In the Matter of Claire C. Conroy
Claire Conroy was an eighty-four-year-old nursing-home patient suffering from "serious and irreversible mental and physical impairments with a limited life expectancy." In March 1984 her nephew (her guardian and only living relative) petitioned the Superior Court of Essex County, New Jersey, for removal of her nasogastric feeding tube. Conroy's guardian ad litem, appointed by the court, opposed the petition. The Superior Court approved the nephew's request, and the guardian ad litem appealed. Claire Conroy died with the nasogastric tube in place while the appeal was pending. Nonetheless, the appellate court chose to hear the case (In the Matter of Claire C. Conroy, 486 A.2d 1209, [N.J. 1985]). The court reasoned that this was an important case and that its ruling could influence future cases with comparable circumstances.
Conroy suffered from heart disease, hypertension, and diabetes. She also had a gangrenous leg, bedsores, and an eye problem that required irrigation. She lacked bowel control, could not speak, and had a limited swallowing ability. In the appeals trial one medical expert testified that Conroy, although awake, was seriously demented. Another doctor testified that "although she was confused and unaware, 'she responds somehow.'"
Both experts were not sure if the patient could feel pain, although she had moaned when subjected to painful stimuli. They agreed, though, that if the nasogastric tube were removed, Conroy would die a painful death.
Conroy's nephew testified that his aunt would never have wanted to be maintained in this manner. She feared doctors and had avoided them all her life. Because she was Roman Catholic, a priest was brought in to testify. In his judgment the removal of the tube would be ethical and moral even though her death might be painful.
The appeals court held that:
The right to terminate life-sustaining treatment based on a guardian's judgment was limited to incurable and terminally ill patients who are brain dead, irreversibly comatose, or vegetative, and who would gain no medical benefit from continued treatment.
Furthermore, a guardian's decision did not apply to food withdrawal, which hastens death. The court considered this active euthanasia, which it did not consider ethically permissible.
THE THREE TESTS
The court proposed three tests to determine if Conroy's feeding tube should have been removed. The subjective test served to clarify what Conroy would have decided about her tube feeding if she were able to do so. The court listed acceptable expressions of intent that should be considered by surrogates or the court—spoken expressions, living wills, durable power of attorney, oral directives, prior behavior, and religious beliefs.
If the court determines that patients in Conroy's circumstance have not explicitly expressed their wishes, two other "best interests" tests may be used: the limited-objective and the pure-objective tests. The limited-objective test permits discontinuing life-sustaining treatment if medical evidence shows that the patient would reject treatment that would only prolong suffering and that medication would not alleviate pain. Under this test, the court requires the additional evidence from the subjective test.
The pure-objective test applies when there is no trustworthy evidence, or any evidence at all, to help guide a decision. The burden imposed on the patient's life by the treatment should outweigh whatever benefit would result from the treatment. "Further, the recurring, unavoidable and severe pain of the patient's life with the treatment should be such that the effect of administering life-sustaining treatment would be inhumane."
Conroy, the court concluded in January 1985, failed the tests. Her intentions, while perhaps clear enough to help support a limited-objective test (she had shown some evidence of a desire to reject treatment) were not strong enough for the subjective test (clear expressions of her intent). In addition, the information on her possible pain versus benefits of remaining alive was not sufficient for either the limited-objective test (her pain might outweigh her pleasure in life) or the pure-objective test (her pain would be so great it would be inhumane to continue treatment). Had Conroy survived the appellate court's decision, the court would have required her guardian to investigate these matters further before reaching a decision.
Judge Handler, dissenting in part, disagreed with the majority's decision to measure Conroy's "best interests" in terms of the possible pain she could have been experiencing. First, in many cases pain can be controlled through medication. Second, pain levels cannot always be determined, as was shown in Conroy's case. Finally, not all patients make a decision based on pain. Some fear being dependent on others, especially when their bodily functions deteriorate; others value personal privacy and dignity. Bodily integrity may be more important than simply prolonging life. Judge Handler supported reliance on knowledgeable, responsible surrogates as opposed to standards set in a series of tests.
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