When decisions are made to continue or discontinue life support for people who have lost the capacity to make their own decisions, current law generally places greater value on the preservation of life than on the patient's self-determination. This has been accomplished through the requirement that the patient be in certain specified physical conditions (terminal illness, permanent vegetative state) and the requirement that a surrogate's determination that life support be removed be demonstrated by clear and convincing evidence that it is what the patient would have wished (or, in some states, evidence that it is in the patient's best interests to end life support). In some states, there are additional barriers to withholding or withdrawing artificial nutrition and hydration, which more directly and certainly results in the death of the patient. Patient selfdetermination, however, has clearly also been important—Karen Ann Quinlan, Nancy Cruzan, and Terri Schiavo, as well as many other formerly competent individuals who have entered a permanent vegetative state or become terminally ill, have had life support removed and have died on the basis of our understanding of what they would have wanted.
Those who opposed the removal of Terri Schiavo's feeding tube sought, and still seek, changes in law, ethics, and culture that will place greater emphasis on preserving life. This chapter examines how the debate over the preservation of life and its relationship to patient self-determination appeared to change during the Schiavo controversy and the potential consequences of that shift. It attempts to answer a question law professor Charity Scott posed following Terri's death: How in the world did the right to die turn into a right to life?