claiming to have had conversations with her about how she would not ever want to live "like a vegetable."
In September, the state announced it no longer had a "recognizable legal interest" in the case and would no longer contest the Cruzan's attempts to end their daughter's life.
With no party opposing the Cruzans, with her parents and legal guardian in favor of ending her life, and with three new witnesses presenting evidence of Nancy Cruzan's intentions, yesterday's decision was considered by many legal and ethical observers to be inevitable.
The liquid diet that has been fed to Cruzan through a stomach tube since January 1983 will be stopped within 24 hours, according to hospital officials.
With that, her supply of water will also cease. She will be given pain medication and allowed to starve and dehydrate to death.
According to legal experts, however, resolution of the Cruzan case leaves unanswered a number of legal and ethical questions.
The first question is whether the new evidence presented by the Cruzans meets the "clear and convincing" evidence standard set by the Missouri Supreme Court and endorsed by the U.S. Supreme Court.
James Bopp Jr., president of the National Legal Center for the Medically Disabled, said testimony of the new witnesses was not adequate because, in his opinion, the Missouri standard called for her to have made an informed decision explicitly about refusing food and water while in a coma.
"There was absolutely not one shred of evidence that she had made an informed consent refusal in the past," he said. "This shows the lengths to which those who believe that the best thing for people with disabilities is to be dead will go to implement that view."
Nor does the Cruzan case resolve the question of whether families alone can make decisions about the fate of hopelessly ill kin. This case was resolved, because Nancy Cruzan, according to her friends, left at least some evidence of how she felt about living in a coma. But legal experts said the question of whether a family can make a decision for one of its members, in cases where there is no evidence, awaits another court case.
"This is the right decision for Nancy and her family," Caplan said. "But no one should believe that this will end the debate over whether a family's wishes will be respected."