The ethics of Cruzan. Families, not states, should make treatment termination decisions

Although the U.S. Supreme Court justices frequently alluded to ethical concepts in delivering their opinions in the Cruzan decision, no clear or consistent ethical framework supported this jargon. The decision, in fact, resolves none of the ethical and professional questions that initially brought the case to the courts. The various arguments about whether and when it is ethical to terminate treatment are the first source of ethical confusion in questions about death and dying. Individuals arriving at the same conclusion can begin from significantly different ethical principles. An added complexity arises as a result of differences among medical professionals regarding what constitutes a fatal pathological condition. A resolution of these differences would clarify a number of ethical questions. The biggest problem with the Missouri Supreme Court's decision was that it gave absolute precedence to the state's interest in preserving life, excluding quality-of-life considerations and disregarding personal, familial, and professional values that should have affected the decision. In fact, since a medically well-informed family is in most cases in the best position to make a decision that would conform with a family member's wishes, applying the "clear and convincing" evidence standard in the Cruzan case shifts the burden of proof to the wrong party. Instead, the state should be obliged to give convincing evidence of why it has intervened in a decision for which the patient's family and physician should have authority.