The Right to Live--or Die

Curled in a fetal position and shrunk to half her normal 120 Ibs., Karen Ann Quinlan lies helpless in St. Clare's Hospital in Denville, N.J., unaware that she is in effect going on trial for her life. Her eyes are open, unseeing. Her body convulses slightly every few seconds as an artificial respirator, surgically connected to her windpipe, forces her lungs to work, enabling her to continue in what her doctors describe as a "chronic vegetative state." Her heart is beating, and her permanently damaged brain continues to function, sending off slight but steady signals visible on an electroencephalogram (EEG).

Karen's case (TIME, Sept. 29) raises age-old medico-legal questions about human life--now complicated by technology's ability to keep gravely injured victims at the borders of survival. Is there a point at which incurable illness becomes living death? If so, is it permissible for someone's life to be deliberately cut off? And who has the right to make such a decision?

Grace and Dignity. Karen's adoptive parents, Joseph and Julia Ann Quinlan, will appear in court this week in Morris County, N.J., to argue that the 21-year-old girl, who has been in a coma since April, should be allowed to die "with grace and dignity." Both Roman Catholics, they have the support of their priest but not of their doctors or the state authorities. "We sympathize with the Quinlans," says New Jersey Attorney General William Hyland. "We do not wish to add to their anguish." But he insists that state law does not permit a termination of treatment. And no matter how Superior Court Judge Robert Muir rules, the case will probably be appealed, because of its gravity, to the New Jersey Supreme Court. Then, if Karen is still alive, it may well be appealed to the U.S. Supreme Court.

Although the Quinlan case has attracted worldwide attention, it is, in its tragic essentials, not that rare. The only estimate for "terminal patients kept alive by mechanical means," says Dr. Robert Veatch of the Institute of Society, Ethics and the Life Sciences, is "lots and lots." Doctors in such cases often act alone and disconnect life-supporting machinery. "It is done all the time," says New Jersey Neurological Surgeon Arthur Winter. In Denver Anna Mair made the decision two years ago after her son David, 10, had been hit by a truck. Realizing that he would "never be anything but a shell," she told doctors to let him die. Sometimes, as in the Quinlan case, the parents find the doctor unwilling, either for ethical reasons or fear of a malpractice suit. In Elyria, Ohio, for example, Randal Carmen, 17, lapsed into a coma after a football injury and doctors refused to give up on him until he died two weeks later. Some patients are luckier. "I have seen people in comas who have survived after many days on machines," says Tennessee Plastic Surgeon McCarthy DeMere.

Karen Ann Quinlan mysteriously collapsed shortly after drinking gin and tonic with friends. She had apparently taken some tranquilizers earlier, and the combination caused her "to nod out at the bar," as one of the friends put it. He took her to the house she was visiting, and she passed out. He attempted mouth-to-mouth resuscitation, then called an ambulance. After six months in the hospital, her mother says, she "isn't really living any more."

Key Elements. The Quinlans' attorney, Paul Armstrong, 30, filed a court paper three weeks ago arguing that "under the existing legal and medical definitions of death recognized by the state of New Jersey, Karen Ann Quinlan is dead." Karen's doctors disagree. Not only is her heart beating, says the hospital's lawyer, but she can breathe sporadically even without the aid of the respirator.

Until recently, those were the two key elements in a ruling of life or death. Today, however, most doctors place at least as much importance on the condition of the brain. They have generally accepted the criteria suggested in 1968 by researchers at Harvard University: no spontaneous respiration, no reflexive response to external stimuli or to pain, no brain activity showing on an EEG checked first by one observer then again by another 24 hours later. If these criteria hold, most doctors then assume that even if machines are keeping the patient alive, his brain is dead--and so is he. "Brain death" is currently the legal measure of death in eight states --but not in New Jersey, where the only rule for establishing death is absence of breathing and heart beat.

Even if New Jersey had a rule on brain death, Karen's case would not quite fit because of her slight brain activity and occasional spontaneous breathing. To cut off life support now might therefore fall within the area of euthanasia. In outright cases of euthanasia--"when someone is suffering from a terminal disease and you inject a drug to terminate life," as Dr. Winter puts it --the law demands a verdict of intentional homicide. But on the question of a doctor shutting off a life-supporting machine and permitting a patient to die, the law is largely silent. This is considered a mere "act of omission," and whether it constitutes homicide is a matter that has yet to be settled in court.

Quinlan Attorney Armstrong has recently backed away from the claim that Karen is dead. Instead, in a brief made public last week, he argues that Joseph Quinlan, as his daughter's guardian, has the responsibility to care for her best interest--and that includes, Armstrong says, the right to die with dignity. Whether this is legally persuasive remains to be seen, but it has attracted support among religious thinkers. Says Theologian Martin Marty: "When in any other age she would be dead, then I believe that it is not playing God to stop extraordinary treatment; in fact, it is playing God to keep her alive."

Armstrong also offers the rather unusual constitutional argument that the Quinlans' right to let Karen die is protected by the First Amendment's guarantee of religious freedom. As Roman Catholics, he says, the Quinlans believe "that earthly existence is but one phase of a continuing life," and thus it is unnecessary for Karen to cling to her present life by "the futile use" of a respiratory machine. Further still, Armstrong contends that the Eighth Amendment also gives the Quinlans the right to let Karen die, claiming that the denial of that right is "cruel and unusual" punishment. Though several cases have held that a mentally competent person has a constitutional right to choose to die rather than be treated, the law is far from settled. It is even foggier on when, if ever, the guardian of an incompetent like Karen can exercise that same right on her behalf.

Preserving Life. Arguing against the Quinlans, Attorney General Hyland and Deputy Attorney General David Baime totally reject Armstrong's constitutional claims. The state's position is largely based on a decision by the New Jersey Supreme Court, which held that a member of the Jehovah's Witnesses did not have the right to refuse a blood transfusion on religious grounds. The court then said: "There is no constitutional right to choose to die." Moreover, Hyland and Baime insist that because the state's interest in preserving life outweighs the expressed desire of a patient to die, "it can hardly be argued that a guardian may choose to terminate the life of his ward."

Attorney Donald G. Collester Jr., representing Morris County, also rejects Armstrong's case. Citing the same court precedent, Collester concludes that in New Jersey "it is clear no one has the right, constitutional or otherwise, to be a martyr or make his child a martyr." This view, too, has its ethical supporters. Says Arthur Dycks, professor of ethics at Harvard Divinity and Medical Schools: "One should err on the side of saving this woman's life. Doctors should keep people alive. Otherwise, hospitals become Frankenstein monsters."

While the Quinlans and the state authorities confront one another, the unconscious Karen also has an attorney. Daniel Coburn, 32, a part-time New Jersey public defender, was appointed by the court to guard what he calls her "constitutional right to life." Coburn has gone so far as to say that Karen could recover. And if the evidence he puts forward supports him in any way, he seems certain to prevail.

Of the eight lawyers in the case, two declare that the matter should not be argued in court at all. The hospital's attorney, Theodore Einhorn, says that the court ought to leave the patient to her doctors. So does Ralph Porzio, the lawyer for those doctors. "Miss Quinlan must be viewed as a patient undergoing treatment," says Porzio. Some outside doctors feel the same way. To allow the court to decide the Quinlan case, says Dr. David Posqanzer, a neurologist at Massachusetts General Hospital, "is taking the judgment of a doctor and putting it in the hands of those not competent to make a decision--the courts."

Central to this controversy of doctors v. judges is the whole problem of skyrocketing malpractice suits (TIME, June 16). "Physicians I have known for years stare at me in bewilderment, wondering what kind of situation we're in now," says Dr. William Curran of the Harvard School of Public Health. "They are more afraid than they were before" about pulling the plug. The hospital where Karen lies is asking the court this week for immunity from civil suits or criminal prosecution if the court rules that she should be allowed to die.

Cool and Balanced. Once all the arguments have been heard, Judge Muir intends to make his decision next week. It will probably be the toughest question that has ever faced the 43-year-old jurist, who specialized in municipal law before his appointment to the bench in 1971. "He is cool, and very balanced," says one observer. "He does his homework and weighs everything very carefully." Judge Muir will have plenty of weighing to do, for the courts have generally been reluctant to make life and death decisions. Nonetheless, the question of whether the plug can be pulled is unlikely to disappear. And now that the issue has reached the courts, doctors and families around the country await a decision.

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