Chapter 2. Harnessing the evolution of firm value of air transport industry toward a sustainable
3.4 Empirical results
3.4.2 Discussion of results
T h e g e n e r a l public p r o b a b l y first b e c a m e a w a r e of t h e i s s u e s a d d r e s s e d i n this c h a p t e r following t h e t r a g e d y t h a t b e g a n for a N e w J e r s e y family o n April 15, 1975. O n t h a t d a y , K a r e n A n n , t h e 21-year-old d a u g h t e r of J o s e p h a n d Julia Q u i n l a n , l a p s e d i n t o a c o m a from w h i c h s h e h a s n e v e r recovered.' I n t h e y e a r s since, a s h e r s i t u a t i o n c e a s e d being solely a p r i v a t e , family c o n c e r n and- because of legal p r o c e e d - ingsz- became front-page n e w s , people a c r o s s t h e c o u n t r y h a v e c o n f r o n t e d s u c h difficult q u e s t i o n s a s :
.
w h a t i s t h e relationship of p e r m a n e n t u n c o n - s c i o u s n e s s t o life a n d d e a t h ?Sometime after she ceased breathing for unknown reasons, Karen Quinlan was brought, unconscious, to a hospital emergency room.
After her condition stabilized, feeding required a nasogastric tube and breathing required a respirator. She never experienced irreversible cessation of all brain functions (that is, death) but rather retained function of the brain stem and w a s diagnosed as being in a "persistent vegetative state," a condition that has not changed. Joseph Quinlan and Julia Quinlan, with Phyllis Battelle, KAREN ANN: THE QUINLANS
TELL THEIR STORY, Doubleday &Co., Garden City, N.Y. (1977).
Karen Quinlan's father sought court appointment a s guardian of her person for the express purpose of authorizing the removal of her respirator, whether or not she died a s a consequence. He was opposed not only by Karen's physicians but by the local prosecutor and the state attorney general. The New Jersey Supreme Court, however, granted his request. Her physicians gradually discontinued the respirator during May of 1976 and she was able to breathe on her own;
at this writing she is alive, cared for in a New Jersey nursing home. In re Quinlan, 70 N.J. 10,355 A. 2d 647, cert. denied 429 U.S. 922, (1976); IN THE MATTER OF KAREN QUINLAN (2 vol.), Univ. Publications of America, Frederick, Md. (1977).
172 Foregoing Life-Sustaining Treatment: Chapter 5
how reliable is the medical prognosis of permanence of unconsciousness?
what life-extending care should be considered unnec- essary in the context of patients with little or no chance of regaining cognitive functions?
Uncertainties regarding the care of long-term unconscious patients have been raised with increasing frequency, 3 though the number of such patients whose care has become the subject of judicial scrutiny still represents only a fraction of the total number of permanently unconscious patients.
The Commission's involvement with the issues raised by this group of patients began with its Congressionally mandated study of the "definition" of death." In a n empirical investiga- tion conducted as part of that study, the Commission found that although two-thirds of the patients who are supported by an artificial respirator during a coma of a t least six hours
See, e.g., Lawrence K . Altman, Princess Death: U.S. Physicians Raise Questions, N.Y. TIMES, Sept. 21, 1982, a t C-1; Glenn Collins, W h e n Life i s a Matter for Debate, N.Y. TIMES, Aug. 16, 1982, a t B-12.
In addition to the well-known Quinlan case, there have been several other court reviews of the case of comatose patients. Dockery v. Dockery, 559 S.W. 2d 952 (Tenn. App. 1977) (appeal of chancery court order, which appointed husband a s guardian for purposes of authorizing removal of respirator from comatose wife, mooted by wife's death); In re Piotrowicz, No. 1948 (Essex Cty., Mass. Probate Ct., Dec. 23, 1977) (husband appointed guardian of 56-year-old comatose wife for purposes of authorizing withdrawal of respirator);
In re Nichols, No. A99511, Orange Cty. Calif. Super. Ct. (March 21, 1979) discussed in Note, Comatose Conservatee-Restrictions of
Legal Capacity-Substance or Procedure?, 7 WASH ST. U. L. REV. 205 (1980); Leach v. Akron General Medical Center, 426 N.E.2d 809 (Ohio Com. Pl. 1980) (family sought directive to disconnect life support); In re Storar 52 N.Y.2d 363, 420 N.E.2d 64 (1981), modifying Eichner v. Dillon, 426 N.Y.S.2d 527 (App. Div. 1980) (in which a comatose Catholic priest, Brother Joseph Fox, was allowed to have treatment stopped because he had given strong advance directives); Severns v. Wilmington Medical Center, Inc., 421 A.2d1334 (Del. 1980) (comatose woman with substantial advance deliberation allowed to stop all treatment); In re Lydia Hall Hospital, No. 23730182 (Special Term, Part II, Sup. Ct., Nassau County, N.Y., Oct. 22, 1982) (Peter Cinque, while competent, asked to cease dialysis and then became comatose after a resuscita- tion effort and court ordered discontinuation of treatment on family request); In re Cruse, No. J914419 and In re Guardianship of Cruse No.
P645318 (Sup. Ct., Los Angeles, Cal., Feb. 15, 1979) (3-year-old child in coma, life-support discontinuance authorized): I n r e Young, No.
A100863 (Sup. Ct., Orange County, Cal., Sept. 11, 1979)(removal of respirator allowed for comatose automobile accident victim).
.I
4 President's Commission for the Study of Ethical Problems in Medi- cine and Biomedical and Behavioral Research, Defining Death, U.S.Government Printing Office, Washington (1981).
Permanent Loss of Consciousness 173 duration are dead within a month, about 6% remained indefi- nitely in a "persistent vegetative s t a t e . "5 T he Commission w a s especially interested in this group for two reasons. First, for many years the leading set of clinical criteria for the determi- nation of "brain death" were those published in 1968 under the title "A Definition of Irreversible Coma."6 Using this term a s synonymous with death unfortunately served to perpetuate a confusion in the medical field between the state of being permanently unconscious, as are patients in a persistent vegetative state, and that of being dead.7 Second, and more importantly, once it is acknowledged that permanently uncon- scious patients are not dead, difficult questions are raised about the type and extent of care that should be provided for them.
Since permanently unconscious patients raise issues a t least as difficult a s those considered in Defining Death, the Commission resolved to give this group special attention in the present study. Two major issues are presented: Who are these patients exactly? And what issues arise during their care that are different from those of other incompetent patients? The first section of this chapter addresses the theoretical concerns in making a diagnosis of permanent loss of consciousness and identifies the major groups of patients in this state, though the Commission leaves to the appropriate biomedical experts the task of providing working guidelines for making the medical diagnosis. After establishing that some patients' uncon- sciousness can be reliably predicted to be permanent, the chapter attempts to clarify what should be considered permis- sible care of these patients. The second section evaluates the considerations that would justify continued treatment of these patients. Next, current treatment practices are described and the Commission's analysis is used to distinguish unacceptable practices from desirable ones. The final section presents the Commission's recommendations for decisionmaking processes that encourage both justifiable assignment of authority to decide and ethically defensible decisions.
About 12%, typically those whose coma w a s due to drug intoxica- tion, made a good to moderate recovery, and about a n equal number were left with severe disability, though they regained consciousness.
Id. at 94.
Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death, A Definition of Irreversible Coma, 205 J.A.M.A. 377 (1968).
7See Julius Korein, Terminology, Definitions and Usage, 315 Annals N . Y. ACAD. Sci. 6 (1978); testimonies of Dr. Lawrence Pitts, Dr. Robert Kaiser, a n d Mr. Leslie Rothenberg, transcript of 12th meeting o f t h e President's Commission (Sept. 12, 1981) at 348-65; testimony o f D r .
David Levy, transcript of 15th meeting of the President's Commission (Dec. 12, 1981) at 275-82.
174 Foregoing Life-Sustaining Treatment: Chapter 5