Public Health Law Map - Beta 5 - Medical and Public Health Law Site

use every possible avenue to prolong the grandmother’s life because they feel guilty
for putting her in a nursing home.
In the worst cases, family interests are shaped by potential inheritances. Since many
wills contain clauses that shift the distribution of the estate depending on the time
of death, there can be substantial financial interests in either artificially prolonging
or shortening life. A major function of probate courts is to resolve family members’
conflicts over estates. It would be unrealistic to assume that these conflicts had no
influence on family decisions on termination of life support.
e) Society’s Interests
Until recently, American society was uncritically committed to prolonging the life
of all citizens. Insurance payments influenced physicians through direct financial
incentives and through the indirect incentive of societal approbation. Insurance
companies, as powerful representatives of society, clearly approved of the
prolongation of life with advanced life-support technologies. The insurers ratified
the life-at-any-cost mentality that physicians were adopting in the 1960s and 1970s.
This is not surprising because the dominant insurers of this period—Blue Cross and
Blue Shield— were controlled by physicians and hospitals.
This mentality lead to striking increases in the cost of medical care. Employers,
who buy most health insurance, and government, which pays for Medicare and
Medicaid, became concerned with resource allocation. Resources expended on
supporting the life of a patient are not available for other objectives, such as
education or preventive medical care. [Murphy DJ, Matchar DB. Life-sustaining
therapy: a model for appropriate use. JAMA. 1990;264:2103–2108.] The enactment
of the Medicare prospective payment system is one manifestation of this concern.
Implicit in the prospective payment system is a repudiation of the life-at-all-cost
signal sent by the previous cost-based reimbursement system. [Veatch RM. Justice
and the economics of terminal illness. Hastings Cent Rep. 1988;18:34.]
Societal interests have become more complicated as antiabortion forces have sought
legislation that demands that the state favor life under all circumstances. Although
intended to limit abortions, such statutory presumptions can also be read as limiting
termination of life-support decisions. This is at issue in the Cruzan decision by the
Missouri Supreme Court. The court held that its refusal of an order to terminate life
support for an incompetent person was mandated by a pro-life statutory provision in
the state’s antiabortion law.
2. The Cruzan Case
On June 15, 1990, the U.S. Supreme Court rendered its long-awaited decision in the
Cruzan “right-to-die” case. The actual law established by this case is very narrow
and is only tangentially related to the termination of life support. This decision has
discomfited many physicians because it does not establish an easy- to-administer,
national standard for the termination of life support. Cruzan is an important
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