All instances of the word "ARTIFICIAL"
appear in RED
In the Matter of Quinlan (1976)
70 N.J. 10, 355 A. 2d.
IN THE MATTER OF KAREN QUINLAN AN ALLEGED INCOMPETENT
[NO NUMBER IN ORIGINAL]
Supreme Court of New Jersey
70 N.J. 10; 355 A.2d 647; 1976 N.J. LEXIS 181; 79
January 26, 1976, Argued
March 31, 1976, Decided
Mr. Paul W. Armstrong and Mr. James M. Crowley, a
member of the New York bar, argued the cause for appellant Joseph T.
Quinlan (Mr. Paul W. Armstrong, attorney).
Mr. Daniel R. Coburn argued the cause for respondent
Guardian ad Litem Thomas R. Curtin.
William F. Hyland, Attorney General of New Jersey, argued the cause
for respondent State of New Jersey (Mr. Hyland, attorney; Mr.
David S. Baime and Mr. John DeCicco, Deputy Attorneys General,
of counsel; Mr. Baime, Mr. DeCicco, Ms. Jane E. Deaterly, Mr. Daniel
Louis Grossman and Mr. Robert E. Rochford, Deputy Attorneys
General, on the brief).
Mr. Donald G.
Collester, Jr., Morris County Prosecutor, argued the cause for
respondent County of Morris.
Porzio argued the cause for respondents Arshad Javed and Robert J.
Morse (Messrs. Porzio, Bromberg and Newman, attorneys; Mr.
Porzio, of counsel; Mr. Porzio and Mr. E. Neal
Zimmermann, on the brief).
Mr. Theodore E.
B. Einhorn argued the cause for respondent Saint Clare's Hospital.
Mr. Edward J. Leadem filed a brief on behalf
of amicus curiae New Jersey Catholic Conference.
JUDGES: For modification [***2] and
remandment -- Chief Justice Hughes, Justices Mountain, Sullivan,
Pashman, Clifford and Schreiber and Judge Conford. Opposed -- None.
The opinion of the Court was delivered by Hughes, C.J.
[*18] [**651] THE LITIGATION
The central figure in this tragic case is Karen Ann
QUINLAN a New Jersey resident. At the age of 22, she lies in a debilitated
and allegedly moribund state at Saint Clare's Hospital in Denville, New
Jersey. The litigation has to do, in final analysis, with her life, -- its
continuance or cessation, -- and the responsibilities, rights and duties,
with regard to any fateful decision concerning it, of her family, her
guardian, her doctors, the hospital, the State through its law enforcement
authorities, and finally the courts of justice.
The issues are before this Court following its direct
certification of the action under the rule, R. 2:12-1, prior to
hearing in the Superior Court, Appellate Division, to which the appellant
(hereafter "plaintiff") Joseph QUINLAN Karen's father, had appealed the
adverse judgment of the Chancery Division.
extensive physical damage fully described in the able opinion of the
trial [***3] judge, Judge Muir, supporting that judgment, Karen
allegedly was incompetent. Joseph Quinlan sought the adjudication of that
incompetency. He wished to be appointed guardian of the person and
property of his daughter. It was proposed by him that such letters of
guardianship, if granted, should contain an express power to him as
guardian to authorize the discontinuance of all extraordinary medical
procedures now allegedly sustaining Karen's vital processes and hence her
life, since these measures, he asserted, present no hope of her eventual
recovery. A guardian ad litem was appointed by Judge Muir to
represent the interest of the alleged incompetent.
By a supplemental complaint, in view of the extraordinary nature
of the relief sought by plaintiff and the involvement therein of their
several rights and responsibilities, other parties were added. These
included the treating physicians and the hospital, the relief sought being
that they be restrained from interfering with the carrying out of any such
extraordinary [*19] authorization in the event it were to be
granted by the court. Joined, as well, was the Prosecutor of Morris County
(he being charged with responsibility [***4] for enforcement of
the criminal law), to enjoin him from interfering with, or projecting a
criminal prosecution which otherwise might ensue in the event of,
cessation of life in Karen resulting from the exercise of such
extraordinary authorization were it to be granted to the guardian.
The Attorney General of New Jersey intervened as of
right pursuant to R. 4:33-1 on behalf of the State of New Jersey,
such intervention being recognized by the court in the pretrial conference
order (R. 4:25-1 et seq.) of September 22, 1975. Its basis,
of course, was the interest of the State in [**652] the
preservation of life, which has an undoubted constitutional foundation. n1
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- - - - - - - - - -
importance of the preservation of life is memorialized in various organic
documents. The Declaration of Independence states as self-evident truths
"that all men * * * are endowed by their Creator with certain unalienable
Rights, that among these are Life, Liberty and the pursuit of Happiness."
This ideal is inherent in the Constitution of the United States. It is
explicitly recognized in our Constitution of 1947 which provides for
"certain natural and unalienable rights, among which are those of enjoying
and defending life * * *." N.J. Const. (1947), Art. I, par. 1. Our
State government is established to protect such rights, N.J. Const.
(1947), Art. I, par. 2, and, acting through the Attorney General (
N.J.S.A. 52:17A-4(h)), it enforces them.
- - - - - - - - - - - - End Footnotes- - - - - - - -
- - - - - - [***5]
The matter is of
transcendent importance, involving questions related to the definition and
existence of death; the prolongation of life through artificial means
developed by medical technology undreamed of in past generations of the
practice of the healing arts; n2 the impact of such durationally
[*20] indeterminate and artificial life prolongation on the
rights of the incompetent, her family and society in general; the bearing
of constitutional right and the scope of judicial responsibility, as to
the appropriate response of an equity court of justice to the
extraordinary prayer for relief of the plaintiff. Involved as well is the
right of the plaintiff, Joseph QUINLAN to guardianship of the person of
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Footnotes - - - - - - - - - - - - - - -
n2 Dr. Julius Korein, a neurologist, testified:
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
Q. Doctor, can the art of medicine
repair the cerebral damage that was sustained by Karen?
In my opinion, no. * * *
Q. Doctor, in your opinion is there
any course of treatment that will lead to the improvement of Karen's
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- - - - - - [***6]
Among his "factual
and legal contentions" under such Pretrial Order was the following:
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
contention, made in the context of Karen's profound and allegedly
irreversible coma and physical debility, was discarded during trial by the
following stipulated amendment to the Pretrial Order:
Under any legal standard
recognized by the State of New Jersey and also under standard medical
practice, Karen Ann Quinlan is presently alive.
Other amendments to the Pretrial Order
made at the time of trial expanded the issues before the court. The
Prosecutor of Morris County sought a declaratory judgment
[*21] as to the effect any affirmation by the court of a right
in a guardian to terminate life-sustaining procedures would have with
regard to enforcement of the criminal laws of New Jersey with reference to
homicide. Saint Clare's Hospital, in the face of trial testimony on the
subject of "brain death," sought declaratory judgment as to:
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
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- - - - - - - -
n3 The Harvard Ad
Hoc standards, with reference to "brain death," will be discussed
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- - - - End Footnotes- - - - - - - - - - - - - -
It was further stipulated during trial that Karen was indeed
incompetent and guardianship was necessary, although there exists a
dispute as to the determination later reached by the court that such
guardianship should be bifurcated, and that Mr. Quinlan should be
appointed as guardian of the trivial property but not the person of his
After certification the Attorney
General filed as of right (R. 2:3-4) a cross-appeal n3.1
challenging the action of the trial court in admitting evidence of prior
statements made by Karen while competent as to her distaste for
continuance of life by extraordinary [***8] medical procedures,
under circumstances not unlike those of the present case. These quoted
statements were made in the context of several conversations with regard
to others terminally ill and being subjected to like heroic measures. The
statements were advanced as evidence of what she would want done in such a
contingency as now exists. She was said to have firmly evinced her wish,
in like circumstances, not to have her life prolonged by the otherwise
futile use of extraordinary means. Because we [*22] agree with
the conception of the trial court that such statements, since they were
remote and impersonal, lacked significant probative weight, it is not of
consequence to our opinion that we decide whether or not they were
admissible hearsay. Again, after certification, the guardian of the person
of the incompetent (who had been appointed as a part of the judgment
appealed from) resigned and was succeeded by another, but that too seems
irrelevant to decision. It is, however, of interest to note the trial
court's delineation (in its supplemental opinion of November 12, 1975) of
the extent of the personal guardian's authority with respect to medical
care of his ward:
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.
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Footnotes - - - - - - - - - - - - - - -
n3.1 This cross-appeal was later informally withdrawn but in view
of the importance of the matter we nevertheless deal with it.
n4 Dr. Robert J. Morse, a neurologist,
and Karen's treating physisician from the time of her admission to Saint
Clare's Hospital on April 24, 1975 (reference was made supra to
"treating physicians" named as defendants; this term included Dr. Arshad
Javed, a highly qualified pulmonary internist, who considers that he
manages that phase of Karen's care with primary responsibility to the
"attending physician," Dr. Morse).
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Essentially then, appealing to the power of
equity, and relying on claimed constitutional rights of
free [***10] exercise of religion, of privacy and of protection
against cruel and unusual punishment, Karen Quinlan's father sought
judicial authority to withdraw the life-sustaining mechanisms temporarily
preserving his daughter's life, and his appointment as guardian of her
person to that end. His request was opposed by her doctors, the hospital,
the Morris County Prosecutor, the State of New Jersey, and her guardian
THE FACTUAL BASE
An understanding of the issues in their basic
perspective suggests a brief review of the factual base developed in the
[*23] testimony and documented in greater detail in the
opinion of the trial judge. In re Quinlan, 137 N.J. Super.
227 (Ch. Div. 1975).
On the night of April 15,
1975, for reasons still unclear, Karen Quinlan ceased [**654]
breathing for at least two 15 minute periods. She received some
ineffectual mouth-to-mouth resuscitation from friends. She was taken by
ambulance to Newton Memorial Hospital. There she had a temperature of 100
degrees, her pupils were unreactive and she was unresponsive even to deep
pain. The history at the time of her admission to that hospital was
essentially incomplete and uninformative. [***11]
Three days later, Dr. Morse examined Karen at the
request of the Newton admitting physician, Dr. McGee. He found her
comatose with evidence of decortication, a condition relating to
derangement of the cortex of the brain causing a physical posture in which
the upper extremities are flexed and the lower extremities are extended.
She required a respirator to assist her breathing. Dr. Morse was unable to
obtain an adequate account of the circumstances and events leading up to
Karen's admission to the Newton Hospital. Such initial history or etiology
is crucial in neurological diagnosis. Relying as he did upon the Newton
Memorial records and his own examination, he concluded that prolonged lack
of oxygen in the bloodstream, anoxia, was identified with her condition as
he saw it upon first observation. When she was later transferred to Saint
Clare's Hospital she was still unconscious, still on a respirator and a
tracheotomy had been performed. On her arrival Dr. Morse conducted
extensive and detailed examinations. An electroencephalogram (EEG)
measuring electrical rhythm of the brain was performed and Dr. Morse
characterized the result as "abnormal but it showed some
activity [***12] and was consistent with her clinical state."
Other significant neurological tests, including a brain scan, an
angiogram, and a lumbar puncture were normal in result. Dr. Morse
testified that Karen has been in a state of coma, lack of consciousness,
[*24] since he began treating her. He explained that there are
basically two types of coma, sleep-like unresponsiveness and awake
unresponsiveness. Karen was originally in a sleep-like unresponsive
condition but soon developed "sleep-wake" cycles, apparently a normal
improvement for comatose patients occurring within three to four weeks. In
the awake cycle she blinks, cries out and does things of that sort but is
still totally unaware of anyone or anything around her.
Dr. Morse and other expert physicians who examined her
characterized Karen as being in a "chronic persistent vegetative state."
Dr. Fred Plum, one of such expert witnesses, defined this as a "subject
who remains with the capacity to maintain the vegetative parts of
neurological function but who * * * no longer has any cognitive
Dr. Morse, as well as the several
other medical and neurological experts who testified in this case,
believed with certainty [***13] that Karen Quinlan is not
"brain dead." They identified the Ad Hoc Committee of Harvard Medical
School report (infra) as the ordinary medical standard for
determining brain death, and all of them were satisfied that Karen met
none of the criteria specified in that report and was therefore not "brain
dead" within its contemplation.
In this respect
it was indicated by Dr. Plum that the brain works in essentially two ways,
the vegetative and the sapient. He testified:
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
Because Karen's neurological condition affects her respiratory ability
(the respiratory system being a brain stem function) she requires a
respirator to assist her breathing. From the time of her admission to
Saint Clare's Hospital Karen has been assisted by an MA-1 respirator, a
sophisticated machine which delivers a given volume of air at a certain
rate and periodically provides a "sigh" volume, a relatively large
measured volume of air designed to purge the lungs of excretions. Attempts
to "wean" her from the respirator were unsuccessful and have been
The experts believe that Karen cannot
now survive without the assistance of the respirator; that exactly how
long she would live without it is unknown; that the strong likelihood is
that death would follow soon after its removal, and that removal would
also risk further brain damage and would curtail the assistance the
respirator presently provides in warding off infection.
It seemed to be the consensus not only of the treating physicians
but also of the several qualified experts who testified in the case, that
removal [***15] from the respirator would not conform to
medical practices, standards and traditions.
further medical consensus was that Karen in addition to being comatose is
in a chronic and persistent "vegetative" state, having no awareness of
anything or anyone around her and existing at a primitive reflex level.
Although she does have some brain stem function (ineffective for
respiration) and has other reactions one normally associates with being
alive, such as moving, reacting to light, sound and noxious stimuli,
blinking her eyes, and the like, the quality of her feeling impulses is
unknown. She grimaces, makes sterotyped cries and sounds and has chewing
motions. Her blood pressure is normal.
remains in the intensive care unit at Saint Clare's Hospital, receiving
24-hour care by a team of four nurses characterized, as was the medical
attention, as "excellent." She is nourished by feeding by way of a
nasal-gastro tube and is routinely examined for infection, which under
these [*26] circumstances is a serious life threat. The result
is that her condition is considered remarkable under the unhappy
Karen is described as
emaciated, having suffered [***16] a weight loss of at least 40
pounds, and undergoing a continuing deteriorative process. Her posture is
described as fetal-like and grotesque; there is extreme flexion-rigidity
of the arms, legs and related muscles and her joints are severely rigid
From all of this evidence, and
including the whole testimonial record, several basic findings in the
physical area are mandated. Severe brain and associated damage, albeit of
uncertain etiology, has left Karen in a chronic and persistent vegetative
state. No form of treatment which can cure or improve that condition is
known or available. As nearly as may be determined, considering the
guarded area of remote uncertainties characteristic of most medical
science predictions, she can never be restored to cognitive or
sapient life. Even with regard to the vegetative level and improvement
therein (if such it may be called) the prognosis is extremely poor and the
extent unknown if it should in fact occur.
debilitated and moribund and although fairly stable at the time of
argument before us (no new information having been filed in the meanwhile
in expansion of the record), no physician risked the opinion that
she [***17] could live more than a year and indeed she may die
much earlier. Excellent medical and nursing care so far has been able to
ward off the constant threat of infection, to which she is peculiarly
susceptible because of the respirator, the tracheal tube and other
incidents of care in her vulnerable condition. Her life
[**656] accordingly is sustained by the respirator and tubal
feeding, and removal from the respirator would cause her death soon,
although the time cannot be stated with more precision.
The determination of the fact and time of death in past years of
medical science was keyed to the action of the heart and blood
circulation, in turn dependent upon pulmonary [*27] activity,
and hence cessation of these functions spelled out the reality of death.
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- - - - - - - - - - -
n5 Death. The
cessation of life; the ceasing to exist; defined by physicians as a total
stoppage of the circulation of the blood, and a cessation of the animal
and vital functions consequent thereon, such as respiration, pulsation,
etc. Black's Law Dictionary 488 (rev. 4th ed. 1968).
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Footnotes- - - - - - - - - - - - - - [***18]
Developments in medical technology have obfuscated the use of the
traditional definition of death. Efforts have been made to define
irreversible coma as a new criterion for death, such as by the 1968 report
of the Ad Hoc Committee of the Harvard Medical School (the Committee
comprising ten physicians, an historian, a lawyer and a theologian), which
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
The Ad Hoc standards, carefully delineated, included
absence of response to pain or other stimuli, pupilary reflexes, corneal,
pharyngeal and other reflexes, blood pressure, spontaneous respiration, as
well as "flat" or isoelectric electro-encephalograms and the like, with
all tests repeated "at least 24 hours later with no change." In such
circumstances, where all of such criteria have been met as showing "brain
death," the Committee recommends with regard to the respirator:
[*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
indicated, it was the consensus of medical [***20] testimony in
the instant case that Karen, for all her disability, met none of these
criteria, nor indeed any comparable criteria extant in the medical world
and representing, as does the Ad Hoc Committee report, according to the
testimony in this case, prevailing and accepted medical standards.
We have adverted to the "brain death" concept and
Karen's disassociation with any of its criteria, to emphasize the basis of
the medical decision made by Dr. Morse. When plaintiff and his family,
finally reconciled to the certainty of Karen's impending death, requested
the withdrawal of life support mechanisms, he demurred.
[**657] His refusal was based upon his conception of medical
standards, practice and ethics described in the medical testimony, such as
in the evidence given by another neurologist, Dr. Sidney Diamond, a
witness for the State. Dr. Diamond asserted that no physician would have
failed to provide respirator support at the outset, and none would
interrupt its life-saving course thereafter, except in the case of
cerebral death. In the latter case, he thought the respirator would in
effect be disconnected from one already dead, entitling the physician
under medical standards [***21] and, he thought, legal
concepts, to terminate the supportive measures. We note Dr. Diamond's
distinction of major surgical or transfusion procedures in a terminal case
not involving cerebral death, such as here:
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
distinction is adverted to also in the testimony of Dr. Julius Korein, a
neurologist called by plaintiff. Dr. Korein described a medical practice
concept of "judicious neglect" under which the physician will say:
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.
Dr. Korein also told of the unwritten and unspoken
standard of medical practice implied in the foreboding initials DNR (do
not resuscitate), as applied to the extraordinary [***22]
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
thread of logic in such distinctions may be elusive to the non-medical lay
mind, in relation to the supposed imperative to sustain life at all costs,
they nevertheless relate to medical decisions, such as the decision of Dr.
Morse in the present case. We agree with the trial court that that
decision was in accord with Dr. Morse's conception of medical standards
We turn to that branch of the
factual case pertaining to the application for guardianship, as
distinguished from the nature of the authorization sought by the
applicant. The character and general suitability of Joseph Quinlan as
guardian for his daughter, in ordinary circumstances,
could [***23] not be doubted. The record bespeaks the high
degree of [*30] familial love which pervaded the home of
Joseph Quinlan and reached out fully to embrace Karen, although she was
living elsewhere at the time of her collapse. The proofs showed him to be
deeply religious, imbued with a morality so sensitive that months of
tortured indecision preceded his belated conclusion (despite earlier moral
judgments reached by the other family members, but unexpressed to him in
order not to influence him) to seek the termination of life-supportive
measures sustaining Karen. A communicant of the Roman Catholic Church, as
were other family members, he first sought solace in private prayer
looking with confidence, as he says, to the Creator, first for the
recovery of Karen and then, if that were not possible, for guidance with
respect to the awesome decision confronting him.
[**658] To confirm the moral rightness of the
decision he was about to make he consulted with his parish priest and
later with the Catholic chaplain of Saint Clare's Hospital. He would not,
he testified, have sought termination if that act were to be morally wrong
or in conflict with the tenets of the religion he so [***24]
profoundly respects. He was disabused of doubt, however, when the position
of the Roman Catholic Church was made known to him as it is reflected in
the record in this case. While it is not usual for matters of religious
dogma or concepts to enter a civil litigation (except as they may bear
upon constitutional right, or sometimes, familial matters; cf. In re Adoption of E, 59 N.J. 36 (1971)), they were
rightly admitted in evidence here. The judge was bound to measure the
character and motivations in all respects of Joseph Quinlan as prospective
guardian; and insofar as these religious matters bore upon them, they were
properly scrutinized and considered by the court.
Thus germane, we note the position of that Church as illuminated
by the record before us. We have no reason to believe that it would be at
all discordant with the whole of Judeo-Christian tradition, considering
its central respect and reverence for the sanctity of human life. It was
in this sense of relevance that we admitted as amicus curiae the
New Jersey [*31] Catholic Conference, essentially the
spokesman for the various Catholic bishops of New Jersey, organized to
give witness to spiritual values [***25] in public affairs in
the statewide community. The position statement of Bishop Lawrence B.
Casey, reproduced in the amicus brief, projects these views:
(a) The verification of the fact of death in a
particular case cannot be deduced from any religious or moral principle
and, under this aspect, does not fall within the competence of the church;
-- that dependence must be had upon traditional and medical standards, and
by these standards Karen Ann Quinlan is assumed to be alive.
(b) The request of plaintiff for authority to
terminate a medical procedure characterized as "an extraordinary means of
treatment" would not involve euthanasia. This upon the reasoning expressed
by Pope Pius XII in his "allocutio" (address) to anesthesiologists on
November 24, 1957, when he dealt with the question:
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
answer made the following points:
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.
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
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.
[*32] [**659] So it was that
the Bishop Casey statement validated the decision of Joseph Quinlan:
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)
And the mind and purpose of the
intending guardian were undoubtedly influenced by factors included in the
following reference to the interrelationship of the three disciplines of
theology, law and medicine as exposed in the Casey statement:
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.
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.
And the gap in the law is aptly
described in the Bishop Casey statement:
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
turning to the legal and constitutional issues involved, we feel it
essential to reiterate that the "Catholic view" of religious neutrality in
the circumstances of this case is considered by the Court only in the
aspect of its impact upon the conscience, motivation and purpose of the
intending guardian, Joseph QUINLAN and not as a precedent in terms of the
If Joseph QUINLAN for instance, were a
follower and strongly influenced by the teachings of Buddha, or if, as an
agnostic or atheist, his moral judgments were formed without reference to
religious feelings, but were nevertheless formed and viable, we would with
equal attention and high respect consider these elements, as bearing upon
his character, [*34] motivations and purposes as relevant to
his [***31] qualification and suitability as guardian.
It is from this factual base that the Court
confronts and responds to three basic issues:
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
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
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
brings us to a consideration of the constitutional and legal issues
underlying the foregoing determinations.
CONSTITUTIONAL AND LEGAL ISSUES
At the outset we note the dual role in which plaintiff comes
before the Court. He not only raises, derivatively, what he perceives to
be the constitutional and legal rights of his daughter Karen, but he also
claims certain rights independently as parent.
Although generally a litigant may assert [***32] only
his own constitutional rights, we have no doubt that plaintiff has
sufficient standing to advance both positions.
While no express constitutional language limits judicial activity
to cases and controversies, New Jersey courts will not render advisory
opinions or entertain proceedings by plaintiffs who do not have sufficient
legal standing to maintain their actions. Walker v. Stanhope, 23
N.J. 657, 660 (1957). However, as in this case, New Jersey courts
commonly grant declaratory relief. Declaratory Judgments Act,
N.J.S.A. 2A:16-50 et seq. And our courts [*35]
hold that where the plaintiff is not simply an interloper and the
proceeding serves the public interest, standing will be found. Walker
v. Stanhope, supra, 23 N.J. at 661-66; Koons v. Atlantic
City Bd. of Comm'rs, 134 N.J.L. 329, 338-39 (Sup. Ct. 1946),
aff'd, 135 N.J.L. 204 (E. & A. 1947). In Crescent
Park Tenants Ass'n v. Realty Equities Corp., 58 N.J. 98 (1971),
Justice Jacobs said:
* * * [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))].
The father of Karen Quinlan is
certainly no stranger to the present controversy. His interests are real
and adverse and he raises questions of surpassing importance. Manifestly,
he has standing to assert his daughter's constitutional rights, she being
incompetent to do so.
I. The Free
Exercise of Religion
We think the contention
as to interference with religious beliefs or rights may be considered and
dealt with without extended discussion, given the acceptance of
distinctions so clear and simple in their precedential definition as to be
dispositive on their face.
Simply stated, the
right to religious beliefs is absolute but conduct in pursuance thereof is
not wholly immune from governmental restraint. John F.
[***34] Kennedy Memorial Hosp. v. Heston, 58
N.J. 576, 580-81 (1971). So it is that, for the sake of life,
courts sometimes (but not always) order blood transfusions for Jehovah's
Witnesses (whose religious beliefs abhor such procedure), Application
of President & Directors of Georgetown College, Inc., 118 U.S.
App. D.C. 80, 331 F. 2d 1000 (D.C. Cir.), cert. den.,
377 U.S. 978, [*36] 84 S. Ct. 1883, 12 L.
Ed. 2d 746 (1964); United States v. George, 239 F. Supp.
752 (D. Conn. 1965); John F. Kennedy Memorial Hosp. v. Heston, supra; Powell v. Columbian Presbyterian Medical Center, 49
Misc. 2d 215, 267 N.Y.S. 2d 450 (Sup. Ct. 1965); but see In re Osborne, 294 A. 2d 372 (D.C. Ct. App. 1972); In
re Estate of Brooks, 32 Ill. 2d 361, 205 N.E. 2d 435
(Sup. Ct. 1965); Erickson v. Dilgard, 44 Misc. 2d 27, 252
N.Y.S. 2d 705 (Sup. Ct. 1962); see generally Annot., "Power
Of Courts Or Other Public Agencies, In The Absence of Statutory Authority,
To Order Compulsory Medical Care for Adult," 9 A.L.R. 3d 1391
(1966); forbid exposure to death from handling virulent snakes or
ingesting poison (interfering with deeply [***35] held
religious sentiments in such regard), e.g., Hill v. State,
38 Ala. App. 404, 88 So. 2d 880 (Ct. App.), cert.
den., 264 Ala. 697, 88 So. 2d 887 (Sup. Ct. 1956); State
v. Massey, 229 N.C. 734, 51 S.E. 2d 179 (Sup. Ct.),
appeal dismissed sub nom., Bunn v. North Carolina, 336
U.S. 942, 69 S. Ct. 813, 93 L. Ed. 1099 (1949);
State ex rel. Swann v. Pack,
Tenn. , 527 S.W. 2d 99
(Sup. Ct. 1975), cert. den., U.S.
, 96 S. Ct. 1429, 47 L. Ed. 2d 360 (1976);
and protect the public health as in the case of compulsory vaccination
(over the strongest of religious objections), e.g., Wright v.
DeWitt School Dist. 1, 238 Ark. 906, 385 S.W. 2d 644
(Sup. Ct. 1965); Mountain Lakes Bd. of Educ. v. Maas, 56 N.J.
Super. 245 (App. Div. 1959), aff'd o.b., 31 N.J. 537
(1960), cert. den., 363 U.S. 843, 80 S. Ct. 1613, 4
L. Ed. 2d 1727 (1960); McCartney v. Austin, 57 Misc.
2d 525, 293 N.Y.S. 2d 188 (Sup. Ct. 1968). The public interest is
thus considered paramount, without essential dissolution of respect for
We think, without
further [***36] examples, that, ranged against the State's
interest in the preservation of life, the impingement of religious belief,
much less religious "neutrality" as here, does not reflect a
constitutional question, in the circumstances at least of the case
presently before the Court. [*37] Moreover, like the trial
court, we do not recognize an independent parental right of religious
freedom to support [**662] the relief requested. 137 N.J.
Super. at 267-68.
II. Cruel and
Similarly inapplicable to
the case before us is the Constitution's Eighth Amendment protection
against cruel and unusual punishment which, as held by the trial court, is
not relevant to situations other than the imposition of penal sanctions.
Historic in nature, it stemmed from punitive excesses in the infliction of
criminal penalties. n6 We [*38] find no precedent in law which
would justify its extension to the correction of social injustice or
hardship, such as, for instance, in the case of poverty. The latter often
condemns the poor and deprived to horrendous living conditions which could
certainly be described in the abstract as "cruel and unusual punishment."
Yet the constitutional [***37] base of protection from "cruel
and unusual punishment" is plainly irrelevant to such societal ills which
must be remedied, if at all, under other concepts of constitutional and
- - - - - - - - - - - - - -
Footnotes - - - - - - - - - - - - - - -
n6 It is generally agreed that the Eighth Amendment's provision
of "[n]or cruel and unusual punishments inflicted" is drawn verbatim from
the English Declaration of Rights. See 1 Wm. & M., sess. 2, c.
2 (1689). The prohibition arose in the context of excessive punishments
for crimes, punishments that were barbarous and savage as well as
disproportionate to the offense committed. See generally Granucci,
"'Nor Cruel and Unusual Punishments Inflicted:' The Original Meaning," 57
Calif. L. Rev. 839, 844-60 (1969); Note, "The Cruel and Unusual
Punishment Clause and the Substantive Criminal Law," 79 Harv. L.
Rev. 635, 636-39 (1966). The principle against excessiveness in
criminal punishments can be traced back to Chapters 20-22 of the Magna
Carta (1215). The historical background of the Eighth Amendment was
examined at some length in various opinions in Furman v. Georgia,
408 U.S. 238, 92 S. Ct. 2726, 33 L. Ed. 2d 346
The Constitution itself is silent as to
the meaning of the word "punishment." Whether it refers to the variety of
legal and nonlegal penalties that human beings endure or whether it must
be in connection with a criminal rather than a civil proceeding is not
stated in the document. But the origins of the clause are clear. And the
cases construing it have consistently held that the "punishment"
contemplated by the Eighth Amendment is the penalty inflicted by a court
for the commission of a crime or in the enforcement of what is a criminal
law. See, e.g., Trop v. Dulles, 356 U.S. 86, 94-99,
78 S. Ct. 590, 594-97, 2 L. Ed. 2d 630, 638-41 (1957).
See generally Note, "The Effectiveness of the Eighth Amendment: An
Appraisal of Cruel and Unusual Punishment," 36 N.Y.U.L. Rev. 846,
854-57 (1961). A deprivation, forfeiture or penalty arising out of a civil
proceeding or otherwise cannot be "cruel and unusual punishment" within
the meaning of the constitutional clause.
- - - - - - - - - - - - End Footnotes- - - - - - - -
- - - - - - [***38]
So it is in the
case of the unfortunate Karen Quinlan. Neither the State, nor the law, but
the accident of fate and nature, has inflicted upon her conditions which
though in essence cruel and most unusual, yet do not amount to
"punishment" in any constitutional sense.
the judgment of the court below, nor the medical decision which confronted
it, nor the law and equity perceptions which impelled its action, nor the
whole factual base upon which it was predicated, inflicted "cruel and
unusual punishment" in the constitutional sense.
III. The Right of Privacy n7
- - - - - - - - - - - - Footnotes - - - - - - - - - - - - - - -
n7 The right we here discuss is
included within the class of what have been called rights of
"personality." See Pound, "Equitable Relief against Defamation and
Injuries to Personality," 29 Harv. L. Rev. 640, 668-76 (1916).
Equitable jurisdiction with respect to the recognition and enforcement of
such rights has long been recognized in New Jersey. See, e.g., Vanderbilt v. Mitchell, 72 N.J. Eq. 910, 919-20 (E.
& A. 1907).
- - - - - - -
- - - - - End Footnotes- - - - - - - - - - - - - - [***39]
It is the issue of the constitutional right of
privacy that has given us most concern, in the exceptional circumstances
of this case. Here a loving parent, qua parent and raising the
rights of his incompetent and profoundly damaged daughter, probably
irreversibly doomed to no more than a biologically vegetative remnant of
life, is before the court. He seeks authorization [**663] to
abandon specialized technological procedures which can only maintain for a
time a body having [*39] no potential for resumption or
continuance of other than a "vegetative" existence.
We have no doubt, in these unhappy circumstances, that if Karen
were herself miraculously lucid for an interval (not altering the existing
prognosis of the condition to which she would soon return) and perceptive
of her irreversible condition, she could effectively decide upon
discontinuance of the life-support apparatus, even if it meant the
prospect of natural death. To this extent we may distinguish Heston,
supra, which concerned a severely injured young woman (Delores Heston), whose life depended on surgery and blood transfusion; and who was
in such extreme shock that she was unable to express an
informed [***40] choice (although the Court apparently
considered the case as if the patient's own religious decision to resist
transfusion were at stake), but most importantly a patient apparently
salvable to long life and vibrant health; -- a situation not at all like
the present case.
We have no hesitancy in
deciding, in the instant diametrically opposite case, that no external
compelling interest of the State could compel Karen to endure the
unendurable, only to vegetate a few measurable months with no realistic
possibility of returning to any semblance of cognitive or sapient life. We
perceive no thread of logic distinguishing between such a choice on
Karen's part and a similar choice which, under the evidence in this case,
could be made by a competent patient terminally ill, riddled by cancer and
suffering great pain; such a patient would not be resuscitated or put on a
respirator in the example described by Dr. Korein, and a fortiori
would not be kept against his will on a respirator.
Although the Constitution does not explicitly mention a right of
privacy, Supreme Court decisions have recognized that a right of personal
privacy exists and that certain areas of privacy are
guaranteed [***41] under the Constitution. Eisenstadt v.
Baird, 405 U.S. 438, 92 S. Ct. 1029, 31 L. Ed. 2d
349 (1972); Stanley v. Georgia, 394 U.S. 557, 89 S.
Ct. 1243, [*40] 22 L. Ed. 2d 542 (1969). The Court
has interdicted judicial intrusion into many aspects of personal decision,
sometimes basing this restraint upon the conception of a limitation of
judicial interest and responsibility, such as with regard to contraception
and its relationship to family life and decision. Griswold v.
Connecticut, 381 U.S. 479, 85 S. Ct. 1678, 14 L.
Ed. 2d 510 (1965).
The Court in
Griswold found the unwritten constitutional right of privacy to
exist in the penumbra of specific guarantees of the Bill of Rights "formed
by emanations from those guarantees that help give them life and
substance." 381 U.S. at 484, 85 S. Ct. at 1681, 14 L.
Ed. 2d at 514. Presumably this right is broad enough to encompass a
patient's decision to decline medical treatment under certain
circumstances, in much the same way as it is broad enough to encompass a
woman's decision to terminate pregnancy under certain conditions. Roe
v. Wade, 410 U.S. 113, 153, 93 [***42] S.
Ct. 705, 727, 35 L. Ed. 2d 147, 177 (1973).
Nor is such right of privacy forgotten in the New Jersey
Constitution. N.J. Const. (1947), Art. I, par. 1.
The claimed interests of the State in this case are essentially
the preservation and sanctity of human life and defense of the right of
the physician to administer medical treatment according to his best
judgment. In this case the doctors say that removing Karen from the
respirator will conflict with their professional judgment. The plaintiff
answers that Karen's present treatment serves only a maintenance function;
that the respirator cannot cure or improve her condition but at best can
only prolong her inevitable slow deterioration and death; and that the
interests of the patient, as seen by her surrogate, the guardian, must be
evaluated by the [**664] court as predominant, even in the
face of an opinion contra by the present attending physicians.
Plaintiff's distinction is significant. The nature of Karen's care and the
realistic chances of her recovery are quite unlike [*41] those
of the patients discussed in many of the cases where treatments were
ordered. In many of those cases the medical procedure [***43]
required (usually a transfusion) constituted a minimal bodily invasion and
the chances of recovery and return to functioning life were very good. We
think that the State's interest contra weakens and the individual's
right to privacy grows as the degree of bodily invasion increases and the
prognosis dims. Ultimately there comes a point at which the individual's
rights overcome the State interest. It is for that reason that we believe
Karen's choice, if she were competent to make it, would be vindicated by
the law. Her prognosis is extremely poor, -- she will never resume
cognitive life. And the bodily invasion is very great, -- she requires 24
hour intensive nursing care, antibiotics, the assistance of a respirator,
a catheter and feeding tube.
Our affirmation of
Karen's independent right of choice, however, would ordinarily be based
upon her competency to assert it. The sad truth, however, is that she is
grossly incompetent and we cannot discern her supposed choice based on the
testimony of her previous conversations with friends, where such testimony
is without sufficient probative weight. 137 N.J. Super. at 260.
Nevertheless we have concluded that Karen's right [***44] of
privacy may be asserted on her behalf by her guardian under the peculiar
circumstances here present.
If a putative
decision by Karen to permit this non-cognitive, vegetative existence to
terminate by natural forces is regarded as a valuable incident of her
right of privacy, as we believe it to be, then it should not be discarded
solely on the basis that her condition prevents her conscious exercise of
the choice. The only practical way to prevent destruction of the right is
to permit the guardian and family of Karen to render their best judgment,
subject to the qualifications hereinafter stated, as to whether she would
exercise it in these circumstances. If their conclusion is in the
affirmative this decision should be accepted by a society the overwhelming
[*42] majority of whose members would, we think, in similar
circumstances, exercise such a choice in the same way for themselves or
for those closest to them. It is for this reason that we determine that
Karen's right of privacy may be asserted in her behalf, in this respect,
by her guardian and family under the particular circumstances presented by
Regarding Mr. Quinlan's right of
privacy, we agree with [***45] Judge Muir's conclusion that
there is no parental constitutional right that would entitle him to a
grant of relief in propria persona. Id. at 266. Insofar as a
parental right of privacy has been recognized, it has been in the context
of determining the rearing of infants and, as Judge Muir put it, involved
"continuing life styles." See Wisconsin v. Yoder, 406
U.S. 205, 92 S. Ct. 1526, 32 L. Ed. 2d 15 (1972);
Pierce v. Society of Sisters, 268 U.S. 510, 45 S. Ct.
571, 69 L. Ed. 1070 (1925); Meyer v. Nebraska, 262
U.S. 390, 43 S. Ct. 625, 67 L. Ed. 1042 (1923). Karen
Quinlan is a 22 year old adult. Her right of privacy in respect of the
matter before the Court is to be vindicated by Mr. Quinlan as guardian, as
IV. The Medical
Having declared the substantive legal
basis upon which plaintiff's rights as representative of Karen must be
deemed predicated, we face and respond to the assertion on behalf of
defendants that our premise unwarrantably offends prevailing medical
standards. We thus turn to consideration of the medical decision
supporting the determination made below, conscious of
the [***46] paucity of pre-existing legislative
[**665] and judicial guidance as to the rights and liabilities
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)].
Perhaps the confusion there adverted to stems from mention by
some courts of statutory or common law condemnation [***47] of
suicide as demonstrating the state's interest in the preservation of life.
We would see, however, a real distinction between the self-infliction of
deadly harm and a self-determination against artificial life support or
radical surgery, for instance, in the face of irreversible, painful and
certain imminent death. The contrasting situations mentioned are analogous
to those continually faced by the medical profession. When does the
institution of life-sustaining procedures, ordinarily mandatory, become
the subject of medical discretion in the context of administration to
persons in extremis? And when does the withdrawal of such
procedures, from such persons already supported by them, come within the
orbit of medical discretion? When does a determination as to either of the
foregoing contingencies court the hazard of civil or criminal liability on
the part of the physician or institution involved?
The existence and nature of the medical dilemma need hardly be
discussed at length, portrayed as it is in the present case and
complicated as it has recently come to be in view of the dramatic advance
of medical technology. The dilemma is there, it is real, it is constantly
resolved [***48] in accepted medical practice without attention
in the courts, it pervades the issues in the very case we here examine.
The branch of the dilemma involving the doctor's responsibility and the
relationship of the court's duty was thus conceived by Judge Muir:
[*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].
Such notions as to the distribution of responsibility, heretofore
generally entertained, should however neither impede this Court in
deciding matters clearly justiciable nor preclude a re-examination by the
Court as to underlying human values and rights.
Determinations [***49] as to these must, in the ultimate, be
responsive not only to the concepts of medicine but also to the common
moral judgment of the community at large. In the latter respect the Court
has a non-delegable judicial responsibility.
in another way, the law, equity and justice must not themselves quail and
be helpless in the face of modern technological marvels presenting
questions hitherto unthought of. Where a Karen QUINLAN or a parent, or a
doctor, or a hospital, or a [**666] State seeks the process
and response of a court, it must answer with its most informed conception
of justice in the previously unexplored circumstances presented to it.
That is its obligation and we are here fulfilling it, for the actors and
those having an interest in the matter should not go without remedy.
Courts in the exercise of their parens
patriae responsibility to protect those under disability have
sometimes implemented medical decisions and authorized their carrying out
under the doctrine of "substituted judgment." Hart v. Brown, 29
Conn. Sup. 368, 289 A. 2d 386, 387-88 (Super. Ct. 1972);
Strunk v. Strunk, 445 S.W. 2d 145, 147-48 (Ky. Ct. App.
1969). For as Judge [***50] Muir pointed out:
"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
as a court, having no inherent medical expertise, is called upon to
overrule a professional decision made according to prevailing medical
practice and standards, a different question is presented. As mentioned
below, a doctor is required
"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
obligation is related to standards and practice prevailing in the
profession. The physicians in charge of the case, as noted above, declined
to withdraw the respirator. That decision was consistent with the proofs
below as to the then existing medical standards and practices.
Under the law as it then stood, Judge Muir was
correct in declining to authorize withdrawal of the respirator.
However, in relation to the matter of the
declaratory relief sought by plaintiff as representative of Karen's
interests, we are required to reevaluate the applicability of the medical
standards projected in the court below. The question is whether there is
such internal consistency and rationality in the application of such
standards as [***52] should warrant their constituting an
ineluctable bar to the effectuation [*46] of substantive
relief for plaintiff at the hands of the court. We have concluded not.
In regard to the foregoing it is pertinent that we
consider the impact on the standards both of the civil and criminal law as
to medical liability and the new technological means of sustaining life
The modern proliferation of
substantial malpractice litigation and the less frequent but even more
unnerving possibility of criminal sanctions would seem, for it is beyond
human nature to suppose otherwise, to have bearing on the practice and
standards as they exist. The brooding presence of such possible liability,
it was testified here, had no part in the decision of [**667]
the treating physicians. As did Judge Muir, we afford this testimony full
credence. But we cannot believe that the stated factor has not had a
strong influence on the standards, as the literature on the subject
plainly reveals. (See footnote 8, infra). Moreover our attention is
drawn not so much to the recognition by Drs. Morse and Javed of the extant
practice and standards but to the widening ambiguity of
those [***53] standards themselves in their application to the
medical problems we are discussing.
of the medical community in the face of modern life prolongation
technology and its search for definitive policy are demonstrated in the
large volume of relevant professional commentary. n8
- - - - - - - - - - - - - - Footnotes - - - - - - - - - - - - - -
n8 See, e.g., Downing,
Euthanasia and the Right to Death (1969); St. John-Stevas, Life,
Death and the Law (1961); Williams, The Sanctity of Human Life and
the Criminal Law (1957); Appel, "Ethical and Legal Questions Posed by
Recent Advances in Medicine," 205 J.A.M.A. 513 (1968); Cantor, "A
Patient's Decision To Decline Life-Saving Medical Treatment: Bodily
Integrity Versus The Preservation of Life," 26 Rutgers L. Rev. 228
(1973); Claypool, "The Family Deals with Death," 27 Baylor L. Rev.
34 (1975); Elkington, "The Dying Patient, The Doctor and The Law," 13
Vill. L. Rev. 740 (1968); Fletcher, "Legal Aspects of the Decision
Not to Prolong Life," 203 J.A.M.A. 65 (1968); Foreman, "The
Physician's Criminal Liability for the Practice of Euthanasia," 27
Baylor L. Rev. 54 (1975); Gurney, "Is There A Right To Die? -- A
Study of the Law of Euthanasia," 3 Cumb.-Sam. L. Rev. 235 (1972);
Mannes, "Euthanasia vs. The Right To Life," 27 Baylor L. Rev. 68
(1975); Sharp & Crofts, "Death with Dignity and The Physician's Civil
Liability," 27 Baylor L. Rev. 86 (1975); Sharpe & Hargest,
"Lifesaving Treatment for Unwilling Patients," 36 Fordham L. Rev.
695 (1968); Skegg, "Irreversibly Comatose Individuals: 'Alive' or
'Dead'?," 33 Camb. L.J. 130 (1974); Comment, "The Right to Die," 7
Houston L. Rev. 654 (1970); Note, "The Time of Death -- A Legal,
Ethical and Medical Dilemma," 18 Catholic Law. 243 (1972); Note,
"Compulsory Medical Treatment: The State's Interest Re-evaluated," 51
Minn. L. Rev. 293 (1966).
- - - - - - - - - - - - End Footnotes- - - - - - - - - - - - -
[*47] The wide
debate thus reflected contrasts with the relative paucity of legislative
and judicial guides and standards in the same field. The medical
profession has sought to devise guidelines such as the "brain death"
concept of the Harvard Ad Hoc Committee mentioned above. But it is
perfectly apparent from the testimony we have quoted of Dr. Korein, and
indeed so clear as almost to be judicially noticeable, that humane
decisions against resuscitative or maintenance therapy are frequently a
recognized de facto response in the medical world to the
irreversible, terminal, pain-ridden patient, especially with familial
consent. And these cases, of course, are far short of "brain death."
We glean from the record here that physicians
distinguish between curing the ill and comforting and easing the dying;
that they refuse to treat the curable as if they were dying or ought to
die, and that they have sometimes refused to treat the hopeless and dying
as if they were curable. In this sense, as we were reminded by the
testimony of Drs. Korein and Diamond, many of them have refused to inflict
an undesired prolongation of the process of dying on a patient in
irreversible condition [***55] when it is clear that such
"therapy" offers neither human nor humane benefit. We think these
attitudes represent a balanced implementation of a profoundly realistic
perspective on the meaning of life and death and that they respect the
whole Judeo-Christian tradition of regard for human life. No less would
they seem consistent with the moral matrix of medicine, "to heal,"
[*48] very much in the sense of the endless mission of the
law, "to do justice."
Yet this balance, we feel,
is particularly difficult to perceive and apply in the context of the
development by advanced technology of sophisticated and artificial
life-sustaining devices. For those possibly curable, such devices are of
great value, and, as ordinary medical procedures, are essential.
Consequently, as pointed out by Dr. Diamond, they are necessary because of
the ethic of medical practice. But in light of the situation in the
present case (while the record here is somewhat hazy in distinguishing
[**668] between "ordinary" and "extraordinary" measures), one
would have to think that the use of the same respirator or like support
could be considered "ordinary" in the context of the possibly curable
patient [***56] but "extraordinary" in the context of the
forced sustaining by cardio-respiratory processes of an irreversibly
doomed patient. And this dilemma is sharpened in the face of the
malpractice and criminal action threat which we have mentioned.
We would hesitate, in this imperfect world, to
propose as to physicians that type of immunity which from the early common
law has surrounded judges and grand jurors, see, e.g., Grove v.
Van Duyn, 44 N.J.L. 654, 656-57 (E. & A. 1882); O'Regan
v. Schermerhorn, 25 N.J. Misc. 1, 19-20 (Sup. Ct. 1940), so
that they might without fear of personal retaliation perform their
judicial duties with independent objectivity. In Bradley v. Fisher,
80 U.S. (13 Wall.) 335, 347, 20 L. Ed. 646, 649
(1872), the Supreme Court held:
[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.
Lord Coke said of judges that "they are only to make an account
to God and the King [the State]." 12 Coke Rep. 23, 25,
77 [***57] Eng. Rep. 1305, 1307 (S.C. 1608).
[*49] Nevertheless, there must be a way
to free physicians, in the pursuit of their healing vocation, from
possible contamination by self-interest or self-protection concerns which
would inhibit their independent medical judgments for the well-being of
their dying patients. We would hope that this opinion might be serviceable
to some degree in ameliorating the professional problems under
A technique aimed at the underlying
difficulty (though in a somewhat broader context) is described by Dr.
Karen Teel, a pediatrician and a director of Pediatric Education, who
writes in the Baylor Law Review under the title "The Physician's
Dilemma: A Doctor's View: What The Law Should Be." Dr. Teel recalls:
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
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
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)].
The most appealing factor in the technique suggested by Dr. Teel
seems to us to be the diffusion of professional responsibility for
decision, comparable in a way to the value of multi-judge courts in
finally resolving on appeal difficult questions of law. Moreover, such a
system would be protective to the hospital as well as the doctor in
screening out, so to speak, a case which might be contaminated by less
than worthy motivations of family or physician. In the real world and in
relationship to the momentous decision contemplated, the value of
additional views and diverse knowledge is apparent.
We consider that a practice of applying to a court to confirm
such decisions would generally [***60] be inappropriate, not
only because that would be a gratuitous encroachment upon the medical
profession's field of competence, but because it would be impossibly
cumbersome. Such a requirement is distinguishable from the judicial
overview traditionally required in other matters such as the adjudication
and commitment of mental incompetents. This is not to say that in the case
of an otherwise justiciable controversy access to the courts would be
foreclosed; we speak rather of a general practice and procedure.
And although the deliberations and decisions which
we describe would be professional in nature they should obviously include
at some stage the feelings of the family of an incompetent relative.
Decision-making within health care if it is considered as an expression of
a primary obligation of the physician, primum non nocere, should be
controlled primarily within the patient-doctor-family relationship, as
indeed was recognized by Judge Muir in his supplemental opinion of
November 12, 1975.
If there could be created not
necessarily this particular system but some reasonable counterpart, we
would have no [*51] doubt that such decisions, thus determined
to be in accordance [***61] with medical practice and
prevailing standards, would be accepted by society and by the courts, at
least in cases comparable to that of Karen Quinlan.
The evidence in this case convinces us that the focal point of
decision should be the prognosis as to the reasonable possibility of
return to cognitive and sapient life, as distinguished from the forced
continuance of that biological vegetative existence to which Karen seems
to be doomed.
In summary of the present Point of
this opinion, we conclude that the state of the pertinent medical
standards and practices which guided the attending physicians in this
matter is not such as would justify this Court in deeming itself bound or
controlled thereby in responding to the case for declaratory relief
established by the parties on the record before us.
V. Alleged Criminal Liability
Having concluded that there is a right of privacy that might
permit termination of treatment in the circumstances of this case, we turn
to consider the relationship of the exercise of that right to the criminal
law. We are aware that such termination of treatment would accelerate
Karen's death. The County Prosecutor and the Attorney General
maintain [***62] that there would be criminal liability for
such acceleration. Under the statutes of this State, the unlawful killing
of another human being is criminal homicide. N.J.S.A. 2A:113-1, 2,
5. We conclude that there would be no criminal homicide in the
circumstances of this case. We believe, first, [**670] that
the ensuing death would not be homicide but rather expiration from
existing natural causes. Secondly, even if it were to be regarded as
homicide, it would not be unlawful.
conclusions rest upon definitional and constitutional bases. The
termination of treatment pursuant to the right of privacy is, within the
limitations of this case, ipso facto [*52] lawful.
Thus, a death resulting from such an act would not come within the scope
of the homicide statutes proscribing only the unlawful killing of another.
There is a real and in this case determinative distinction between the
unlawful taking of the life of another and the ending of artificial
life-support systems as a matter of self-determination.
Furthermore, the exercise of a constitutional right such as we
have here found is protected from criminal prosecution. See Stanley v. Georgia, supra [***63] , 394 U.S.
at 559, 89 S. Ct. at 1245, 22 L. Ed. 2d at 546. We do not
question the State's undoubted power to punish the taking of human life,
but that power does not encompass individuals terminating medical
treatment pursuant to their right of privacy. See id. at
568, 89 S. Ct. at 1250, 22 L. Ed. 2d at 551. The
constitutional protection extends to third parties whose action is
necessary to effectuate the exercise of that right where the individuals
themselves would not be subject to prosecution or the third parties are
charged as accessories to an act which could not be a crime. Eisenstadt
v. Baird, supra, 405 U.S. at 445-46, 92 S. Ct. at
1034-35, 31 L. Ed. 2d at 357-58; Griswold v. Connecticut,
supra, 381 U.S. at 481, 85 S. Ct. at 1679-80, 14 L.
Ed. 2d at 512-13. And, under the circumstances of this case, these
same principles would apply to and negate a valid prosecution for
attempted suicide were there still such a crime in this State. n9
- - - - - - - - - - - - - - Footnotes - - - - - - -
- - - - - - - -
n9 An attempt to
commit suicide was an indictable offense at common law and as such was
indictable in this State as a common law misdemeanor. 1 Schlosser,
Criminal Laws of New Jersey ? 12.5 (3d ed. 1970); see N.J.S.A.
2A:85-1. The legislature downgraded the offense in 1957 to the status of a
disorderly persons offense, which is not a "crime" under our law.
N.J.S.A. 2A:170-25.6. And in 1971, the legislature repealed all
criminal sanctions for attempted suicide. N.J.S.A. 2A:85-5.1.
Provision is now made for temporary hospitalization of persons making such
an attempt. N.J.S.A. 30:4-26.3a. We note that under the proposed
New Jersey Penal Code (Oct. 1971) there is no provision for criminal
punishment of attempted suicide. See Commentary, ? 2C:11-6. There
is, however, an independent offense of "aiding suicide." ? 2C:11-6b. This
provision, if enacted, would not be incriminatory in circumstances similar
to those presented in this case.
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The Guardianship of the Person
judge bifurcated the guardianship, as we have noted, refusing to appoint
Joseph Quinlan to be guardian of the person and limiting his guardianship
to that of the property of his daughter. Such occasional division of
guardianship, as between responsibility for the person and the property of
an incompetent person, has roots deep in the common law and was well
within the jurisdictional capacity of the trial judge. In re
Rollins, 65 A. 2d 667, 679-82 (N.J. Cty. Ct. 1949).
The statute creates an initial presumption of
entitlement to guardianship in the next of kin, for it provides:
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)].
The trial court was apparently convinced of the high
character of Joseph Quinlan and his general suitability as
[**671] [***65] guardian under other
circumstances, describing him as "very sincere, moral, ethical and
religious." The court felt, however, that the obligation to concur in the
medical care and treatment of his daughter would be a source of anguish to
him and would distort his "decision-making processes." We disagree, for we
sense from the whole record before us that while Mr. Quinlan feels a
natural grief, and understandably sorrows because of the tragedy which has
befallen his daughter, his strength of purpose and character far outweighs
these sentiments and qualifies him eminently for guardianship of the
person as well as the property of his daughter. Hence we discern no valid
reason to overrule the statutory intendment of preference to the next of
We thus arrive at the formulation of
the declaratory relief which we have concluded is appropriate to this
case. Some time has passed since Karen's physical and mental condition was
described to the Court. At that time her continuing deterioration was
plainly projected. Since the record has not been expanded we assume that
she is now even more fragile and nearer to death than she was then. Since
her present [***66] treating physicians may give
reconsideration to her present posture in the light of this opinion, and
since we are transferring to the plaintiff as guardian the choice of the
attending physician and therefore other physicians may be in charge of the
case who may take a different view from that of the present attending
physicians, we herewith declare the following affirmative relief on behalf
of the plaintiff. Upon the concurrence of the guardian and family of
Karen, should the responsible attending physicians conclude that there is
no reasonable possibility of Karen's ever emerging from her present
comatose condition to a cognitive, sapient state and that the life-support
apparatus now being administered to Karen should be discontinued, they
shall consult with the hospital "Ethics Committee" or like body of the
institution in which Karen is then hospitalized. If that consultative body
agrees that there is no reasonable possibility of Karen's ever emerging
from her present comatose condition to a cognitive, sapient state, the
present life-support system may be withdrawn and said action shall be
without any civil or criminal liability therefor on the part of any
participant, whether [***67] guardian, physician, hospital or
others. n10 We herewith specifically so hold.
- - - - - - - - - - - - - Footnotes - - - - - - - - - - - - - - -
n10 The declaratory relief we here
award is not intended to imply that the principles enunciated in this case
might not be applicable in divers other types of terminal medical
situations such as those described by Drs. Korein and Diamond,
supra, not necessarily involving the hopeless loss of cognitive or
- - - - - - - -
- - - - End Footnotes- - - - - - - - - - - - - -
therefore remand this record to the trial court to implement (without
further testimonial hearing) the following decisions:
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
for the sake of emphasis and clarity that upon the concurrence of the
guardian and family [***68] of Karen, should the responsible
attending physicians conclude that there is no reasonable possibility of
Karen's ever emerging from her present comatose condition to a cognitive,
sapient state and that the life-support apparatus [**672] now
being administered to Karen should be discontinued, they shall consult
with the hospital "Ethics Committee" or like body of the institution in
which Karen is then hospitalized. If that consultative body agrees that
there is no reasonable possibility of Karen's ever emerging from her
present comatose condition to a cognitive, sapient state, the present
life-support system may be withdrawn and said action shall be without any
civil or criminal liability therefor, on the part of any participant,
whether guardian, physician, hospital or others.
By the above ruling we do not intend to be understood as implying
that a proceeding for judicial declaratory relief is necessarily required
for the implementation of comparable decisions in the field of medical
Modified and remanded.