Comparative Analysis Case Study on Nancy Cruzan and Teri Schiavo

  1. Introduction

The question of whether human beings have the freedom to do what they please with their life and how to end it is a subject of ethical, philosophical, and religious discourses. From a religious perspective, people are supposed to be stewards but not just owners of the life that God has entrusted them with. According to various religions such as Christianity human individuals are prohibited from taking their lives or those of other people. Christians consider suicide as a sin. They believe that God is the originator of life and only He can decide whether to end one’s life or not, no matter the situation at hand. The American constitution also recognizes the need to respect and preserve human life, as enshrined in the Fourteenth Amendment. Over the years, Americans and the world at large have been treated to several landmark cases of the right-to-die nature. The Nancy Cruzan case of 1983 and Teri Schiavo’s case of 1990 are two of the most prominent instances in which there are legal challenges on whether to end the life of a patient in a persistent vegetative state or to uphold a life-sustaining treatment (Colby, 2006). This paper will explore the legal facts and rulings of the Nancy Cruzan case and compare them with those of Teri Schiavo’s case. Such a comparative analysis is intended to help shed light on the significance of cases concerning healthcare ethical issues.

  1. Comparative Study

Nancy Cruzan was involved in a serious car accident in January 11, 1983, that rendered her incompetent. Cruzan remained in a comma for nearly three weeks at the Missouri state hospital. Her surgeons sought consent form her husband to implant a hydration and gastronomy feeding tube as a means of aiding her to feed and recover. Nevertheless, Cruzan remained in a persistent vegetative state. Nancy’s parents started to doubt that she would ever recover and accordingly requested the hospital staff to disconnect the artificial hydration and nutrition tube that was sustaining the life of their child. However, the medical team declined to grant this wish, without having a court approval first. Cruzan’s parents went to the state trial court to obtain approval, but the court established that an individual in Nancy’s condition still enjoyed the fundamental right to accept or refuse the use of life-supporting procedures (Fine, 2005). In this complex ruling made by the Supreme Court, Cruzan’s parents obtained the consent needed to direct physicians to withdraw life support to the patient and let her die.

Terri Schiavo was only 27 when she had a cardiac arrest. This was in February 1990. It was highly suspected that the condition was induced by her bulimic behaviors. Four months after the appearance of the disease, the court appointed Terri’s husband, Michael Schiavo, as her legal guardian. Terri would go on to receive speech, experimental and rehabilitative therapy in various facilities in the United States between 1990 and 1994. A malpractice lawsuit against Terri’s obstetrician-gynecologist won her a $ 1 million settlement over her eating disorder. Most of the money, $ 700,000, was put in a trust to facilitate Terri’s care while her husband received $ 300,000 due to the loss of consortium (Fine, 2005). In March 1994, Teri was moved to a nursing home. Four years later, she entered into a permanent vegetative state. Accordingly, Michael Schiavo filed a petition requesting the court to allow the physicians at the health care facility to remove the gastrostomy tube so that she could die. He argued that it would not have been Teri’s wish to remain in a vegetative state. However, the petition was opposed by Terri’s parents. The case would drag on for years, in multiple court challenges involving Terri’s husband, her parents, and the state. Finally, on March 18, 2005, the gastrostomy tube that had kept Terri alive was removed, and she died.

  1. B) Legal and Ethical Details of Each Case
  2. Issues before the Court.

In Nancy Cruzan’s case, the Court was faced with the legal question of establishing if the State of Missouri was legally mandated to refuse Cruzan’s parents’ request to have their daughter removed from life support. The Supreme Court considered if by doing so, the State of Missouri had indicted in contravention of the Fourteenth Amendment Clause on Due Process, which indicated that the State did not have the powers to deprive of an individual’s life, property, or freedom without first having subjected such a person to due process. In Terri Schiavo’s case, the Supreme Court sought to establish if there existed any persuasive evidences that the patient expressed the opinion that in case she was ever in a vegetative state, she would not want to continue living through the support of artificial nutrition and hydration.

  1. The rule apply by the Court in resolving each case.

In resolving Nancy Cruzan’s case, the Supreme Court demanded that clear and convincing proof of her demands before her death to be provided. Indeed, Nancy Cruzan had made known to family and friends her wishes not to be put on life support in the unfortunate event that she degenerated into a vegetative state. Towards this end, the Supreme Court was not satisfied that such proof had been given (Stonecipher, 2006). Consequently, the Missouri Supreme Court ruled out that Nancy Cruzan should receive further treatment in spite of the findings of the trial court that it was not her wish to be given such treatment. Her parents appealed the court decision at the U.S. Supreme Court. Here, it was first necessary to convince the Court of the constitutional legislation that recognized a patient’s right to refuse medical attention. They also needed to persuade them that the tight restrictions by the Missouri’s Supreme Court had unduly affected that right. The U.S. Supreme Court, therefore, adopted a rational balancing test to balance the states interests against the patient’s interests. It is important to note that Cruzan was the first time in the history of the U.S constitution that a balancing test found explicit approval in deciding a private case.

Unlike Nancy Cruzan who had at least hinted to her roommate of her desire not to be on life support, Teri Schiavo had not expressed such a wish. Nancy Cruzan’s family was also united in the belief that their daughter would not want to remain in a persistent vegetative state but Terri Schiavo’s family appeared divided on this. Her husband was of the view that Teri would not have desired to remain in a vegetative state, but her parents were opposed to ending her life. Florida law relating to physician-assisted suicide demands that there must be explicit and convincing evidence that the patient in question would have opted for decision arrived at by the court if they could do so. In the absence of such a clear t evidence, then the court would have to settle for a decision that would place the patient’s best interests first.  Indeed, people lack societal consensus regarding keeping a person in a persistent vegetative state alive through feeding him or her through a tube is in the patient’s “best interest” (Quill, 2005). Therefore, the Court was faced with a key legal question of whether this would have been the wish of Terri Schiavo.

iii. Legally significant facts as established by the Court.

The Supreme Court established that when Nancy was twenty-five, she was engaged in a rather serious conversation with her friend about her wish not to continue living in case she got injured or was sick if there was no hope that she would regain half her normal life again. What this seemed to suggest, given her present predicament, was that keeping Nancy alive through nutrition and hydration was against her wish (Fine, 2005). However, the Court could not take an appropriate decision about whether to keep Nancy on nutrition hydration or not, based on her roommate’s statement. That is because the facts that Nancy’s friend revealed were not reliable enough in honoring her desire to live or die. The Florida High Court upheld the decision to respect Teri Schiavo’s wish to be removed from life support. A restraining order filed on behalf of Terri Schiavo’s parents to reinstall her feeding tube was denied. The U.S. Supreme Court also upheld the decision made by the High Court in Florida by declining to grant an emergency order that would have seen Terri Schiavo’s feeding tube restored.

  1. Identify the Court’s reasoning and ruling in the case. The Court rejected the argument that Cruzan’s parents had the right to end her treatment. It surmised that a person cannot make such a decision on behalf of an incompetent individual unless they stipulated so in his or her living will, or in case there was convincing evidence on which the court could rely on. The Court further reasoned that the case of Nancy Cruzan which called to mind broad policy question on death and life would be better dealt with not by judicial bodies but by parliament. While the U.S. Supreme Court was quick to acknowledge that the common law doctrine identified the right to refuse treatment as a key doctrine in as far as the issue of informed consent is concerned, they nonetheless, were hesitant to apply such a doctrine in the current case (Colby, 2006). Further, the court refused to apply the issue of privacy as expressed in the State Constitution as it applied to the case. In this instance, the State Constitution acknowledged that an individual had the right to decline medical treatment under any circumstances. The Supreme Court was doubtful if the U.S Constitution enshrined such a right. Therefore, the Court made a ruling in favor of preserving the life of Nancy Cruzan, pronouncing that the Missouri Living Will statute favored such a position.

In Terri Schiavo’s case, the U.S. Supreme Court established that there is no legal provision under the U.S Constitution to compel Missouri from asking for clear and compelling evidences on the wishes of an incompetent person to be withdrawn from life support. While recognizing that the Due Process Clause grants a competent individual the freedom to decline unwanted medical treatment, this should not be taken to mean that an incompetent individual such as Terri Schiavo would also possess a similar right, because they are not in a position to make voluntary and informed decisions.

  1. Evaluate the public response to each case and the rulings. Nancy Cruzan’s case divided the American public. It brought to light the issue of patient self-determination. This, in turn, prompted the U.S Congress to limit the decision’s reach via the passage of the Patient Self-Determination Act (Devins & Fisher, 2015). The case was also a clear indication that the American public and lawmakers were not willing to approve physician-assisted suicide. Religious organizations and medical professionals expressed their strong opposition to assist suicide. This was evident in the ensuing years where several bills aimed at weakening existing bans on physician-assisted suicide failed to get public or parliamentary approval. Terri Schiavo’s case lasted for seven years, and in the process, it elicited profound activism and public attention. The case further attracted extensive media coverage, not to mention the level of public opinion that each side tried to enlist. Terri Schiavo’s parents even established the Terri Schindler-Schiavo Foundation in an attempt to gather public support and assistance (Larson, 2005). Following the Supreme Court’s ruling which compelled physicians at the nursing home where Terri was hospitalized to remove the feeding tube, activist groups organized vigils outside the facility. Opinion polls conducted a few days following the court’s order to have Terri’s feeding tube removed indicated that majority of Americans were of the view that Michael Schiavo ought to have been in a position to make decisions for Terri (Shepherd, 2009). Opinion polls further showed that Americans believed the U.S Congress had exceeded its boundaries in its involvement in Terri Schiavo’s case.

III. Conclusion

Cases involving end-of-life decisions and physician-assisted suicide elicit a lot of legal, political and ethical attention, and this was no different with the instances of Cruzan and Schiavo. Particularly, Terri Schiavo’s case underscored the importance of ensuring that all close family members agree before withdrawing or withholding life support. However, this contravenes the need for patient autonomy.  Terri Schiavo’s case dragged on for longer than Nancy Cruzan’s case owing to the conflicting interests involving her parents, husband, as well as third parties, such as the civil society and the Catholic Church. Although physician-family communication is vital for overcoming struggles with end-of-life care, Schiavo’s case indicates that certain decisions emanate from non-medical setting. The cases further shed light on the fact that while we have in place legal and clinical mechanisms to protect patients who cannot make a decision, in the absence of a written will that portrays a patient’s wishes, the court will be compelled to rule in the patient’s best interests. These and other similar cases are indicative of the complex nature of end-of-life decisions owing to the diverse legal, ethical, and medical arguments involved.



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