Deciding To Die: The Case of Karen Quinlan
Ronald Munson is Professor of Philosophy of Science and Medicine at University of Missouri-St. Louis. His new book, The Woman Who Decided to Die: Challenges and Choices at the Edges of Medicine, takes readers to the very edges of medicine, where treatments fail and where people must cope with helplessness, mortality, and doubt. In the excerpt below Munson takes us to the crux of medical ethics, with questions about the right to die.
I think the case can be made that the world of American medicine changed decisively at two in the morning on April 14, 1975, when Julie Quinlan of Landing, New Jersey, was awakened by a telephone call.
She was crying when she hung up the phone. “Karen is very sick,” she said to her husband, Joseph. “She’s unconscious, and we have to go to Newton Hospital right away.”
…Karen was in a comatose state for unknown reasons and was being given oxygen through a mask taped over her nose and mouth. It wasn’t clear that she would live.
…Blood and urine tests indicated that Karen hadn’t consumed what would usually be considered a dangerous amount of alcohol. But she had been on a very strict diet and had eaten nothing that day before having two gin-and-tonics at the party. The tests also detected the presence in her blood of .6 milligrams of aspirin combined with the tranquilizer Valium. Two milligrams would have been toxic, five lethal. So why she had stopped breathing was a mystery, yet it was during the brief period she was alone in the bedroom that part of her brain died, apparently from oxygen depletion.
About a week after Karen failed to regain consciousness, her parents moved her to St. Clare’s Hospital… Dr. Robert J. Morse, a neurologist, and Dr. Arshad Javed, a pulmonary internist, became her physicians. They conducted additional studies to rule out several possible causes of her coma… The neurological tests and X-ray studies confirmed, however, that Karen’s brain had undergone extensive damage.
…By early July, Karen’s physicians and her mother, sister, and brother had come to believe that Karen would never regain consciousness…
THE PRIEST AND THE LAWYERS
The Quinlans’ parish priest, Father Thomas Trapasso, assured the Quinlans that the ethical principles of the Roman Catholic Church didn’t require the continuation of extraordinary measures to support a life after any realistic hope of recovery was gone.
…On July 31, 1975, after Karen had been in a coma for three and a half months, Julie and Joseph Quinlan gave Drs. Morse and Jared their permission to take their daughter off the ventilator. They signed a letter authorizing the discontinuance of all extraordinary procedures and absolving the hospital from all legal liability that might result from Karen’s death. “I think you have come to the right decision,” Dr. Morse told them.
But the next morning Dr. Morse called Joseph Quinlan and said, “I have a moral problem about what we agreed on last night…” The next day, Dr. Morse called again. “I find I will not do it,” he said. “And I’ve informed the administrator at the hospital that I will not do it.”
The Quinlans were upset and bewildered… They talked with the hospital’s attorney, and he told them that, because Karen was over twenty-one, they were no longer her legal guardians. They would have to go to court and be appointed to guardianship. After that, they would have the standing to ask the hospital to remove Karen from the respirator, and the hospital might or might not comply…
Joseph Quinlan consulted attorney Paul Armstrong…
…Paul Armstrong filed a plea with Judge Robert Muir of the New Jersey Superior Court on September 12, 1975. He requested that Joseph Quinlan be appointed Karen’s guardian so that he would have “the express power of authorizing the discontinuance of all extraordinary means of sustaining her life.”
Armstrong argued the case on three constitutional grounds. First, he claimed (following the lead of the 1973 U.S. Supreme Court decision in Roe v. Wade) that there is an implicit right to privacy guaranteed by the Constitution and that this right permits individuals or others
acting for them to terminate the use of extraordinary medical measures, even when death may result…
Second, Armstrong argued that the First Amendment guarantee of religious freedom extended to the Quinlan case. If the court didn’t allow them to act in accordance with the doctrines of their church, their religious liberty would be infringed.
Finally, Armstrong appealed to the “cruel and unusual punishment” clause of the Eighth Amendment. He claimed that “for the state to require that Karen Quinlan be kept alive, against her will and the will of her family, after the dignity, beauty, promise and meaning of earthly life have vanished, is cruel and unusual punishment.”…
…On November 10, Judge Muir ruled against Joseph Quinlan…
Paul Armstrong immediately filed an appeal with the New Jersey Supreme Court. On January 26, 1976, the court convened to hear arguments…
This time the court’s ruling was favorable…the court stated, if Karen’s doctors believed she would never emerge from her coma, they should consult an ethics committee that should be established by St. Clare’s Hospital. If the committee accepted their prognosis, then the ventilator could be removed. If Karen’s present physicians were then unwilling to take her off the respirator, Mr. Quinlan was free to find a physician who would.
NOT IN THIS HOSPITAL
…The Quinlans expected Karen to die once she was off the machine, but she was soon breathing on her own without mechanical assistance…
Karen Quinlan continued to breathe on her own. She was given high nutrient feedings through a surgically implanted gastric tube, and she received regular doses of antibiotics to ward off bacterial infections…
…On June 11, 1985…Karen Quinlan finally died. She was thirty-one years old.
To most people in 1975, the case of Karen Quinlan seemed both astonishing and disturbing, and the whole country followed reports of the medical, moral, and legal issues as months passed and Karen neither died nor recovered consciousness. Most of us had never heard the phrase persistent vegetative state, which the neurologists used to describe her condition, and we were puzzled about its implications.
If Karen was trapped in some indefinite, ambiguous territory between life and death, how should we treat her? Were we duty-bound to keep her body functioning, even when she had no hope of recovery?