Court and the End of Life - The Right To Privacy: Karen Ann Quinlan
supreme medical respirator patient
The landmark case of Karen Ann Quinlan was the first to deal with the dilemma of withdrawing life-sustaining treatment from a patient who was not terminally ill but who was not really "alive." The decision to terminate life support, which was once a private matter between the patient's family and doctor, became an issue to be decided by the courts. The New Jersey Supreme Court ruling on this case became the precedent for nearly all right-to-die cases nationwide.
In 1975, 21-year-old Karen Ann Quinlan suffered cardiopulmonary arrest after ingesting a combination of alcohol and drugs. She subsequently went into a persistent vegetative state (PVS). Dr. Fred Plum, a neurologist, described her as no longer having any cognitive function but retaining the capacity to maintain the vegetative parts of neurological function. She grimaced, made chewing movements, uttered sounds, and maintained a normal blood pressure, but was entirely unaware of anyone or anything. The medical opinion was that Quinlan had some brain-stem function, but that in her case it could not support breathing. She had been on a respirator since her admission to the hospital.
Quinlan's parents asked that her respirator be removed and that she be allowed to die. Quinlan's doctor refused, claiming that his patient did not meet the Harvard Criteria for brain death. Based on the existing medical standards and practices, a doctor could not terminate a patient's life support if that patient did not meet the legal definitions for brain death. According to the Harvard Criteria, Quinlan could not be declared legally dead, and medical experts believed she would die if the respirator were removed.
Quinlan's father, Joseph Quinlan, went to court to seek appointment as his daughter's guardian (since she was of legal age) and to gain the power to authorize "the discontinuance of all extraordinary procedures for sustaining Quinlan's vital processes." The court denied his petition to have Quinlan's respirator turned off and also refused to grant him guardianship over his daughter.
First and Eighth Amendments Are Irrelevant to Case
Joseph Quinlan subsequently appealed to the Supreme Court of New Jersey (In re Quinlan, 70 N.J. 10, 355 A.2d 647, 1976). He requested, as a parent, to have Quinlan's life support removed based on the U.S. Constitution's First Amendment—the right to religious freedom. The court rejected his request. It also considered the Eighth Amendment—protection against cruel and unusual punishment—inapplicable in Quinlan's case, stating that this amendment applied to protection from excessive criminal punishment. The court considered Quinlan's cruel and unusual circumstances not punishment inflicted by the law or state, but the result of "an accident of fate and nature."
The Right to Privacy
The New Jersey Supreme Court stated, however, that an individual's right to privacy was most relevant to the case. Although the U.S. Constitution does not expressly indicate a right to privacy, U.S. Supreme Court rulings in past cases had not only recognized this right but had also determined that some areas of the right to privacy are
guaranteed by the Constitution. For example, the Supreme Court had upheld the right to privacy in Griswold v. Connecticut (the right to marital privacy, or the right to use contraception, 381 US 479, 1965) and in Roe v. Wade (the right to abortion, 410 US 113, 1973). The U.S. Supreme Court had further presumed that the right to privacy included a patient's right to refuse medical treatment in some situations.
Based on these U.S. Supreme Court rulings, the New Jersey Supreme Court ruled that "Karen's right of privacy may be asserted on her behalf by her guardian under the peculiar circumstances here present," and further noted:
We have no doubt … that if Karen were herself miraculously lucid for an interval (not altering the existing prognosis of the condition to which she would soon return) and perceptive of her irreversible condition, she could effectively decide upon discontinuance of the life-support apparatus, even if it meant the prospect of natural death.
The State's Interest
Balanced against Quinlan's constitutional right to privacy was the state's interest in preserving life. Judge Hughes of the New Jersey Supreme Court noted that in many cases, the court had ordered medical treatment continued because the minimal bodily invasion (usually blood transfusion) resulted in recovery. He indicated that, in Quinlan's case, bodily invasion was far greater than minimal, consisting of 24-hour nursing care, antibiotics, respirator, catheter, and feeding tube. Judge Hughes further noted:
We think that the State's interest … weakens and the individual's right to privacy grows as the degree of bodily invasion increases and the prognosis dims. Ultimately there comes a point at which the individual's rights overcome the State's interest.
Prevailing Medical Standards and Practices
Quinlan's physicians had refused to remove the respirator because they did not want to violate the prevailing medical standards and practices. Even though Quinlan's physicians assured the court that the possibility of lawsuits and criminal sanctions did not influence their decision in this specific case, the court believed that the threat of legal ramifications strongly influenced the existing medical standards and practices of health care providers.
The court also observed that life-prolongation advances had rendered the existing medical standards ambiguous (unclear), leaving doctors in a quandary. Moreover, modern devices used for prolonging life, such as respirators, had confused the issue of "ordinary" and "extraordinary" measures. Therefore, the court suggested that respirators could be considered "ordinary" care for a curable patient, but "extraordinary" care for irreversibly unconscious patients.
The court also suggested that hospitals form ethics committees to assist physicians with difficult cases like Quinlan's. These committees would be similar to a multi-judge panel exploring different solutions to an appeal. The committees would not only diffuse professional responsibility, but also eliminate any possibly unscrupulous motives of physicians or families. The justices considered the court's intervention on medical decisions an infringement on the physicians' field of competence.
Is It Homicide?
The state had promised to prosecute anyone who terminated Quinlan's life support because such an act would constitute homicide. The New Jersey Supreme Court, however, rejected this consequence because the resulting death would be from natural causes. The court stated:
The exercise of a constitutional right, such as we have here found, is protected from criminal prosecution.… The constitutional protection extends to third parties whose action is necessary to effectuate the exercise of that right.…
After the Respirator Was Removed
In March 1976 the New Jersey Supreme Court ruled that, if the hospital ethics committee agreed that Quinlan would not recover from irreversible coma, her respirator could be removed. Furthermore, all parties involved would be legally immune from criminal and civil prosecution. However, after Quinlan's respirator was removed, she continued to breathe on her own and remained in a PVS until she died of multiple infections in 1985.
Some people wondered why the Quinlans did not request permission to discontinue Karen's artificial nutrition and hydration. In Karen Ann: The Quinlans Tell Their Story (New York: Doubleday and Company, 1977) the Quinlans stated that they would have had moral problems with depriving their daughter of food and antibiotics.
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