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PAL—The Counterweight to Physician Assisted Suicide


     Whether it is in someone's best interest that his life end in one way rather than another depends on so much else that is special about him—about the shape and character of his life and his own sense of his integrity and critical interests—that no uniform collective decision can possibly hope to serve everyone even decently.1

     CONNECTICUT gave the nation its first hospice. With Physician Assisted Living, Connecticut becomes the first state to adopt the best way to assure the family of a terminally ill patient of a death with dignity and compassion.
In June of this year, the U.S. Supreme Court addressed the issue of physician assisted suicide in Vacco vs Quill, -- U.S. --117 S. Ct. 2293 (1997) and Washington vs Glucksberg, --U.S. --117 S. Ct. 2258 (1997). In these cases the Court determined that a state ban on physician assisted suicide does not violate the Equal Protection Clause of the 14th Amendment.2 In so doing the Court recognized the distinction between letting a patient die and making that patient die, between assisting suicide and withdrawing life-sustaining treatment as "a distinction widely recognized and endorsed in the medical profession and in our legal tradition, [as] both important and logical; it is certainly rational."3

     For two decades courts, legislatures, and the vast majority of medical professionals have respected the "real distinction between the self-infliction of deadly harm and a self-determination against artificial life support."4 In the case of Cruzan vs Director, Mo. Dept. of Health, 497 U.S. 261, 278 (1990) which presented issues similar to the

JOSEPH A. CALIFANO, Jr., ESQ., Chairman and President, The National Center on Addiction and Substance Abuse, Columbia University; Secretary of Health, Education, and Welfare from 1977_1979. During his tenure in that post, at the request of Governor Ella Grasso, he awarded Connecticut the first funds H.E.W. ever gave to establish Connecticut Hospice in New Haven.

Karen Ann Quinlan case, the Court recognized that the State of Missouri's interest did not outweigh Nancy Cruzan's liberty interest in refusing medical treatment. Justice Stevens dissent acknowledged that:

Nancy Curzan's interest in life, no less than that of any other person, includes an interest in how she will be thought of after her death by those whose opinions mattered to her. There can be no doubt that her life made her dear to her family and to others. How she dies will affect how that life is remembered.5

     This passage is especially poignant and applicable to Physician Assisted Living (PAL) The PAL initiative is about each patient and her family's interest in life—how it is lived to its fullest to its end and how it is remembered "by those whose opinions matter." PAL is about making decisions about how to confront serious, advanced, irreversible illness.
     Justice Stevens, concurring in Vacco, notes that Cruzan "did give recognition, not just to vague, unbridled notions of autonomy, but to the more specific interest in making decisions about how to confront an imminent death."6 Justice Stevens goes on to explore this notion in saying:

Although there is no absolute right to physician-assisted suicide, Cruzan makes it clear that some individuals who no longer have the option of deciding whether to live or die because they are already on the threshold of death have a constitutionally protected interest that may outweigh the State's interest in preserving life at all costs. The liberty interest at stake in a case like this differs from, and is stronger than, both the common-law right to refuse medical treatment and the unbridled interest in deciding whether to live or die. It is an interest in deciding how rather than whether, a critical threshold shall be crossed.6 (Emphasis added)

     PAL Partners offers the means to create directives for "how, rather than whether, a critical threshold shall be crossed." Advances in medical technology that created the

ability to sustain life also gave rise to the issues presented in the numerous cases that reached the courts where the withdrawal of life-sustaining treatment was addressed. Federal and state legislatures responded to the issues presented in many cases from Quinlan to Cruzan, with laws that enables patient self-determination and the creation of advance directives in anticipation of an individual becoming unable to decide or articulate a decision previously made.

     As a parallel, Connecticut's PAL initiative responds to the issues presented in Vacco vs Quill and Washington vs Glucksberg. In the same way the Court grapples with the differences between assisting suicide and withdrawing life-sustaining treatment, the PAL Partners initiative assists patients in preparing for the eventuality of those very issues being presented in their lives. PAL offers a dignified solution to the unnecessary dilemma of physician-assisted suicide or a life extended by tubes and machines. It offers a viable alternative to the desperate choice that confronts patients whose life is limited. It offers the patient an opportunity to die in the arms of family and friends rather than tied to tubes and machines.

      As the hospice movement came of age in the United States, the PAL Partners initiative will mature into a fully adopted precept of advance directive initiative. In future years, Americans will remember that these two companion pieces, hospice and Physician Assisted Living, so integral to care of the terminally ill, both originated in Connecticut, as they are integrated into the care of all patients and their families facing irreversible illness, by all providers, in all settings.


1.Dworkin R: Life's Dominion. New York, NY: Kopt; 1993:213.

2.The Fourteenth Amendment of the United States Constitution states in Section 1: No state shall make or enforce any law which

shall abridge the privileges or immunities of citizens of the United

States; nor shall any state deprive any person of life, liberty, or

property, without due process of law; nor deny to any person within

its jurisdiction the equal protection of the laws.
3.Vacco vs Washington,_U.S._, 117 S. Ct. 2293, 2298 (1997).
4.In re Quinlan, 70 N.J. 10,43,52, and n. 9,335 A.2d647, 665, 670 and
n. 9, Cert. Denied sub nom. Garger vs New Jersey, 429 U.S. 922

5.Cruzan vs Director, Mo. Dept. of Health, 497 U.S. 261, 344 (1990)

(STEVENS, J, dissenting).
6.Washington, 117 S. Ct. at (1997).

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