Ethics Cases S-Z

Cases S-Z

Saikewicz, Joseph
Schiavo, Terri
Vacco v. Quill
Wanglie, Helga
Washington v. Glucksberg

Alpha Lists: A-F G-L M-R S-Z

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Joseph Saikewicz was a 67 year-old profoundly retarded man (IQ of 10) who had been institutionalized for 53 years. In 1976, he was diagnosed as having leukemia. Chemotherapy had a 30-50% probability of producing remission of 2-13 months. A guardian was appointed by the court to determine whether Saikewicz should receive the treatment. He recommended against the therapy because treatment is less successful in older patients, would be painful and debilitating, and Saikewicz could not understand or cooperate with treatment. A probate judge agreed. An appellate court reviewed the lower court’s decision and concluded it was correct. The court pointed out that incompetent patients should not be denied a right to refuse treatment. The court clarified the standard of substituted judgment--that is, that which the incompetent patient would have decided for himself or herself "taking into account the present and future incompetence of the individual." If, as in this case, nothing is known about what the patient would have wanted, then the proxy or patient advocate is to cast himself imaginatively into the patient’s perspective, trying to imagine what he or she would have wanted--following the best interests standard. [Source: Superintendent of Belcherton State School v. Saikewicz, 370 N.E. 2d. 417 (1977).]

Principles & Concepts: informed consent, proportionate/ disproportionate means, beneficence, surrogate decision-making.

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Schiavo, Terri

In February of 1990, Michael Schiavo found his wife, Terri, lying unconscious on the floor of their bathroom. Due to a Potassium deficiency, Terri had suffered a heart attack and was in an anoxic state that would ultimately leave her with the diagnosis of being in a Persistent Vegetative State (PVS). In September of 1993, Michael Schiavo authorized the nursing home she resides in to write a DNR order for Terri. In February of the same year, the case entered the Florida court system when Terri's parents filed a petition to have Michael removed as Terri's legal guardian, because he refused to authorize antibiotic therapy on Terri's behalf for a urinary tract infection, which could potentially lead to Sepsis and death. In a deposition to the court, Michael Schiavo testified that he knew that Terri's condition might be fatal without treatment, but that he was making a decision that was consistent with what he understood to be Terri's previously expressed wishes regarding continued treatment in her current condition. Despite the infection, Terri survived, and the guardianship suit was dismissed in February of 1994.

In 1997, Michael's lawyer sent Terri's parents a letter notifying them that Michael was petitioning the court to authorize the withdrawal of Terri's feeding tube, i.e., artificially delivered nutrition and hydration (ADNH). Terri's parents then petitioned the court for an injunction to stop the withdrawal of treatment on the basis that, contrary to what Michael testified, they believed Terri would have wanted treatment continued. In 1998, the court appointed a guardian ad litem for Terri. In June of 1999, the guardian ad litem was dismissed by the court on the basis of failing to act impartially. In 2000, the court approved the removal of the feeding tube, based on clear and convincing evidence that Terri had previously expressed a desire not to receive life-sustaining treatment in such circumstances. Subsequently, Terri's parents filed an appeal with the Florida Appellate Court to overturn the lower court's ruling, claiming that Terri is not in fact in a PVS and had never expressed to them a desire to forego life-sustaining treatment. In January of 2001, the Appellate Court found that Terri is in a PVS and would not have wanted life-sustaining treatment. On this basis, the Appellate Court refused to overturn the decision of the lower court, but did issue a 30 day stay on the action. Over the next two years, the case worked its way up to the Florida Supreme Court, which ultimately ruled that Terri is in a PVS and that there is clear and convincing evidence that she would not have wanted ADNH.

On Tuesday, October 21, 2003, just after the Florida Supreme Court ordered the withdrawal of the ADNH, the Florida Legislature enacted a law giving Florida Governor Jeb Bush the authority to override a court's ruling in cases in which a patient is in a PVS, has not executed a written advance directive and in which there is disagreement between family members regarding the appropriateness of life-sustaining medical treatment - in essence, tailoring the legislation to this specific case. The Governor signed the Act into law and issued an Executive Order to stay the withholding of nutrition and hydration from Terri. Medical facilities and personnel providing medical care to Terri Schiavo were directed to provide nutrition and hydration to her immediately. The action of the Florida Legislature in this case is unprecedented insofar as it gives the Governor the authority to intervene in individual cases and overturn a court's rulings. Ordinarily, it is the role of the judicial branch of government to rule on individual cases, not the role of the legislative or executive branches. Michael Schiavo filed suit in Florida State Court to have the new law overturned as unconstitutional.

On September 23, 2004 the Florida Supreme Court declared the Act unconstitutional because it violates the cornerstone of American democracy known as 'separation of powers'. Separation of powers recognizes three separate branches of government - the executive, the legislative, and the judicial - each with its own powers and responsibilities. The Florida Constitution expressly prohibits one branch of government from exercising the powers of the other two branches. The Florida Supreme Court found that this Act violates separation of powers on two levels: as it is written (on its face) and as it is applied to Terri Schiavo. The Act is unconstitutional 'on its face' because it gives legislative power to the Governor. Since the Act fails to incorporate adequate guidelines and criteria, it improperly gives the Governor unrestricted discretion in applying the law. The Act is unconstitutional 'as applied' because it encroaches on the power and the authority of the judicial branch, which ordered the discontinuation of Terri Schiavo's life support after the issues had been fully litigated. Pursuant to the Governor's executive order, however, the nutrition and hydration tube was reinserted. Thus the Act as applied in this case effectively reversed a proper judicial order.

On July 20, 2004, while the constitutionality of the Act was under review by the Florida Supreme Court, the parents of Terri Schiavo filed a motion for relief in the probate court; they urged the court to reconsider its order of February 2000 to withdraw life-prolonging procedures. This motion was based on a previous ruling of the Second District Court of Appeal which stated that the parents of Terri Schiavo have standing "at any time" to seek relief from the February 11, 2000 order. If they challenge the order, however, they must do so by alleging and proving "new circumstances" that would have influenced the courts decision. The parents contend that the March 20, 2004 Papal Allocution of Pope John Paul II regarding ADNH for persons in a PVS constitutes such "new circumstances," and no longer make it equitable to enforce the order to withhold the ADNH. They are arguing that, given the papal allocution, Terri, as a faithful Catholic, would not have made the decision to have the ADNH withheld, as the trial court concluded.

[See also: Ascension Health's Talking Points on the Case of Terri Schiavo.]

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Vacco v. Quill

This 1997 U.S. Supreme Court ruling reversed a Second Circuit ruling, upholding New York State’s ban on assisted suicide, holding that the terminally ill do not have a right to physician-assisted suicide under the Equal Protection Clause of the U.S. Constitution. Rehnquist, in his ruling opinion, reaffirmed that the equal protection clause creates no substantive rights. "Instead, it embodies a general rule that States must treat like cases alike but may treat unlike cases accordingly." The ruling held that New York's prohibition does not treat those terminally ill who are seeking assisted suicide differently from those terminally ill who could hasten death by ending life-sustaining treatment. The court maintained that all competent persons have a right to refuse treatments, but this is not the same as suicide--a distinction long recognized by both the medical and legal professions. In other words, it has long been recognized that people have a right to refuse unwanted treatments, but this is not tantamount to self-killing. [Source: Vacco v. Quill, 117 S.Ct. 2293 (1997).]

In her concurring opinion on Vacco v. Quill and Washington v. Glucksberg, Justice O’Connor confirmed that individual States might choose to permit physician assisted suicide, not as a Constitutionally-protected right, but as a "carefully struck balance" between an individual’s liberty interest and the States’ interest in preserving and protecting life:

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Cruzan v. Director, Mo. Dept. of Health

497 U.S. 261

New State Ice Co. v. Liebmann

Principles & Concepts: human dignity, respect for persons, autonomy, informed consent, right to die.

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Wanglie, Helga

Helga Wanglie was an 86 year-old patient in a persistent vegetative state and on a ventilator. Her husband, while purporting to acknowledge her diagnosis, did not accept its irreversibility. When the Hennepin County Medical Center staff proposed cessation of Mrs. Wanglie’s treatment and removal of the ventilator, he refused. The medical center petitioned the Probate Court for appointment of an independent guardian to represent Mrs. Wanglie and to determine whether further treatment was appropriate. Mr. Wanglie simultaneously sought appointment as his wife’s guardian. The Probate Court denied the medical center’s petition, and appointed Mr. Wanglie to serve as Mrs. Wanglie’s guardian and to make treatment decisions on her behalf. The court stated that Mr. Wanglie was "the most suitable and best qualified person" to serve from among the available potential guardians for his wife.

Many have labeled this case a "futile treatment case," presumably because the medical center sought to have appointed a guardian whom it believed would give consent to stopping treatment that the medical center judged to be futile. However, the court decided the case strictly as a guardianship matter and did not address the appropriateness of treatment. It is important to note also that neither Mr. Wanglie nor the medical center actually requested the court to determine the appropriateness of the treatment. Therefore, individuals should not attribute to this court decision any legal principles regarding the futility of medical treatment. [Source: In re the conservatorship of Helga M. Wanglie, No. PX-91-283, District Probate Division, 4^th Judicial district of the County of Hennepin, State of Minnesota.]

Principles & Concepts: surrogate decision-making, autonomy, decision-making capacity.

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Washington v. Glucksberg

This 1997 U.S. Supreme Court ruling upheld Washington State’s legal ban on physician-assisted suicide "as applied to competent, terminally ill adults who wish to hasten their deaths" by obtaining medication from their doctors. The court rejected the claim that a right to commit suicide under these circumstances is a liberty interest found under the due process clause, section one of the Fourteenth Amendment. The Court agreed that the State of Washington has a prevailing interest in the preservation of human life, the prevention of suicide, the integrity of the medical profession, the protection of vulnerable groups, and in avoiding a "slippery slope" into euthanasia. [Source: Washington v. Glucksberg, 117 S.Ct. 2258 (1997); see Justice O’Connor’s concurring opinion.]

Principles & concepts: human dignity, respect for persons, autonomy, informed consent, professional integrity.

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