When most people think of definitions, they think of dictionaries. They assume that the primary purpose of a definition is to inform us of the meaning of some unknown word. In this sense, a definition is no more or less than a handy tool for reference. In a broader and more profound sense, however, definitions are basic to nearly every aspect of our existence. Very complex verbal definitions underlie our scientific and industrial progress, medical practice, legal system and our ethical and religious thinking. Our attempts as humans at understanding what we are and where we are going are in large part a matter of definition and classification. Recent controversies about pornography, the use of the death penalty, abortion, and the prolongation of through artificial means have all been essentially problems of definition and classification. Frequently, the courts must decide such issues. Definitions, carefully developed in terms of statutes and precedents, are essential to the definitions. The Karen Quinlan case is a tragic and arresting example.
THE MATTER OF KAREN QUINLAN
On the evening of April 15, 1975, friends of Karen Quinlan called the police of Sussex County, New Jersey, because Karen had "ceased breathing for at least two 15-minute periods." Her friends had attempted mouth-to-mouth resuscitation and the police applied a respirator. Precisely how long Karen was unable to breathe on her own is unknown. However, the interruptions in her breathing apparently deprived her brain of oxygen and resulted in her coma. By the following day, Karen did not breathe on her own and did not respond to tests of reflexes. Her condition was described as decorticate, a term which indicates that the cortex of her brain did not share in her bodily operation. In such a condition, "the upper arms are drawn into the side of the body. The forearms are drawn in against the chest with the hands generally at right angles to the forearms, pointing towards the waist. The legs are drawn up against the body, knees are up, feet are in near the buttocks and extended in a ballet-type pose." On the second day of her comatose state, Karen weighed 115 pounds. She would lose forty pounds by November.
Karen was later transferred to an intensive care unit at another hospital. At that time she was still unconscious and on a respirator. A tube (catheter) was inserted into her bladder so that her urine could be drained. She was fed through a tube inserted into her nose leading to her stomach. She was given antibiotics because of the constant threat of infection. She was sweating heavily nearly all the time. Nurses on duty were constantly moving and positioning her. Despite the vast number of tests conducted, doctors could not discover the cause of the coma. It was clear, they thought, that neurological damage was responsible for her inability to maintain necessary bodily functions (breathing, eating, emptying her bladder, etc.) without mechanical aids. Over a period of nearly seven months there were no signs of neurological improvement. Karen was in what is called a "persistent vegetative state."
On November 10, 1975, Karen's father petitioned the Superior Court of New Jersey seeking to be appointed "guardian of the person and property of his 2 1 -year-old daughter" with "the express power of authorizing" her disconnection from the machine.
One of the major problems is the case was whether Karen should be regarded as alive or dead. Not many years ago, the definition of death was no problem. The absence of heartbeat or breathing indicated death, but advances in medical technology have made it possible for breathing and circulation to be maintained by mechanical means. The newest definition of death has to do with the brain. One doctor testifying in the case of Karen Quinlan explained that the brain functions at two levels: (1) an "internal vegetative regulation" which controls body temperature, breathing, blood pressure, heart rate, chewing, swallowing, sleeping and walking"; and (2) "a highly developed brain, which is uniquely human, which controls our relation to the outside world, our capacity to talk, to see, to feel, to sing, to think." This is the cognitive or thinking part of the brain. Brain death, the doctor argued, necessarily involves the death of both of these. While the doctors saw no hope of Karen's returning to cognitive functioning (to use of the higher brain), they believed that the vegetative part continued to operate.
The argument that the vegetative part of the brain still operated rested on a definition of brain death developed by the Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death. This definition included four criteria (or tests) must be met to satisfy the definition of brain death. The tests assume the absence of cognitive functioning and are concerned only with very low level neurological responses.
First, the patient is unresponsive or unreceptive to stimuli of various kinds - "Even the most intensely painful stimuli evoke no vocal or other response, not even a groan, withdrawal of a limb, or quickening of respiration."
Second, the patient shows no signs of spontaneous movement or breathing. If the patient is on a respirator, the complete absence of breathing is established by turning off the respirator for three minutes. If the patient shows no attempt at breathing, the observers can conclude that there is no spontaneous respiration.
Third, the patient does not respond to tests of reflexes. The pupils of the eyes do not respond to light. Tapping the tendons of various muscles with a reflex hammer yields no response. There is no eye movement, vocalization, swallowing, yawning, etc.
Fourth, the electroencephalogram is "flat". It reveals no brain-wave activity.
To satisfy the criteria for brain death, all these tests must be repeated no less than 24 hours later with no change. If the patient responds to none of the tests, the physician can conclude that the patient has suffered brain death and is, in fact, dead.
Although Karen Quinlan had no cognitive functions--no intelligent awareness of anything around her--she did not show positive response to the tests of her vegetative function. Though her limbs were rigid most of the time, she did move spastically on occasion. Her pupils responded to light, but very sluggishly. She did respond to painful stimuli. Occasionally, she assisted the respirator, but after one half-hour off the respirator, the attending physicians concluded that she would be unable to maintain her vital processes without it. Clearly, Karen passed the tests. She had not suffered brain death.
The doctors and the hospital (the defendants in this case) argued Karen was medically and legally alive and that disconnecting the respirator would very likely result in her death. Disconnecting the respirator would be an act of homicide and euthanasia (mercy killing). Further, along tradition in medical science asserts that a doctor must do everything in his power to prolong life, none of the doctors stated that there was no hope for recovery, only that the hope for recovery was remote."
Therefore, lawyers for the doctors and the hospital argued against the disconnection of respirator and other mechanical devices. Judge Muir, who wrote the opinion for the court, agreed with the doctors. A decision to disconnect the respirator, he decided, was medical decision and could not be turned over to the father. Therefore, he denied Mr. Quinlan's request to act as guardian of his 2 1-year-old daughter's person.
Two definitions were central to this decision. First, in terms of the definition of brain death used, Karen Quinlan was both medically and legally alive, despite her "persistent vegetative state." The second was Judge Muir's definition of the role interests of a person "suffering under a disability." As Judge Muir saw it, the authorization which Karen's father sought "would be to permit Karen Quinlan to die." He argued that this was "not protection . . . not something in her best interests." He decided that the best course of action was to permit doctors to decide what medical treatment to prescribe. Doctors, of course, had testified that Karen should not be removed from the respirator.
Joseph Quinlan took his case to the Supreme Court of New Jersey. Judge Hughes, the chief justice of the court, made use of the same definition of brain death as had Judge Muir. At the same time, however, Hughes focused attention on other facts of the case and redefined them, namely, Karen's right to privacy and the role of court. The decision of the Supreme Court, written by Judge Hughes, overturned the decision of the lower court, appointing Joseph Quinlan the guardian of Karen and permitting him to authorize the termination of the respirator.
The most important factor in the decision was a definition of the right to privacy. Lawyers for Karen's father had argued that the extraordinary medical treatment (respirator, catheter, feeding tube, etc.) amounted to an invasion of Karen's privacy. In the first case, Judge Muir had reasoned that the "compelling" State interest in the preservation of life should prevail over the parents' assertion of Karen's right to privacy. In other cases involving extremely sick patients, courts had ordered various medical treatments (such as blood transfusion) judged necessary to the recovery of the patient had been ordered despite the patients religious objections and despite appeals to rights of privacy.
In the second case, Judge Hughes based his decision on additional testimony and a shift in the definition of the right to privacy. The additional testimony had come from one doctor who indicated that common medical practice with terminally ill patients was not simply a matter of treatment if any signs of life remain.
For example, even a patient aware of what was going on, but "terminally ill, riddled by cancer and suffering great pain ... would not be resuscitated or put on a respirator. . . ." The doctor, in short, would make a decision not to use extraordinary treatment but to allow the patient to die of natural causes.
Judge Hughes defined the right to privacy as having to do with control over the body and not only with control over "continuing life style." He argued that the state could not "compel Karen to endure the unendurable [the invasion of her body by machines and tubes], only to vegetate a few measurable months with no realistic possibility of returning to any semblance of a cognitive or sapient life." The right to privacy, he argued, was more important, in such a case, than the "right of a physician to administer treatment according to his best judgment." And it was more important than the State's interest in preserving life. The State's interest in the preservation of life weakens and "the individual's right to privacy grows as the degree of bodily invasion increases and the prognosis dims." In other words, the less chance an individual has of returning to some basic degree of conscious life, the less right the state has to force medical treatment on him or her.
Judge Hughes' decision to appoint Joseph Quinlan the guardian of his 2 1-year-old daughter's person was based on the right to privacy which was in conflict, in this case, with the state's interest in the preservation of life. The right to privacy is one that is still being defined. Judge Hughes extended the definition by urging that the State's interest in the preservation of life decreased as the individual's chances of regaining a cognitive existence decreased. After his decision, the courts can no longer automatically decide that the right to be left alone--to dieis less important than the States interest in the preservation of life. Courts may disagree, but they will have to argue his position...