This paper examines the ethical and legal dimensions of end-of-life decision-making through the fictional case of Mildred D., a patient who expressed wishes against heroic life-sustaining measures but left no written living will. Drawing on the U.S. Supreme Court's landmark ruling in Cruzan v. Director, Missouri Department of Health, the paper analyzes whether artificial nutrition constitutes medical treatment subject to patient refusal, the legal standards required for withdrawing life support, and the moral standing of family members to act on a patient's behalf. The paper concludes that, absent a state requirement for written evidence, deferring to the unanimous wishes of Mildred's family represents the most compassionate and morally defensible course of action.
The central dilemma in the case of Mildred D. revolves around her alleged statement to her children that she wanted no heroic means used to continue her life. A related question is whether intravenous feeding constitutes "heroic" means, since removing the nasogastric (NG) tube would effectively cause her to starve — ending her life before it would naturally terminate if the tube remained in place. Food is not usually considered an additional form of life support, although it is debatable whether nutrition not administered orally constitutes heroic intervention. Compounding matters, Mildred had no living will clarifying her wishes and is no longer competent to make the decision herself.
In the landmark U.S. Supreme Court case of Cruzan v. Director, Missouri Department of Health, the Court considered whether Missouri could insist on proof by "clear and convincing evidence" of a comatose patient's desire to terminate her life before allowing her family's wish to disconnect her feeding tube to be carried out (The right to die, 2012, Exploring Constitutional Conflicts). In an 8–9 majority decision, the Court concluded that although "the right to die was a liberty protected by the Due Process Clause," a bare majority upheld the state's insistence upon clear and specific evidence that the patient would wish to have intravenous feeding discontinued (The right to die, 2012, Exploring Constitutional Conflicts).
In the Cruzan case, the Court's findings provide both ethical and legal guidance about how to view the administration of artificial nutrition, treating it as medical treatment in the same way as artificial respiration. Justice O'Connor wrote: "Whether or not the techniques used to pass food and water into the patient's alimentary tract are termed 'medical treatment,' it is clear they all involve some degree of intrusion and restraint… Requiring a competent adult to endure such procedures against her will burdens the patient's liberty, dignity, and freedom to determine the course of her own treatment. Accordingly, the liberty guaranteed by the Due Process Clause must protect, if it protects anything, an individual's deeply personal decision to reject medical treatment, including the artificial delivery of food and water" (O'Connor, paragraph 59 in Cruzan v. Director, Missouri Department of Health). The refusal of resuscitation can therefore legitimately be considered an indicator that a patient would also refuse artificial nutrition, even though the Court upheld Missouri's specific requirement for written evidence.
"Applying Cruzan's principles to Mildred's situation"
"Why Mildred's lack of written directive matters"
However, given the available evidence and the medical prognosis, deferring to the patient's family in this instance remains the best alternative. The unanimous position of Mildred's children, combined with the ethical principles articulated in Cruzan regarding patient liberty and the nature of artificial nutrition as medical treatment, supports the conclusion that withholding continued artificial feeding is the most morally defensible course of action in the absence of a contrary state-law requirement.
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