If you are headed for Missouri -- a layover in St. Louis, a weekend in Kansas City -- let me suggest that you pack a little something extra in your baggage. A living will for example.
Better yet, a signed and notarized durable power of attorney. Or perhaps a checklist of 30 life-sustaining treatments and your personal attitudes toward them.
You might be wise to send copies of these to a lawyer and to a member of your family. And be sure to tell them that if you get sick or have an accident in Missouri, they'd better get your body out of the state as quickly as possible.
This traveler's advisory comes to you courtesy of the Supreme Court. Last Monday, the court ruled that people do have the right to stop medical treatment, but only if they are conscious and competent or have left "clear and convincing evidence" of what they want. Otherwise, you may have no more rights than a museum exhibit, a comatose testimony to some state's definition of "life."
If you are like Nancy Cruzan, for example, 25 years old at the time of a car crash, you could end up in a permanent vegetative state for 10, 20, 30 years with no way out. If you are struck down without leaving behind a full record of your attitudes about the major bioethics questions of the day, you could become, as Justice Brennan put it in his eloquent dissent, "a passive prisoner of medical technology."
This is the bottom line in the case of Joe and Joyce Cruzan's daughter. She has spent the seven unconscious years in a Missouri hospital being fed what the nurses call "supper," through a feeding tube. It's the case as well for Christine Busalacchi, a 20-year-old patient in the same hospital, who is wheeled in the same unconscious state to "music therapy" where they play gospel to the former fan of heavy metal.
The court ruled that Nancy had not made her wishes known clearly enough. She had only talked about life and death the way most of us do, conversationally, casually. She "wouldn't want to live that way." She "didn't want to live as a vegetable."
Without more certainty, the majority ruled that Missouri's right to protect "life" was greater than the family's right to defend her "liberty" from medical treatment. In a striking passage, Justice Rehnquist said that there is "no automatic assurance that the view of close family members will necessarily be the same as the patient's."
In short, the state was more trustworthy than the family. Especially the state of Missouri, which has set itself on the extreme end of the pro-life spectrum.
"Once you become incompetent, you're out of it, and your family's out of it" says Boston University's bioethicist George Annas. "The view of the court is that Nancy Cruzan should exist to protect the state's unqualified interest in life. That it's always better to be alive than dead. You can treat someone without her consent, but you can't STOP treating her without consent."
Missouri is so far the most intrusive state, but the court gives the green light to others. In the meantime, the Cruzans' only hope for an end to the intrusive treatment is to move their daughter, perhaps down the road to Arkansas.
Once, in the '70s, there were families that took a brain-dead child from one state to another that recognized this death. In the 1990s, we may have to shop again for a state that will allow patients and families to end treatment without a suitcase full of documents.
For now, however, a recommendation. The living will. Don't leave home without it.