Eight years after the auto crash that left her in a vegetative state, six months after the U.S. Supreme Court's ruling on her right to die and 12 days after her parents won their fight to remove the feeding tube that was keeping her alive, Nancy Beth **TC Cruzan died early yesterday at the age of 33 in Mount Vernon, Mo., with her family at her bedside.
Miss Cruzan's case became the centerpiece of a bitter debate about how and when families can decide to withdraw nourishment or medical treatment to bring about the death of an incapacitated loved one.
That debate continued yesterday, even as the final chapter of the Cruzan case had been written.
"The Cruzan case has focused national attention on this issue in an unprecedented way," said Doron Weber, a spokesman for the Society for the Right to Die.
"While it's been a horrible agony for the Cruzans, having intimate private details on the public stage, and having to defend themselves, we owe them a debt for educating us and giving so much impetus to living wills and legislation that helps people plan ahead."
But the Rev. Joseph Foreman, the leader of an Atlanta anti-abortion group who was among a knot of protesters outside the hospital that housed Miss Cruzan, disagreed.
"I sympathize with the hardship of caring for a helpless woman, but I have no sympathy for a family who solves their problems by starving their daughter to death when there were hundreds of bona fide offers to care for her regardless of her condition," he said yesterday in a prepared statement.
L "Even a dog in Missouri cannot be legally starved to death."
In a statement read yesterday by the director of the Missouri Rehabilitation Center, where their daughter was cared for, Lester and Joyce Cruzan said that she had died peacefully and apparently without pain.
"She remained peaceful throughout and showed no sign of discomfort or distress in any way," the statement said.
In a 5-4 decision in the Cruzan case in June, its first ruling on the right to die, the Supreme Court recognized such a right but said that Missouri could stop the Cruzans from withholding food and water from their daughter unless there was "clear and convincing" evidence that she would have wanted to die.
The ruling spurred enormous interest in living wills and other directives that allow people to spell out, in advance, what treatment they want and who should make decisions for them if they become incapacitated. In the month after the ruling, the Society for the Right to Die answered nearly 300,000 requests for advance-directive forms.
The case also helped to generate support for congressional passage of the Patient Self-Determination Act, effective November 1991, under which hospitals and nursing homes that receive Medicaid or Medicare funds must give patients written information about such directives, explaining what right-to-die options are available under state law.
All but a handful of states now have laws providing a way for people to make known, in advance, their wishes about medical treatment.
The American Hospital Association has estimated that 70 percent of all hospital deaths are already negotiated in some way, with the concerned parties privately agreeing not to start, or to withdraw, some form of life-support technology or treatment.
The Supreme Court ruling in the Cruzan case set no uniform national guidelines on the right to die, but left it to states to set their own standards.
Miss Cruzan had been in what doctors described as an irreversible vegetative state ever since her car overturned Jan. 11, 1983, as she drove home from her job at a cheese factory in Carthage, Mo. She was found face down in a ditch, and paramedics restarted her heart. But because she had stopped breathing for about 15 minutes, she suffered severe brain damage.
For almost eight years, her body was rigid and her feet and hands contracted and bent. She had occasional seizures and vomited, and while her eyes sometimes opened and moved, she showed no sign of recognizing her family.
A month after the accident, a feeding tube was implanted in Miss Cruzan's stomach to allow her to receive nourishment. She breathed without assistance from a ventilator.
In 1987, Miss Cruzan's parents went to court to ask that the feeding tube be removed and that she be allowed to die a dignified death as they said she would have wanted.
Since then, the agony of her parents and sister, and their recollections of Miss Cruzan before the crash, became a staple of news accounts and television talk shows.
But a loose coalition of euthanasia and abortion opponents describing themselves as right-to-life advocates quickly took up her cause. They argued that every life has meaning, even life in a vegetative state.
The opponents went to court seven times to try to force the state to resume feeding Miss Cruzan but were found to have no legal standing to intervene.