Artificial Nutrition and Hydration and the Permanently Unconscious Patient: The Catholic Debate

21. Caring or Starving? The Case of Claire Conroy

฀ 265 21 Caring฀or฀Starving?฀The฀Case฀of฀Claire฀Conroy Richard฀A.฀McCormick,฀SJ Claire฀Conroy฀was฀an฀eighty-four-year-old฀nursing฀home฀resident.฀She฀suffered฀ from฀irreversible฀physical฀and฀mental฀impairments฀including฀arteriosclerotic฀ heart฀disease,฀diabetes,฀and฀hypertension.฀She฀could฀neither฀speak฀nor฀swallow฀ and฀was฀fed฀by฀a฀nasogastric฀tube.฀Her฀movements฀were฀very฀limited฀though฀she฀ could฀smile฀or฀moan฀in฀response฀to฀some฀stimuli.฀She฀was฀restricted฀to฀a฀semifetal ฀position฀and฀lacked฀control฀of฀her฀excretory฀functions.฀Thomas฀C.฀Whittemore ,฀Miss฀Conroy’s฀nephew฀and฀guardian,฀requested฀that฀the฀nasogastric฀tube฀ be฀removed฀from฀his฀awake฀but฀severely฀demented฀aunt.฀The฀application฀was฀ opposed฀by฀Miss฀Conroy’s฀guardian฀“ad฀litem”฀(for฀purposes฀of฀litigation). At฀trial,฀two฀physicians฀testified฀that฀Miss฀Conroy฀would฀die฀of฀dehydration฀ in฀about฀a฀week฀after฀removal฀of฀the฀nasogastric฀tube.฀They฀also฀concurred฀in฀ the฀opinion฀that฀her฀death฀would฀be฀painful.฀One฀physician฀regarded฀the฀nasogastric ฀feeding฀as฀optional฀medical฀treatment.฀Miss฀Conroy’s฀own฀physician,฀ however,฀believed฀that฀removal฀of฀the฀tube฀would฀be฀unacceptable฀medical฀practice .฀The฀trial฀court฀(Judge฀Reginald฀Stanton,฀Feb.฀2,฀1983)฀decided฀to฀permit฀ removal฀of฀the฀tube฀because฀Miss฀Conroy’s฀life฀had฀become฀intolerably฀and฀ permanently฀burdensome. This฀decision฀was฀appealed฀by฀Miss฀Conroy’s฀guardian฀ad฀litem,฀but฀she฀died฀ while฀the฀appeal฀was฀pending.฀However,฀the฀appellate฀division฀considered฀the฀ matter฀too฀important฀to฀be฀left฀unresolved.฀It฀reversed฀the฀trial฀court’s฀judgment ฀and฀stated฀that฀removal฀of฀the฀nasogastric฀tube฀would฀be฀tantamount฀to฀ ฀ killing฀her.฀A฀guardian’s฀decision,฀the฀court฀argued,฀may฀never฀be฀used฀to฀withhold ฀nourishment฀from฀an฀incompetent฀patient.฀As฀the฀court฀worded฀it:฀“The฀ trial฀judge฀authorized฀euthanasia฀[homicide].฀.฀.฀.฀If฀the฀trial฀judge’s฀order฀had฀ been฀enforced,฀Conroy฀would฀not฀have฀died฀as฀the฀result฀of฀an฀existing฀medical฀ condition,฀but฀rather฀she฀would฀have฀died,฀and฀painfully฀so,฀as฀the฀result฀of฀a฀ new฀and฀independent฀condition:฀dehydration฀and฀starvation.฀Thus฀she฀would฀ have฀been฀actively฀killed฀by฀independent฀means.” Mr.฀Whittemore฀took฀the฀question฀to฀the฀New฀Jersey฀Supreme฀Court,฀the฀ same฀court฀that฀had฀decided฀the฀Karen฀Quinlan฀case.฀The฀court฀released฀its฀ decision฀Jan.฀17,฀1985.฀After฀acknowledging฀the฀right฀of฀a฀competent฀adult฀ to฀decline฀medical฀treatment—a฀right฀embraced฀within฀the฀common-law฀right฀ of฀self-determination—the฀court฀addressed฀the฀rights฀of฀the฀incompetent.฀It฀ noted:฀“The฀right฀of฀an฀adult฀who,฀like฀Claire฀Conroy,฀was฀once฀competent,฀to฀ determine฀the฀course฀of฀her฀medical฀treatment฀remains฀intact฀even฀when฀she฀is฀ no฀longer฀able฀to฀assert฀that฀right฀or฀to฀appreciate฀its฀effectuation.” Clearly฀a฀substitute฀decision-maker฀or฀proxy฀must฀be฀called฀upon฀to฀function ฀at฀this฀point.฀May฀a฀proxy฀ever฀decide฀that฀life-sustaining฀treatment฀may฀ be฀withheld฀or฀withdrawn฀from฀an฀incompetent฀but฀not฀comatose฀patient?฀The฀ court฀responded฀in฀the฀affirmative฀and฀proposed฀three฀tests฀or฀standards฀corresponding ฀to฀three฀different฀situations.฀First,฀there฀is฀the฀“subjective฀standard,”฀ under฀which฀life-sustaining฀treatment฀may฀be฀withheld฀or฀withdrawn฀“when฀it฀ is฀clear฀that฀the฀particular฀patient฀would฀have฀refused฀the฀treatment฀under฀the฀ circumstances฀involved”฀(emphasis฀added).฀This฀clear฀intent฀can฀be฀concluded฀ from฀written฀directives฀(living฀will)฀or฀oral฀statements฀made฀to฀family,฀friends฀ or฀health฀providers.฀It฀might฀also฀derive฀from฀a฀durable฀power฀of฀attorney฀or฀ appointment฀of฀a฀proxy฀with฀authorization฀to฀make฀medical฀decisions฀on฀the฀ patient’s฀behalf. Second,฀there฀is฀the฀“limited฀objective฀test.”฀Life-sustaining฀treatment฀may฀ be฀withheld฀or฀withdrawn฀from฀a฀patient฀like฀Claire฀Conroy฀when฀there฀is฀trustworthy ฀evidence฀that฀the฀patient฀would฀have฀refused฀the฀treatment฀and฀the฀proxy฀ is฀satisfied฀that฀the฀burdens฀of฀the฀patient’s฀continued฀life฀with฀the฀treatment฀ outweigh฀the฀benefits฀of฀that฀life฀for฀the฀patient. Finally฀there฀is฀the฀“pure฀objective฀test.”฀Under฀this฀test฀the฀burdens฀of฀the฀ patient’s฀life฀with฀treatment฀should฀clearly฀and฀markedly฀outweigh฀the฀benefits฀ the฀patient฀derives฀from฀life.฀Furthermore,฀the฀unavoidable฀and฀severe฀pain฀of฀ the฀patient’s฀life฀with฀treatment฀must฀be฀such฀that฀continued฀life-sustaining฀ treatment฀would฀be฀inhumane. 266฀ ฀ ฀฀฀฀ In฀elaborating฀its฀decision,฀which฀was฀a฀reversal฀of฀the฀appellate฀division’s฀ judgment฀that฀cessation฀of฀artificial฀feeding฀was฀a฀killing฀act,฀the฀New฀Jersey฀ Supreme฀Court฀made฀several฀interesting฀points.฀First,฀it฀stated฀that...