Saturday, April 22, 2017

S is for Suicide

The right to die.  Also called physician-assisted suicide, death with dignity, and end-of-life choice.  Now accomplished by advance directives, “do not resuscitate” orders, and “no extraordinary measures” orders. 

Not the same as euthanasia, in which the doctor administers the lethal drugs.  In the right to die context, the doctor prescribes the drugs, the patient [or legal representative] administers them to himself.  Also not the same as mercy killing, in which a third party, typically a relative, performs the killing.

Cruzan v. Director, Missouri Department of Health

[June 25, 1990, decided 5-4]

This was the first “right to die” case heard by the Supreme Court.

On January 11, 1983, Nancy Cruzan lost control of her car. She was thrown from the vehicle and landed face-down in a water-filled ditch.  Paramedics found her with no vital signs, but they resuscitated her.  After three weeks in a coma, she was diagnosed as being in a persistent vegetative state (PVS).  She was given a feeding tube for her long-term care.

In 1988, Cruzan's parents asked her doctors to remove her feeding tube.  The hospital refused to do so without a court order, since removal of the tube would cause Cruzan's death.

The Court agreed that competent people had the right to refuse medical treatment, but it noted that incompetent people were not able to exercise this right for themselves. Because there was no guarantee that family members would always act in the best interests of incompetent patients, and because the decision to end treatment was irreversible, the Court said there had to be clear and convincing evidence that the patient would have wanted treatment to end.

After the Supreme Court's decision, the Cruzans gathered additional evidence that Nancy would have wanted her life support terminated.  The additional evidence met the “clear and convincing” standard and the feeding tube was removed.  She died on December 26, 1990.

The Cruzan case set several important precedents:  (1) the right to die is not a right guaranteed by the Constitution; (2)  established specific rules for what was required in order for a third party to refuse treatment on behalf of an incompetent person; (3) absent a living will or clear and convincing evidence of what the incompetent person would have wanted, the state's interests in preserving life outweigh the individual's rights to refuse treatment; and (4) the states determine their own right to die standards, no uniform national standard.

This case created a great deal of interest in living wills and advance directives.  In the first month after the Supreme Court ruling in Cruzan, the Society for the Right to Die received 300,000 requests for advance directive forms.

In re Theresa Marie [Schindler] Schiavo


For this case, the US Supreme Court denied certiorari [four times], which means the Supreme Court decided not to hear the case, and allowed the lower court ruling to stand.

Terri had a heart attack in February 1990.  She was resuscitated, but suffered brain damage from lack of oxygen.  Two and a half months later, doctors determined she was in a “persistent vegetative state.”

After several years of therapy and other attempts to bring her back to awareness, in 1998 her husband Michael Schiavo petitioned the Florida court to have her feeding tube removed, stating Terri had told him she would not want to be kept alive with machines if there was no chance of revival.  Terri's parents opposed the petition, stating Terri was conscious.

In all, this case involved 14 appeals and numerous motions, petitions, and hearings in the Florida courts; five suits in federal district court; extensive political intervention at the levels of the Florida state legislature, then-governor Jeb Bush, the US Congress, and President George W. Bush; and four denials of certiorari from the Supreme Court of the United States.  The case also attracted activism from the pro-life movement, the right-to-die movement, and disability rights groups.  Since Schiavo's death, both her husband and her family have written books about the case, and both have been involved in activism over its larger issues.

Gonzales v Oregon
[January 17, 2006, decided 6-3]

In 1994, Oregon enacted the Death with Dignity Act, which permits physicians to prescribe a lethal dose of medication to a competent adult, agreed by two doctors to be within six months of dying from an incurable condition.  This was the first state law authorizing physicians to prescribe lethal doses of controlled substances to terminally ill patients.

In 2001, US Attorney General John Ashcroft declared that physician-assisted suicide violated the Controlled Substances Act of 1970 (CSA), and stated that any physician prescribing drugs under the Death with Dignity Act would have his medical license revoked.

The Supreme Court ruled that Congress intended the CSA to prevent doctors from engaging in illicit drug dealing, not to define general standards of state medical practice. Additionally, the CSA did not authorize the Attorney General to declare a medical practice authorized under state law to be illegitimate.  The Court ruled that the US Attorney General cannot enforce the federal Controlled Substances Act against physicians who prescribed drugs, in compliance with Oregon state law, to terminally ill patients seeking to end their lives.

Did you guess right?
Here's Monday's hint - T is for Texas.  Can you guess the case and what it's about?  Leave a comment!


  1. I remember the Schiavo case. Even though her husband had started a new family, he remained married to his wife so that he could act according to her wishes against her parents who insisted she was still conscious. What a media circus that was. The husband was proved right in the end after they weighed her brain. A sad and tense case all around.

    1. Yes, very sad for everyone. The moral of the story - make your wishes known, preferably in writing.

  2. Very informative. I didn't know there was a Supreme Court case about the Oregon act. Saw a film about the right to suicide in Oregon recently. Your site looks very informative - I'll go back and read it some more. Maui Jungalow

    1. Pretty much any law that's even remotely controversial will have a court case attached to it. Glad you find my site informative!

  3. Excellent reminder to get our paperwork in order! I imagine just sending an email to family stating wishes would hold up in a court until I get the properly completed documents with my wishes.

    1. The more documentation you have, the better off you are. Yes, get your paperwork in order!

  4. In the UK at the moment there have been a number of Right to Die cases. Many people are arguing for the right to allow other people to help them end their suffering, rather than having to withdraw feeding tubes as this could be a long drawn out process as opposed to one which is quick and peaceful.

    I know I'd rather go quickly and quietly, rather than in some way which would be painful and drawn out.

    Cait @ Click's Clan

    1. I definitely have the same opinion as you do. Quickly and quietly is better than painful and drawn out.

      Thanks for stopping by!

  5. Replies
    1. I agree. Quick and peaceful. But the bottom line is - YOU get to make the choice.