Nancy Cruzan Before her Accident

From: A Merciful End: The Euthanasia Movement in Modern America, by Ian Dowbiggin (Oxford University Press, New York 2003) p. 164.

While Concern for Dying and the Society for the Right to Die were engaged in their second bitter civil war within a decade, many Americans were impatiently awaiting a U.S. Supreme Court ruling on a death with dignity case that rivaled the legal wrangle over Karen Ann Quinlan.

The story had begun one night in 1983, when the car of twenty-five-year-old Nancy Cruzan slid off an icy Missouri road. The ensuing crash threw her out of the car and left her breathless and without a pulse. Minutes later, paramedics revived her heartbeat and respiration, but Cruzan never regained consciousness. She spent the next seven years of her life in a permanent vegetative state, able to breathe but kept alive by a feeding tube; she was one of 10,000 Americans in a similar predicament. [3 “To Feed or Not to Feed?” Time, 31 March 1986, 60; “Changing the Rules on Dying,” U.S. News and World Report, 9 July 1990, 22–23.]

Nancy Cruzan in a Persistent Vegetative State Lester Joe Cruzan, Nancy's Father, Family Spokesman

When the Missouri Supreme Court refused to grant her parents’ request to withdraw her feeding tube, stating that without a living will Nancy Cruzan’s real wishes were unclear, the case went to the U.S. Supreme Court, the first time the court agreed to hear a rightto-die case. In 1990 the justices ruled that a competent person had a constitutionally protected right to refuse any medical treatment, but it upheld Missouri’s right to insist on clear and convincing evidence of the wishes of patients who did not have decision-making capacity before such treatment was discontinued. In the ruling’s aftermath, the Cruzans’ lawyer went back to court with new evidence of Nancy’s prior wishes, and this time Missouri withdrew from the case, paving the way for her parents to finally remove the controversial feeding tube.

The Cruzan Family receives the legal decision Nancy on Dec, 25, 1990, the day before her death

Twelve days later, on 26 December 1990, Nancy Cruzan died at the age of thirty-three, seven years after being thrown from her car. But the Cruzans’ suffering did not end, even with Nancy’s death. In 1996 her father, Joe, hanged himself in the family’s carport. [4 Filene, In the Arms of Others, 168–83.]

The U.S. Supreme Court ruling in the Cruzan case, like its ruling seven years later on physician-assisted suicide, was a fittingly opaque decision for an issue that was just “not that simple,” in Donald McKinney’s words. The five-to-four split among the justices demonstrated how by the 1990s the right to die had become an exceedingly complex matter. Different interpretations of Cruzan v. Missouri Director, Department of Health abounded. Unusually, there were four separate written opinions among the justices, a reflection of the conflicting emotions it aroused. 5

The Society for the Right to Die submitted an amicus curiae (friend of the court) brief in the Cruzan case and worked closely with the Cruzans, providing them with counseling and putting them in touch with a lawyer to represent them. The SRD castigated the Missouri Supreme Court’s decision to overrule the lower court finding that Nancy Cruzan should be allowed to die. Rose Gasner, the SRD’s director of legal services, remarked that the state supreme court made her “ashamed to be a lawyer,” but she applauded the Missouri Department of Health’s decision that it would not stand in Cruzan’s parents’ way to remove her life support. According to Gasner, who with Sidney Rosoff and Richard Wasserman wrote the SRD brief, no state interest outweighed Nancy Cruzan’s constitutional and common law right to refuse the continuation of artificial feeding, nor— significantly—did she forfeit this right because of her incompetence. “A surrogate decision-maker, including a guardian, must be permitted to exercise these rights,” the SRD brief stated. The U.S. Supreme Court’s ruling that individuals did enjoy such a right as long as there was clear and convincing evidence of the person’s wishes caused Boston Globe columnist Ellen Goodman to remark: “The Living Will. Don’t leave home without it.” 6

Euthanasia activists, including Derek Humphry and many in the SRD, optimistically interpreted Cruzan v. Missouri Director, Department of Health as a constitutional recognition of the right to die, and thus a giant legal step closer to a similar recognition of a right to assisted suicide. 7 Equally hopeful news for Humphry and Hemlock came from a series of stunning events that in the late 1980s and early 1990s propelled the right-to-die debate to the center of national attention. The first shock came in 1988 when an anonymous article in the Journal of the American Medical Association, titled “It’s Over, Debbie,” told of how a gynecology resident in a large American private hospital had injected a patient suffering from painful ovarian cancer with an overdose of morphine sulphate. Called to her bedside in the middle of the night, the resident claimed she told him “Let’s get this over with,” whereupon he administered the lethal dose. 8

Many condemned the resident for what he had done, arguing that, because he did not know the patient and had not talked to her or consulted with other physicians, he had essentially flouted all the safeguards euthanasia advocates normally proposed. Others attacked the JAMA for publishing the article in the first place, and some, such as columnist Charles Krauthammer, thought it was all a hoax, alleging that even extreme euthanasia proponents would not have killed in this way. 9 Hemlock’s Derek Humphry disapproved of the young doctor’s methods, though he acknowledged his compassion. Others expressed relief that the “Debbie” article had forced the fact that doctors did perform active euthanasia out into the open. “It makes no sense to hide our heads in the sand,” one physician advised the JAMA’s readers. 10

The controversy that greeted the publication of the “Debbie” story intensified in 1990 when Jack Kevorkian helped Janet Adkins to die. Before that date, Kevorkian had been an obscure pathologist, whose unconventional ideas about experimenting on dying, condemned criminals had caused his ostracism from the medical profession. Ever the maverick, Kevorkian believed in euthanasia on demand, provided by doctors without government regulation, for both mentally competent and incompetent patients. 11 Adkins, a Hemlock Society member, had seen Kevorkian on the Donahue television program and heard about Kevorkian’s “mercitron,” the suicide machine he had built. In June 1990, recently diagnosed with Alzheimer’s disease, she agreed to meet Kevorkian in Michigan, where there was then no law against assisted suicide, and it was there, in the retired pathologist’s rusty Volkswagen van, that she died. 12

When news of Adkins’s death broke, vigorous condemnation of Kevorkian quickly ensued. The Michigan Board of Medicine suspended his medical license in 1991, and in 1992 the state of Michigan passed a law making assisted suicide a felony. Like “Debbie” ‘s death, Adkins’s suicide at Kevorkian’s hands had not been approved by other physicians, nor had Kevorkian known Adkins for long or her full clinical history. Adkins had not been dying, and, although apparently perfectly sane, had never been screened by a psychiatrist. 13 Nonetheless, the Hemlock Society called Kevorkian a “brave pioneer,” and he enjoyed the staunch support of the founder of


Notes to Chapter 6

1 The only exception to Oregon in U.S. history was Texas, where until 1973 there was no law prohibiting the aiding and abetting of suicide. See H. Tristam Engelhardt, Jr., Edmund L. Erde, and John Moskop, “Euthanasia in Texas: A Little Known Experiment,” Hospital Physician, September 1976: 30–31.

2  Author’s telephone interview with Derek Humphry, 13 December 2001.

3 “To Feed or Not to Feed?” Time, 31 March 1986, 60; “Changing the Rules on Dying,” U.S. News and World Report, 9 July 1990, 22–23.

4 Filene, In the Arms of Others, 168–83.

5 Zucker, ed., The Right to Die Debate, 190–201, quote on 192.

6 Ellen Goodman, “The High-Tech Twilight Zone,” Boston Globe, 28 June 1990; “State Supreme Court’s Cruzan Ruling Certain to Affect Nation,” Springfield News Leader, 20 November 1988; Linda Greenhouse, “Liberty to Reject Life,” New York Times, 27 June 1990, A16.

7 Humphry and Clement, Freedom to Die, 124. See also Larson and Amundsen, A Different Death, 184.

8 “It’s Over, Debbie,” JAMA 259 (1988): 272.

9 Charles Krauthammer, “The ‘Death’ of ‘Debbie,’” Washington Post, 26 February 1988. A similar view was expressed in Willard Gaylin, Leon R. Kass, Edmund R. Pellegrino, and Mark Siegler, “Doctors Must Not Kill,” in Moreno, ed., Arguing Euthanasia, 33–36, quote on 34. See also Garrett, “The Last Civil Right?” 205; Isabel Wilkerson, “Essay on Mercy Killing Reflects Conflict on Ethics for Physicians and Journalists,” New York Times, 23 February 1988, A16; Isabel Wilkerson, “Judge Stalls Inquiry into a Mercy-Killing Case,” New York Times, 19 March 1988, A15.

10 “Letters,” JAMA 259 (1988): 2094–98; Kenneth L. Vaux, “Debbie’s Dying: Mercy Killing and the Good Death,” JAMA 259 (1988): 2140–41; George D. Lundberg, “ ‘It’s Over, Debbie’ and the Euthanasia Debate,” JAMA 259 (1988): 2142–43.

11 Michael Betzold, “The Selling of Doctor Death,” New Republic, 26 May 1997, 22– 28.

12 “The Doctor’s Suicide Van,” Newsweek, 18 June 1990, 46–49.

13 In fact, of the sixty-nine patients Kevorkian helped to die up to 1998, only seventeen were actually dying before they sought his assistance. Lisa Priest, “Most Kevorkian Suicides Weren’t Terminally Ill,” The Globe and Mail, 7 December 2000.

14 Hemlock Society, Press Release, 26 October 1989. Cited in Garrett, “The Last Civil Right?” 213. See also Jack Lessenberry, “Death and the Matron,” Esquire 127 (April 1997): 80–85, 130–31.

15 Humphry and Clement, Freedom to Die, 136.

16 Stephanie Gutmann, “Death and the Maiden,” New Republic, 24 June 1996, 20– 28.

17 Woodman, Last Rights, 146–48.

18 “Voters Turn Down Mercy Killing Idea,” New York Times, 7 November 1991, B16.

19 Garrett, “The Last Civil Right?” 192–94.

20 Woodman, Last Rights, 143–44. The split between Mero and Hemlock was “amicable.” Half the members of the Compassion board in 1993 also sat on the local Hemlock board, and the two organizations had adjacent office space. Lisa Belkin, “There’s No Simple Suicide,” New York Times, 14 November 1993, 50–56, 74–75, quote on 54.

21 Lawrence K. Altman, “A How-To Book on Suicide Surges to Top of Best-Seller List in Week,” New York Times, 9 August 1991.

22 Garrett, “The Last Civil Right?” 248; Annas, Some Choice, 214–15. See also New York State Task Force on Life and the Law, When Death Is Sought, 133–34. For Dutch euthanasia, see P. J. Van der Maas et al., “Euthanasia and Other Medical Decisions Concerning the End of Life,” Lancet 338 (1991): 669–74; P. J. Van der Maas et al., “Euthanasia, Physician-Assisted Suicide, and Other Medical Practices Involving the End of Life in the Netherlands, 1990–1995,” New England Journal of Medicine 335 (1996): 1699–1705; G. Van der Wal et al., “Evaluation of the Notification Procedure for Physician-Assisted Suicide in the Netherlands,” New England Journal of Medicine 335 (1996): 1706–11. For American reactions to these studies, see Herbert Hendin, Chris Rutenfrans, and Zbigniew Zylicz, “PhysicianAssisted Suicide and Euthanasia in the Netherlands,” JAMA 277 (1997): 1720– 22; Marcia Angell, “Euthanasia in the Netherlands—Good News or Bad?” New England Journal of Medicine 335 (1996): 1676–98. Defenders of Dutch euthanasia contend that in the majority of nonvoluntary euthanasia cases assistance in dying was at least discussed with the patients, that the decision was rarely the physician’s solely, and that in almost all the cases the patients were in the last stages of dying. Woodman, Last Rights, 83–84.

23 Garrett, “The Last Civil Right?” 251–52. A Louis Harris and Associates 1987 poll, commissioned by the Harvard Community Health Plan, showed that 66 percent of doctors considered it wrong for a physician to comply with patients’ wishes to end their lives, in contrast to 38 percent of the general public. Wilkerson, “Essay on Mercy Killing,” A16.

24 “Foes of Euthanasia Measure Gain Ground in Washington State,” New York Times, 4 November 1991, A16; Garrett, “The Last Civil Right?” 271.


Nancy Cruzan in a Persistent Vegetative State Lester Joe Cruzan, Nancy's Father, Family Spokesman

If the decisions wrong if were playing God then I'll have to live with that. And Im going to.”
Lester (Joe)Cruzan, Frontline Documentary, The Death of Nancy Cruzan (1991)

Lester Cruzan Is Dead at 62; Fought to Let His Daughter Die

Lester Cruzan, a sheet-metal worker who figured in a ground-breaking 1990 Supreme Court “right-to-die” ruling that involved his daughter Nancy Beth Cruzan, was found dead on Saturday at his home in Carterville, Mo. He was 62.

Mr. Cruzan, who was called Joe, apparently committed suicide, by hanging, law-enforcement officials said, according to The Associated Press. Jerry Neil, chief deputy in the sheriff’s department of Jasper County, reported that Mr. Cruzan had left a note, found by his wife, Joyce, that mentioned their daughter. Mr. Neil did not disclose what the note said about her.

Nancy Cruzan was left in a vegetative state by an auto crash in 1983, and her parents went on to wage a prolonged legal campaign to remove her feeding tube. The case became the focus of a widespread, acrimonious debate about when and how relatives can decide to stop nourishment or medical treatment in order to end the life of an incapacitated loved one.

Mr. and Mrs. Cruzan’s legal efforts eventually succeeded. The State of Missouri, which had opposed them, dropped out of the case after the Supreme Court ruling, in June 1990, which affirmed in general terms that a patient whose wishes are clearly known has the right to have his or her life-sustaining treatment ended. After further legal steps, Miss Cruzan was permitted to die, late in 1990.

Later, Mr. Cruzan expressed uncertainty about whether the right action had been taken. “I’ve wondered sometimes if we have finally accomplished for God what he set out to do,” he said in 1991. “People say that’s blasphemy, but I don’t mean it that way. I mean it as, ‘Where does God fit into the equation?’ “

Miss Cruzan had been comatose for more than seven years by the time the Supreme Court ruled in her case. Eight Justices affirmed that a person with clearly known wishes has a constitutional right to have life-sustaining treatment ended.

But the court ruled, 5 to 4, that the State of Missouri could keep Miss Cruzan alive because her family had not demonstrated by “clear and convincing evidence” that she would have wanted the treatment stopped.

Two months later, Mr. and Mrs. Cruzan asked a Jasper County Probate Judge, Charles Teel, for a hearing to present new evidence from three of Miss Cruzan’s co-workers.

At a hearing in November 1990, the co-workers testified that they remembered her saying that she would never wish to live “like a vegetable.” Judge Teel ruled that there was clear evidence of her wishes, and he gave permission for the removal of the tube, which was carried out on Dec. 14, 1990. She died on Dec. 26, 1990, she was 33.

Afterward, Mr. and Mrs. Cruzan became active in a campaign to persuade people to make known their wishes about life-sustaining treatment before such treatment could become necessary.

Mr. Cruzan was born near Lakeside, Mo., graduated from high school in Carterville and was a sheet-metal worker most of his working life. He retired about a year ago.

In addition to his wife, Mr. Cruzan is survived by two daughters, Christy White of Carterville and Donna McGurk of Webb City, Mo.; four grandchildren, and two brothers, Jim, who lives near Seneca, Mo., and Butch of Springfield, Mo.

Joe Cruzan's Struggle Probably Led to Suicide
By Nicholas C. Wishart Of The Post-Dispatch The Contributed Information . | St Louis Post-Dispatch (MO), August 19, 1996 |

Cruzan, 62, a sheet metal worker whose case sparked national debate and precedent-setting court cases, was found by police early Saturday morning hanged in the carport adjacent to his home in Carterville, Mo.

Authorities say he left a note for his wife on their dining room table, a note mentioning their daughter Nancy and instructing her to stay inside and call police. His body was found around 7 a.m.



Tragedy compounded: Joe Cruzan commits suicide

After years of reoccurring bouts of depression, Lester “Joe” Cruzan, father of Nancy Beth Cruzan, tragically committed suicide on August 17, 1996. The family’s lawyer, Kansas City attorney William Colby, said that Joe never recovered from his daughter’s 1983 car accident, which left her permanently brain damaged.

But Joe, 62, had earlier expressed concern and uncertainty over whether the right action had been taken after Nancy’s accident, action which resulted in her induced death seven years later. “I’ve wondered sometimes if we have finally accomplished for God what he set out to do,” Joe said in 1991. “People say that’s blasphemy, but I don’t mean it that way. I mean it as, ‘Where does God fit into the equation?’“ [New York Times, 8/19/96]

Nancy had been the subject of a three and a half year landmark legal battle the family waged to have her food and fluids withheld. In May 1987 Joe and his wife, Joyce, began court proceedings to force the hospital staff caring for their daughter to stop her feeding and hydration. The Cruzans maintained that they just wanted to allow Nancy to die, since she would not want to continue living in her condition. They took legal action after months of consulting with the organization then called The Society for the Right to Die (formerly known as The Euthanasia Society of America; now operating under the name Choice in Dying).

While Nancy was left severely disabled and brain damaged from the accident, she was not comatose, nor was she on any life-support equipment. She could hear, see, and experience pain. There were times when she would smile at a funny story, cry when visitors would leave, and even try to form words. After the accident, court records indicate that she was eating mashed potatoes, bananas, eggs, and even link sausages, but a gastrostomy feeding tube was eventually inserted to make her long-term care easier for caregivers. She required no skilled nursing care and could have been cared for in a home environment. [Transcript, Cruzan v. Harmon & Lampkins, Case No. CV384-9P, Circuit Ct. of Jasper County, MO, 3/9/88-3/11/88]

In 1988, Jasper County Circuit Court Judge Charles E. Teel, Jr., issued a ruling directing the hospital to comply with the Cruzans’ request to withhold Nancy’s food and water. Later that same year, however, the Missouri State Supreme Court reversed the lower court ruling stating, “This is not a case in which we are asked to let someone die.... This is a case in which we are asked to allow the medical profession to make Nancy die by starvation and dehydration.” [Cruzan v. Harmon, 760 S.W.2nd 408, 412 (Mo. banc 1988), aff’d sub nom. Cruzan v. Director, Missouri Dept. of Health, 497 U.S. 261 (1990)]

The case eventually ended up before the U.S. Supreme Court. The question before the high court was the constitutionality of Missouri’s requirement that there be “clear and convincing evidence” concerning an incompetent patient’s wishes regarding medical treatment. The court ruled that the state requirement was indeed constitutional, and that, since there was no such clear and convincing evidence of Nancy’s wishes prior to her accident, her food and fluids could not be withheld. [Cruzan v. Director, Missouri Department of Health, 497 U.S. 261, 110 S.Ct. 2841 (1990)]

But the Cruzans, with the help of their right-to-die attorney, persisted. In August 1990, two months after the U.S. Supreme Court ruling, they once again went to court -- this time with 3 witnesses they said could provide the needed “clear and convincing evidence” that Nancy would want to die rather than live in her disabled condition. Each of the witnesses testified that years earlier, during a casual conversation, Nancy had indicated that she would not want to live in a severely disabled state. On December 14, 1990, Jasper County Circuit Court Judge Charles E. Teel, Jr., the same judge who in 1988 ordered Nancy’s caregivers to withhold all food and water, did so again. [Cruzan v. Mouton, No. CV384-9P (Mo. Cir. Ct., Dec. 14, 1990)] Twelve days later, on December 26, 1990, Nancy Beth Cruzan died of dehydration. She was 33 years-old.

Minneapolis neurologist Ronald Cranford, a family friend and regular expert witness in favor of removing food and fluids in cases like Nancy’s, said Joe had been chronically depressed for some time. According to Cranford, Joe was “an ordinary man with extraordinary abilities.” “But he ran out of energy after [Nancy] died,” Cranford said. Commenting on Joe’s death by hanging, Cranford added that, in his opinion, Joe’s was “a rational suicide” since “he was never going to get better.” [American Medical News, 9/2/96:8]

Joe Cruzan was buried alongside Nancy in Carterville Cemetery. At the funeral, attorney William Colby commented, “I think he counted the final authorization of the court to set his daughter free as both his greatest and his saddest accomplishment in life.” [Kansas City Star, 8/18/96; Contra Costa Times, 8/20/96:1A]






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