euthanasia, Dr. Jack Kevorkian, provided a lethal
injection (i.e., euthanasia) to a patient suffering from
amyotrophic lateral sclerosis (ALS, also known as
Lou Gehrig’s disease) on national television. He was
subsequently convicted of second-degree murder and
sentenced to 10 to 25 years in prison. Although
euthanasia is now legal in the Netherlands and
Belgium, it remains illegal in the United States.
Both PAS and euthanasia are distinguished from the
clinical practice of administering high doses of pain
medication in an effort to control severe pain, often
with the awareness that death is likely to occur. This
practice, referred to as “the law of double effect,” dif-
fers because the express purpose of the medication is to
control pain, not to end life.
In addition to interventions that have the direct
effect of ending life immediately, there are a number
of other death-hastening procedures that are often the
source of controversy and psycholegal inquiry. For
example, death can be hastened by withdrawing or
refusing life-sustaining medical care, sometimes
referred to as “passive euthanasia.” This includes
decisions to remove mechanical ventilation (i.e., a
machine to keep a comatose patient breathing), refuse
needed renal dialysis, or refuse or terminate artificial
nutrition and hydration. In such cases, the rejection of
needed medical interventions can hasten a death that
might otherwise be delayed for weeks, months, or
even years. Yet while legal debate and controversy
surrounds more direct interventions such as PAS and
euthanasia, the right of a mentally competent adult to
refuse life-sustaining interventions is uncontested.
Refusal of life-sustaining interventions becomes
more complex and controversial when the patient no
longer has the capacity to make or articulate a compe-
tent decision. In patients with life-threatening or ter-
minal illness, such situations are often anticipated,
and patients provide their consent in advance.There
are two legal mechanisms to accomplish this goal:
Advance Directives (ADs, sometimes called “Living
Wills”) and the Durable Power of Attorney or Health
Care Proxy (although different jurisdictions have used
slightly different labels to describe these two types of
legal instruments). Regardless of the term used, both
alternatives enable the patient to influence treatment
decisions that may arise after he or she has lost the
capacity to provide informed consent.
ADs are broad in range and encompass highly spe-
cific interventions and situations such as the DNR
order (a refusal of CPR if the patient’s heart stops) to
very broad documents that specify multiple scenariosin which different treatments are desired or rejected.
The broadest mechanism of all is the health care
proxy or durable power of attorney, where the med-
ically ill or elderly person appoints another individual
to make treatment decisions on his or her behalf in the
event that he or she becomes incapacitated. Each of
these ADs provides a mechanism for individuals to
protect their autonomy and influence treatment deci-
sions, although both ultimately rely on another per-
son’s willingness or ability to carry out the patient’s
wishes. Moreover, while these instruments remain
dormant until the patient loses the capacity to make
treatment decisions, controversies often arise as to
whether the situation described in an AD exists (e.g.,
if the patient has specified that treatment should be
withheld if no chance of recovery exists). In such
cases, medical, mental health, and forensic specialists
are often asked to provide input to determine appro-
priate directions.Legal History of the “Right to Die”
Although case law regarding the right to determine
what medical treatments are implemented is long-
standing, end-of-life treatment decisions were rarely
addressed before the seminal New Jersey Supreme
Court decision In re Quinlan(1976). Although this
case never reached the Supreme Court, the request by
Karen Quinlan’s parents to terminate the mechanical
respirator that was keeping their daughter alive was
widely recognized as the first significant challenge to
the medical profession’s practice of extending life as
long as possible.
The right-to-die issue first reached the U.S.
Supreme Court roughly 15 years later, in Cruzan v.
Director, Missouri Department of Health (1990).
Like Quinlan, this case also involved a young
woman, Nancy Cruzan, who fell into a persistent veg-
etative state (i.e., comatose with no evidence of brain
activity) that required the insertion of a feeding tube.
After 4 years, her parents requested the removal of
the feeding tube to allow their daughter to die. The
hospital refused to comply, and the Cruzans subse-
quently sued the Missouri Department of Health.
Although the Court ruled in favor of the state, the
decision affirmed the right of competent persons to
refuse life-sustaining medical intervention, whether
through their own decision making or through ADs.
However, the Court left standards for determining
decision-making competency and guidelines for deci-
sion making to the states.End-of-Life Issues——— 255E-Cutler (Encyc)-45463.qxd 11/18/2007 12:42 PM Page 255