Long Goodbye: The Deaths of Nancy Cruzan
By William H. Colby
Hay House, Carlsbad, CA
415 pp., 2002, $27.95
REVIEWED BY FR. KEVIN O'ROURKE, OP, JCD
Nancy Beth Cruzan was injured seriously in a one-car accident on January 11,
1983, on an isolated country road in southwest Missouri. Arriving early at the
accident scene, Dale Lappin and his father George found that Nancy had been
thrown from the car. They thought she was dead, but called an ambulance anyway.
After working for "a long time," the emergency crew was able to restore a heartbeat
and took the unconscious Nancy Beth first to a hospital clinic and then to Freeman
Hospital in nearby Joplin, MO. Nancy's parents, Joyce and Joe Cruzan, having
been notified of Nancy's accident by their daughter Chris Cruzan White, were
quick to arrive at the hospital's emergency room. Thus did Joyce, Joe, and Chris
begin a vigil of care and concern for Nancy Beth that would last almost eight
years.
At first, at the urging of doctors and friends, the Cruzans sought rehabilitation
for Nancy Beth, hoping that consciousness might be restored. But after two years
she was moved to a state hospital for brain- injured patients in Mount Vernon,
MO, about 50 miles from Joplin. The injury to her cerebral cortex—the thinking,
loving, and relating part of the brain—was so severe that there was little hope
of recovery.
This condition is often referred to as "persistent vegetative state." Though
some object to this terminology, it is clear that people can be in such an unresponsive
condition for years, with no hope that they will regain meaningful human function.
Often, in the initial stages of this cerebral pathology, life support in the
form of artificial hydration and nutrition will be administered to the patient
in the hope that such sustenance may enable the body to recover at least some
of its cerebral function.
This form of life support was given to Nancy Beth in the early stages of her
recuperation. But it was not effective, and in August 1988 the Cruzan family
sought to have this form of life support removed because it was not helping
Nancy Beth to recover. "Most of the time when a young adult such as Nancy Beth
Cruzan has an accident, her loved ones talk to doctors and make medical decisions
as a group," writes the author of this book. "When disputes arise, they are
worked out at the bedside" (p. 63).
In the Catholic tradition of medical ethics, "hope of benefit" and "excessive
burden" are the criteria that guide decision making of physicians and patient
proxies (who are usually family members) as they make efforts to confront this
difficult decision (see Directives 56 and 57, and the endnotes to them, in the
Ethical and Religious Directives for Catholic Health Care Services*).
The purpose of withholding life support is not to kill the patient, but rather
to avoid doing something that is useless or an excessive burden. Often, the
patient dies as a result of removing life support, but this is not the intention
of the action. Rather, death is an unintended side effect. But, in the case
of Nancy Beth, the administrators of the state rehabilitation hospital in Mount
Vernon declined to remove the life support without a court order. Enter the
author of the book, the Cruzans's lawyer and later friend, William Colby, who
guided the Cruzans through the court system of Missouri and then to the Supreme
Court of the United States.
* Ethical and Religious Directives for Catholic Health Care Services,
4th ed., U.S. Conference of Catholic Bishops, Washington, DC, 2001, pp.
31 and 42.
Colby describes how Missouri officials, especially Attorney General William
Webster and Governor John Ashcroft, saw to it that a Carthage, MO, probate court
decision favorable to the Cruzans was tried in the Missouri Supreme Court, which
reversed it. Clearly the legal process did not involve direct action on the
part of Webster and Ashcroft. But the fact that the state supreme court's chief
justice asked the probate court's Judge Charles Teel to have his opinion ready
for early consideration by the higher court is significant (p. 236).
There is no doubt that the decision by the probate court judge to allow the
removal of life support was contrary to the opinion of Webster and Ashcroft.
The Missouri Court of Appeals was skipped in this process. Judge Teel asked
Nancy Beth's legal guardian to appeal his decision directly to the state supreme
court, which was done (p. 235). That court accepted the petition without delay.
Colby does not attribute political motives to Webster and Ashcroft but readers
may suspect that the fact that they did not oppose the case when it came back
to the same probate court after having gone to the U.S. Supreme Court indicates
that their earlier efforts were inspired by potential political gain rather
than ethical or legal arguments.
Colby is also rather benign in discussing the logic involved in the Missouri
Supreme Court opinion reversing the lower court's decision. The latter would
have enabled the Cruzan family to withdraw life support in the form of artificial
hydration and nutrition because it offered no hope of benefit and imposed an
excessive burden upon Nancy Beth and her family. In overturning the lower court's
opinion, the state supreme court offered the ethically erroneous statement that
removing life support "seeks to cause the death of the incompetent patient"
(p. 41, quoting the state supreme court's petition for a writ of certiorari
to the U.S. Supreme Court) and that the Cruzans were therefore "choosing the
death of their daughter" (p. 44). The state supreme court could have been aided
by any beginning student in moral theology, who would have explained to the
justices the principle of double effect and its role in the removal of life
support from permanently incompetent persons.
In the main, the U.S. Supreme Court upheld the decision of the Missouri Supreme
Court, stating that Missouri could require "clear and convincing evidence" before
allowing life support to be removed. But in the several opinions written by
members of the court, it was clearly stated that artificial hydration and nutrition
is a life support system, not comfort care. Moreover, the possibility that fresh
evidence might justify another trial was stated in Chief Justice William Rehnquist's
opinion. This possibility was later realized when, once again, Judge Teel declared
that new witnesses offered "clear and convincing evidence" that Nancy Beth had
expressed well before her death the desire to have life support removed if she
were ever in a permanent comatose condition.
Life support was removed from Nancy Beth in late December 1990 and she died
a few days later of the brain injury sustained in the original accident.
This is a compelling book. In addition to explaining the legal and ethical
aspects of the case, Colby steps behind the scenes and depicts both the suffering
that self-righteous people inflicted on the Cruzans and the love and courage
they manifested throughout the almost eight years of this traumatic experience.
Through their suffering, they raised the consciousness of the nation and, as
this book's publishers say, "freed countless American families from the fears
attending death."
Fr. Kevin O'Rourke, OP, JCD
Professor of Ethics
Stritch School of Medicine
Loyola University, Chicago
Copyright © 2003 by the Catholic Health Association of the United States
For reprint permission, contact Betty Crosby or call (314) 253-3477.