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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
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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.
REFERENCES
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
(1976).
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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