A. * * * [Y]ou've got a set of possible lesions that prior to the era of advanced technology and advances in medicine were no problem inasmuch as the patient would expire. They could do nothing for themselves and even external care was limited. It was -- I don't know how many years ago they couldn't keep a person alive with intravenous feedings because they couldn't give enough calories. Now they have these high caloric tube feedings that can keep people in excellent nutrition for years so what's happened is these things have occurred all along but the technology has now reached a point where you can in fact start to replace anything outside of the brain to maintain something that is irreversibly damaged.
Q. Doctor, can the art of medicine repair the cerebral damage that was sustained by Karen?
A. In my opinion, no. * * *
Q. Doctor, in your opinion is there any course of treatment that will lead to the improvement of Karen's condition?
A. No.

 
I. Legal and Medical Death

(a) Under the existing legal and medical definitions of death recognized by the State of New Jersey, Karen Ann Quinlan is dead.

Under any legal standard recognized by the State of New Jersey and also under standard medical practice, Karen Ann Quinlan is presently alive.

Whether the use of the criteria developed and enunciated by  [***7]  the Ad Hoc Committee of the Harvard Medical School on or about August 5, 1968, as well as similar criteria, by a physician to assist in determination of the death of a patient whose cardiopulmonary functions  [**653]  are being artificially sustained, is in accordance with ordinary and standard medical practice. n3

 [***9] 

Mr. Coburn's appointment is designed to deal with those instances wherein Dr. Morse, n4 in the process of administering care and treatment to Karen Quinlan, feels there should be concurrence on the extent or nature of the care or treatment. If Mr. and Mrs. Quinlan are unable to give concurrence, then Mr. Coburn will be consulted for his concurrence.

 
We have an internal vegetative regulation which controls body temperature which controls breathing, which controls to a considerable degree blood pressure, which controls to some degree heart rate, which controls chewing, swallowing and which controls sleeping and waking. We have a more 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. Brain death necessarily must mean the death of both of these functions of the brain, vegetative and the sapient. Therefore, the presence of any function which is regulated or governed  [**655]  or controlled by the deeper parts of the brain which in laymen's terms might  [***14]  be considered purely vegetative would mean that the brain is not biologically dead.

From ancient times down to the recent past it was clear that, when the respiration and heart stopped, the brain would die in a few minutes; so the obvious criterion of no heart beat as synonymous with death was sufficiently accurate. In those times the heart was considered to be the central organ of the body; it is not surprising that its failure marked the onset of death. This is no longer valid when modern resuscitative and supportive measures are used. These improved activities can now restore "life" as judged by the ancient standards of persistent respiration and continuing heart beat. This can be the case even when there is not the remotest possibility of an individual recovering consciousness following massive brain damage. ["A Definition of Irreversible Coma," 205 J.A.M.A. 337, 339 (1968)].

 [*28]  The patient's condition can be determined only by a physician. When the patient is hopelessly damaged as defined above, the family and all colleagues who have participated in major decisions concerning the patient, and all nurses involved, should be so informed. Death is to be declared and then the respirator turned off. The decision to do this and the responsibility for it are to be taken by the physician-in-charge, in consultation with one or more physicians who have been directly involved in the case. It is unsound and undesirable to force the family to make the decision. [205 J.A.M.A., supra at 338 (emphasis in original)].

 
The subject has lost human qualities. It would be incredible, and I think unlikely, that any physician would respond to a sudden hemorrhage, massive hemorrhage or a loss of all her defensive blood  [*29]  cells, by giving her large quantities of blood. I think that * * * major surgical procedures would be out of the question even if they were known to be essential for continued physical existence.

 
Don't treat this patient anymore, * * * it does not serve either the patient, the family, or society in any meaningful way to continue treatment with this patient.

 
Cancer, metastatic cancer, involving the lungs, the liver, the brain, multiple involvements, the physician may or may not write: Do not resuscitate. * * * [I]t could be said to the nurse: if this man stops breathing don't resuscitate him. * * * No physician that I know personally is going to try and resuscitate a man riddled with cancer and in agony and he stops breathing. They are not going to put him on a respirator. * * * I think that would be the height of misuse of technology.

 
Does the anesthesiologist have the right, or is he bound, in all cases of deep unconsciousness, even in those that are completely hopeless in the opinion of the competent doctor, to use modern artificial respiration apparatus, even against the will of the family?

 
1. In ordinary cases the doctor has the right to act in this  [***26]  manner, but is not bound to do so unless this is the only way of fulfilling another certain moral duty.
2. The doctor, however, has no right independent of the patient. He can act only if the patient explicitly or implicitly, directly or indirectly gives him the permission.
3. The treatment as described in the question constitutes extraordinary means of preserving life and so there is no obligation to use them nor to give the doctor permission to use them.
4. The rights and the duties of the family depend on the presumed will of the unconscious patient if he or she is of legal age, and the family, too, is bound to use only ordinary means.
5. This case is not to be considered euthanasia in any way; that would never be licit. The interruption of attempts at resuscitation, even when it causes the arrest of circulation, is not more than an indirect cause of the cessation of life, and we must apply in this case the principle of double effect.

Competent medical testimony has established that Karen Ann Quinlan has no reasonable hope of recovery from her comatose  [***27]  state by the use of any available medical procedures. The continuance of mechanical (cardiorespiratory) supportive measures to sustain continuation of her body functions and her life constitute extraordinary means of treatment. Therefore, the decision of Joseph * * * Quinlan to request the discontinuance of this treatment is, according to the teachings of the Catholic Church, a morally correct decision. (emphasis in original)

The right to a natural death is one outstanding area in which the disciplines of theology, medicine and law overlap; or, to put it another way, it is an area in which these three disciplines convene.

Medicine with its combination of advanced technology and professional ethics is both able and inclined to prolong biological life. Law with its felt obligation to protect the life and freedom of the individual seeks to assure each person's right to live out his human life until its natural and inevitable conclusion.  [***28]  Theology with its acknowledgment of man's dissatisfaction with biological life as the ultimate source of joy * * * defends the sacredness of human life and defends it from all direct attacks.

These disciplines do not conflict with one another, but are necessarily conjoined in the application of their principles in a particular instance such as that of Karen Ann Quinlan. Each must in some way acknowledge the other without denying its own competence. The civil law is not expected to assert a belief in eternal life; nor, on the other hand, is it expected to ignore the right of the individual to profess it, and to form and pursue his conscience in accord with that belief. Medical science is not authorized to directly cause natural death; nor, however, is it expected to prevent it when it is inevitable and all hope of a return to an even partial exercise of human life is irreparably lost. Religion is not expected to define biological death; nor, on its part, is it expected to relinquish its responsibility to assist man in the formation and pursuit of a correct conscience as to the acceptance of natural death  [*33]  when science has confirmed its inevitability beyond any hope  [***29]  other than that of preserving biological life in a merely vegetative state.

In the present public discussion of the case of Karen Ann Quinlan it has been brought out that responsible people involved in medical care, patients and families have exercised the freedom to terminate or withhold certain treatments as extraordinary means in cases judged to be terminal, i.e., cases which hold no realistic hope for some recovery, in accord with the expressed or implied intentions of the patients themselves. To whatever extent this has been happening it has been without sanction in civil law. Those involved in such actions, however, have ethical and theological literature to guide them in their judgments and actions. Furthermore, such actions have not in themselves undermined society's reverence for the lives of sick and dying people.

It is both possible and necessary for society to have laws and ethical standards which provide freedom for decisions, in accord with the expressed or implied intentions of the patient, to terminate or withhold extraordinary treatment  [**660]  in cases which are judged to  [***30]  be hopeless by competent medical authorities, without at the same time leaving an opening for euthanasia. Indeed, to accomplish this, it may simply be required that courts and legislative bodies recognize the present standards and practices of many people engaged in medical care who have been doing what the parents of Karen Ann Quinlan are requesting authorization to have done for their beloved daughter.

1. Was the trial court correct in denying the specific relief requested by plaintiff, i.e., authorization for termination of the life-supporting apparatus, on the case presented to him? Our determination on that question is in the affirmative.

2. Was the court correct in withholding letters of guardianship from the plaintiff and appointing in his stead a stranger? On that issue our determination is in the negative.

3. Should this Court, in the light of the foregoing conclusions, grant declaratory relief to the plaintiff? On that question our Court's determination is in the affirmative.

 
* * * [W]e have appropriately confined litigation to those situations where  [**661]  the litigants concerned with the subject matter evidenced a sufficient stake and real  [***33]  adverseness. In the overall we have given due weight to the interests of individual justice, along with the public interest, always bearing in mind that throughout our law we have been sweepingly rejecting procedural frustrations in favor of "just and expeditious determinations on the ultimate merits." [58 N.J. at 107-08 (quoting from Tumarkin v.

Friedman, 17 N.J. Super. 20, 21 (App. Div. 1951), certif. den., 9 N.J. 287 (1952))].

A significant problem in any discussion of sensitive medical-legal issues is the marked, perhaps unconscious, tendency of many to distort what the law is, in pursuit of an exposition of what they would like the law to be. Nowhere is this barrier to the intelligent resolution of legal controversies more obstructive than in the debate over  [*43]  patient rights at the end of life. Judicial refusals to order lifesaving treatment in the face of contrary claims of bodily self-determination or free religious exercise are too often cited in support of a preconceived "right to die," even though the patients, wanting to live, have claimed no such right. Conversely, the assertion of a religious or other objection to lifesaving treatment is at times condemned as attempted suicide, even though suicide means something quite diferent in the law. [Byrn, "Compulsory Lifesaving Treatment For The Competent Adult," 44 Fordham L. Rev. 1 (1975)].

 [*44]  Doctors * * * to treat a patient, must deal with medical tradition and past case histories. They must be guided by what they do know. The extent of their training, their experience, consultation with other physicians, must guide their decision-making processes in providing care to their patient. The nature, extent and duration of care by societal standards is the responsibility of a physician. The morality and conscience of our society places this responsibility in the hands of the physician. What justification is there to remove it from the control of the medical profession and place it in the hands of the courts? [137 N.J. Super. at 259].

"As part of the inherent power of equity, a Court of Equity has full and complete jurisdiction over the persons of those who labor  [*45]  under any legal disability. * * * The Court's action in such a case is not limited by any narrow bounds, but it is empowered to stretch forth its arm in whatever direction its aid and protection may be needed. While this is indeed a special exercise of equity jurisdiction, it is beyond question that by virtue thereof the Court may pass upon purely personal rights." [137 N.J.

Super. at 254 (quoting from Am. Jur. 2d, Equity § 69 (1966))].

"to exercise in the treatment of his patient the degree of care, knowledge and skill ordinarily possessed and exercised in similar situations by the average member of the profession practicing in his field." Schueler v. Strelinger, 43 N.J. 330, 344 (1964). If he is a specialist he "must employ not merely the  [***51]  skill of a general practitioner, but also that special degree of skill normally possessed by the average physician who devotes special study and attention to the particular organ or disease or injury involved, having regard to the present state of scientific knowledge". Clark v. Wichman, 72 N.J.

Super. 486, 493 (App. Div. 1962). This is the duty that establishes his legal obligations to his patients. [137 N.J. Super. at 257-58].

[I]t is a general principle of the highest importance to the proper administration of justice that a judicial officer, in exercising the authority vested in him, shall be free to act upon his own convictions, without apprehension of personal consequences to himself.

Physicians, by virtue of their responsibility for medical judgments are, partly by choice and partly by default, charged with the responsibility of making ethical judgments which we are sometimes ill-equipped to make. We are not always morally and legally authorized to make them. The physician is thereby assuming a civil and criminal liability that, as often as not, he does not even realize as a factor in his decision. There  [***58]  is little or no dialogue in this whole process. The physician assumes that his judgment is called for and, in good faith, he acts. Someone must and it has been the physician who has assumed the responsibility and the risk.

I suggest that it would be more appropriate to provide a regular forum for more input and dialogue in individual situations and to allow the responsibility of these judgments to be shared. Many hospitals have established an Ethics Committee composed of physicians, social workers, attorneys, and theologians, * * * which serves to review the individual circumstances of ethical dilemma and which has provided much in the way of assistance and safeguards for patients and their medical caretakers. Generally, the authority of these committees is primarily restricted to the hospital setting and their official status is more that of an advisory body than of an enforcing body.

The concept of an Ethics Committee which has this kind of organization and is readily accessible to those persons rendering medical care to patients, would be, I think, the most promising direction for further study at this point. * *

 [**669]  * * * * [This would allow] some much needed  [***59]  dialogue regarding these issues and [force] the point of exploring all of the options for a particular patient. It diffuses the responsibility for making these judgments. Many physicians, in many circumstances, would welcome this sharing of responsibility. I believe that such an entity could  [*50]  lend itself well to an assumption of a legal status which would allow courses of action not now undertaken because of the concern for liability. [27

Baylor L. Rev. 6, 8-9 (1975)].

In any case where a guardian is to be appointed, letters of guardianship shall be granted * * * to the next of kin, or if * * * it is proven to the court that no appointment from among them will be to the best interest of the incompetent or his estate, then to such other proper person as will accept the same. [N.J.S.A. 3A:6-36. See In re Roll, 117 N.J. Super. 122, 124 (App. Div. 1971)].

1. To discharge, with the thanks of the Court for his service, the present guardian of the person of Karen Quinlan, Thomas R. Curtin, Esquire, a member of the Bar and an officer of the court.

2. To appoint Joseph Quinlan as guardian of the person of Karen Quinlan with full power to make decisions with regard to the identity of her treating physicians.