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For many physicians, the actions they take often depend more on circumstance than on moral certainty. How far is the patient from death? How great is the pain? How clear the will? Does the patient just want to be left alone, or is he asking to be killed? The Cruzan case has raised the basic medical issue of whether doctors must continue to treat patients they cannot cure. In its amicus brief to the Supreme Court, the American Academy of Neurology argues that the doctor's duty is to continue treating unconscious patients as long as there is some chance of improvement, which Nancy Cruzan does not have. When hope is gone, the duty ends. But the Association of American Physicians and Surgeons argues precisely the opposite. "The obligation of the physician to the comatose, vegetative, or developmentally disabled patient does not depend upon the prospect for recovery," it wrote in its brief. "The physician must always act on behalf of the patient's well-being."
Taken to the extreme, this principle can mean ignoring or overriding the patient's express wishes. When Dax Cowart was critically burned in a propane- gas explosion near Henderson, Texas, he begged a passing farmer for a gun with which to kill himself. On his way to the hospital, he pleaded with the medic to let him die. For weeks his life hung by a thread. For more than a year, against his will, he endured excruciating treatment: his right eye and several fingers were removed, his left eye was sewn shut. His pain and his protests were unrelenting. One night he crawled out of bed to try to throw himself out a window, but was discovered and prevented.
That was 17 years ago. Cowart is now a law school graduate, married, living in Texas and managing his investments. Yet to this day he argues that doctors violated his right to choose not to be treated. "It doesn't take a genius to know that when you're in that amount of pain, you can either bear it or you can't," he says. "And I couldn't." He still resents the powerlessness of patients who are forced to live when they beg to die. "The physicians say that when a patient is in that much pain, he is not competent to make judgments about himself. It's the pain talking. And then when narcotics are given to subdue the pain, they say it's the narcotics talking. It's a no-win situation."
In Cowart's case, doctors acted paternalistically; they overruled his pleas in the belief that he would one day recover sufficiently to be grateful. But what if there were no chance of recovery: no law school, no wedding, no "life" down the road? Are doctors still obliged to fight on for their patients, even in a losing battle, even against their will? When a patient's time is short and his wishes are clear, many doctors these days would say no to life-at-all-costs heroics. Overtreatment of the terminally ill strikes physicians as both wasteful and inhumane. And patients living within sight of death often find themselves more concerned with the quality of the life that remains than with its quantity. Once reconciled to the inevitable, they want to die with dignity, not tethered to a battery of machines in an intensive- care unit like a laboratory specimen under glass.