Court Opinion

ID: 9633766
Source: CourtListenerOpinion
Date Created: 2023-08-22 11:59:12.939996+00
Date Added: 2024-06-11T09:11:06.086890
License: Public Domain

Dore, C.J.
(concurring in part, dissenting in part)—The majority downplays the dissent as irrelevant, saying that:
The dissent's unwarranted foray into the emotionally charged theater of bio-ethics is as dangerous as it is irrelevant. Termination of life support is one of the most complex issues of our time and demands thoughtful and informed analysis. Neither the trial judge nor the parties dealt with this issue, and it has not been presented to this court. As such, it has no place in this case.
Majority, at 662.
I disagree. Both parties addressed the Natural Death Act, the issue of nutrition and hydration removal, and In re Grant, 109 Wn.2d 545, 747 P.2d 445, 757 P.2d 534 (1987), in their briefs.9 Nancy Farnam explained in her August 23, 1989, statement of grounds for direct review, *683In oral argument, both parties asserted that CRISTA's policies complied with the law as stated in In re Colyer, 99 Wn.2d 114, 660 P.2d 738 (1983), and that nutrition and hydration could be legally withdrawn from terminally ill patients.
*682This case certainly involves a fundamental and urgent issue of broad public importance which requires prompt and ultimate determination by the Washington Supreme Court. The case presents a question of first impression as to whether or not the withdrawal of artificial nutrition and hydration to a terminally ill patient could constitute patient abuse . . ..
*683Although CRISTA's acts may have complied with the law at that time, that was before Grant. Grant set this issue to rest: The removal of nutrition and hydration is not life-sustaining procedure within the Natural Death Act or the Colyer decision; rather, it is illegal and contrary to public policy. The majority properly interprets key issues in this case; however, by not addressing the nutrition and hydration issue, it implies that the removal of such essential care is legal. I take strong exception to this statement. This dissent supplements the majority opinion by clarifying our position in In re Grant, supra, which the majority avoided or failed to do.
Analysis
I concur with that part of the majority opinion recognizing Nancy Farnam's failure to state a cause of action for wrongful discharge in violation of public policy. CRISTA Ministries acted in good faith and, under current interpretation of the law, undisputedly complied with the procedural requirements of the Natural Death Act. RCW 70.122. CRISTA also fell within the broad religious organization exemption under Washington State law. RCW 49.60.040. The majority opinion, however, is premised on the assumption that the removal of nutrition and hydration from terminally ill, incompetent persons is sanctioned under the Natural Death Act. That premise is incorrect.
The Natural Death Act
In 1979, the Washington State Legislature, recognizing that medical technology was capable of prolonging human life beyond the natural moment of death, enacted the Natural Death Act. The Natural Death Act permits the *684withdrawal of "'[l]ife-sustaining procedure [s]"' from qualified, terminally ill patients. '"Life-sustaining procedure [s]"' include:
any medical or surgical procedure or intervention which utilizes mechanical or other artificial means to sustain, restore, or supplant a vital function, which, when applied to a qualified patient, would serve only to artificially prolong the moment of death and where, in the judgment of the attending physician, death is imminent whether or not such procedures are utilized. "Life-sustaining procedure" shall not include the administration of medication or the performance of any medical procedure deemed necessary to alleviate pain.
RCW 70.122.020(4). A qualified patient is a competent, terminally ill patient or an incompetent,, terminally ill patient having issued a directive, before becoming incompetent, which indicated a desire to forgo treatment. RCW 70.122.020(6). A patient is considered terminally ill if judged by two physicians to be afflicted with, "an incurable condition caused by injury, disease, or illness, which, regardless of the application of life-sustaining procedures, would, within reasonable medical judgment, produce death . . ..'' RCW 70.122.020(7).
In 1983, we affirmed the terminally ill patient's right to refuse medical treatment under the Natural Death Act. In re Colyer, 99 Wn.2d 114, 660 P.2d 738 (1983). In Colyer, we approved the removal of artificial life support from a terminally ill, incompetent patient. We based our decision on the constitutional right to privacy and the common law right to be free from bodily invasion. We rejected, however, the view that the right to refuse treatment was absolute. 99 Wn.2d at 122. Instead, we balanced the invasiveness of the treatment, the prognosis of the patient, and the presence of state interests that might outweigh the patient's right to refuse treatment. These state interests included: (1) the preservation of life; (2) the prevention of suicide; (3) maintaining the integrity of the medical profession, and (4) the protection of third party interests. I agreed with the majority's affirmation of the right to refuse, treatment in Colyer. I disagreed, however, with the designated waiting period of *685only 25 days before life support could be removed. I believed this period was insufficient to ensure an accurate determination of the patient's chances for recovery. 99 Wn.2d at 146. In 1984, we affirmed and broadened the right to refuse treatment by allowing a guardian to refuse treatment on behalf of a terminally ill, incompetent person. In re Hamlin, 102 Wn.2d 810, 689 P.2d 1372 (1984). In Hamlin, I argued against the majority's analysis which circumvented the regular court appointed guardian proceedings and negated the safeguards inherent in the guardian statutes. In both Hamlin and Colyer, I dissented not from the basic right of a person, incompetent or not, to refuse medical treatment, but rather from the implementation of inadequate procedural safeguards for what is obviously a practice of grave consequence. Although these cases established the parameters and procedural requirements of the Natural Death Act, it was not until later that we addressed the nutrition and hydration removal issue.
In 1987, this court held that the removal of nutrition and hydration did not fall within the meaning of life-sustaining treatment under the Natural Death Act. In re Grant, 109 Wn.2d 545, 747 P.2d 445, 757 P.2d 534 (1987). In Grant, only four justices concurred in the lead opinion. They held that an incompetent person's family had the right to remove nutrition and hydration. A majority of five justices, however, held that the removal of nutrition and hydration was euthanasia of a cruel nature, raised complex policy issues, and necessitated deferral to the Legislature.10
Justice Andersen, with Justices Brachtenbach and Durham concurring, agreed that an incompetent person's family could make decisions regarding life support, but forcefully dissented from the lead opinion's subscription to the removal of nutrition and hydration:
*686I disagree . . . with the . . . decision which allows the patient's life to be taken by withholding intravenous nutrition and hydration or, to use less polite phraseology, to let her die of thirst or starvation. Call it whatever the majority will, this is pure, unadorned euthanasia.
109 Wn.2d at 570. Justice Andersen noted that recent legislative attempts to authorize the removal of nutrition and hydration had failed. During the 1987 session, Engrossed Substitute Senate Bill 5401, which authorized the discontinuance of artificial nutrition and hydration, failed after heated debate.11 109 Wn.2d at 572. Justice Andersen emphasized the Legislature's superior ability to evaluate such far-reaching public policy issues and felt that the issue should be deferred until the Legislature resolved it.
Justice Goodloe and I agreed that the right to "face an inevitable and imminent death in a manner most consistent with our beliefs and with our dignity as humans is vital." 109 Wn.2d at 575. We dissented, however, from both the majority's holding authorizing the removal of nutrition and hydration, and its holding enabling an incompetent person's family to make such decisions on behalf of the patient. We believed that allowing the removal of nutrition and hydration flew in the face of both the Natural Death Act and natural law:
This result is contrary to the legislative dictates of the NDA [Natural Death Act]. . . . [T]he unfortunate result of the majority opinion is that the potential for abuse is increased. ... [B]y authorizing the withholding of intravenous nutrition and hydration, the majority authorizes death by starvation and dehydration. . . .[,] authorizes mercy killing, arguably of a cruel nature. . . .
. . . [and] fails to give appropriate weight to the State's interest in preserving life—whether that of the particular patient, or the sanctity of all human life in general.
109 Wn.2d at 576, 580. We noted recent legal and scholarly debate on the issue of nutrition and hydration removal. 109 *687Wn.2d at 579. We argued that the existence of both the right to withhold nutrition and hydration, and the right of a guardian to exercise this power on behalf of an incompetent patient, was a question best left to the Legislature. We recalled Engrossed Substitute Senate Bill 5401, which would have established these rights, and objected to the majority's circumventing a straightforward legislative failure, "imposing its own morality on the public in extending a legislative act . . . [and] establishing philosophical principles in the guise of constitutional interpretation." 109 Wn.2d at 579-80. Like Justice Andersen, we emphasized that the Legislature was the only appropriate lawmaking body.
Thus in Grant, although seven justices held that an incompetent person's family should be allowed to make decisions regarding the removal of life support, a 5-justice majority qualified this holding and agreed that the removal of nutrition and hydration was a particularly cruel method of euthanasia, inapplicable under the Natural Death Act and meriting deferral to the Legislature for a proper evaluation of public policy.
Other states have experienced difficulty resolving the issue of nutrition and hydration removal as well. A New York court declined to authorize the removal of nutrition and hydration, which it viewed as ordinary care of a "passive and less intrusive" nature, because it reasoned that death should occur naturally from the patient's own untreated illness, rather than any act of either commission or omission.12 A Massachusetts court upheld a hospital's refusal to withdraw a persistently vegetative patient's artificial sustenance, but allowed the patient to move to an institution which would comply with his wishes.13 Conversely, numerous state courts authorize the removal of *688nutrition and hydration. These courts contend that a right to refuse nutrition and hydration, like the right to refuse artificial ventilation, derives from the substantive due process right to privacy, as well as the common law right to be free from bodily intrusion. In re Grant, 109 Wn.2d 545, 562, 747 P.2d 445, 757 P.2d 534 (1987). The United States Supreme Court, however, doubts the validity of such a contention.
Federal Law
The United States Supreme Court recently stated that the medical implications of discontinuing nutrition and hydration may raise a constitutional question about the existence of the right to refuse such treatment. Cruzan v. Director, Mo. Dep't of Health, _U.S._, 111 L. Ed. 2d 224, 110 S. Ct. 2841 (1990). In Cruzan, the Court examined whether the constitution prohibited the State of Missouri from imposing a "clear and convincing" evidence standard bn an incompetent person's right to forgo treatment in order to ensure an accurate determination of the person's wishes. The petitioners in Cruzan insisted that the forced administration of life-sustaining medical treatment, including artificially delivered food and water, implicated an incompetent person's liberty interest which could not be deprived without due process of law. 110 S. Ct. at 2852. They further contended that the imposed evidentiary standard virtually eliminated an incompetent's right to forgo treatment, except in rare instances where that intent had been expressed before the onset of incompetency. 110 S. Ct. at 2851.
Although the Cruzan majority assumed arguendo that a competent person's liberty interest embraced the right to refuse unwanted artificial nutrition and hydration, the Court emphasized that this assumption was only for purposes of the case before it. The majority admonished, "the dramatic consequences involved in refusal of such treat*689ment would inform the inquiry as to whether the deprivation of that interest is constitutionally permissible."14 110 S. Ct. at 2852. The Court held in favor of the State and affirmed the State's right to require "clear and convincing evidence". It reasoned that where uncertainty existed as to an incompetent person's wish to die, the State's cautious approach was merited because only the choice that sustained life could be reversed upon the discovery of conclusive evidence.15 110 S. Ct. at 2853.
Justice Scalia agreed in the result, but filed a concurring opinion which addressed the removal of nutrition and hydration at length. He pointed out that the petitioners' "substantive due process" claim could not be maintained without demonstrating that the State had deprived the claimant of a right "historically and traditionally protected against State interference." 110 S. Ct. at 2860. By challenging the petitioners' rationale distinguishing the abstention of such treatment from suicide, Justice Scalia asserted that such a right could not possibly be established in the case at hand.
*690Petitioners rely on three distinctions to separate Nancy Cruzan's case from ordinary suicide: (1) that she is permanently incapacitated and in pain; (2) that she would bring on her death not by any affirmative act but by merely declining treatment that provides nourishment; and (3) that preventing her from effectuating her presumed wish to die requires violation of her bodily integrity. None of these suffices.
110 S. Ct. at 2860. Justice Scalia easily dismissed petitioners' first argument by pointing out that a person's incapacitation and pain have no bearing on the State's interest in preventing that person's suicide. Quoting 4 W. Blackstone, Commentaries *189, Justice Scalia reasoned, "[s]uicide was not excused even when committed 'to avoid those ills which [persons] had not the fortitude to endure.'" 110 S. Ct. at 2860. He then attacked the petitioners' second line of reasoning, the action/inaction distinction. "It would not make much sense to say . that one may not kill oneself by walking into the sea, but may sit on the beach until submerged by the incoming tide . . .." 110 S. Ct. at .2861. Rather than adopt the action/inaction distinction, Justice Scalia reasoned that the "intelligent line” fell between those forms of inaction abstaining from ordinary care and those abstaining from "heroic" or "excessive" care. 110 S. Ct. at 2861; Justice Scalia cautioned that, unlike the action/inaction distinction, the ordinary/heroic care distinction was not a bright-line analysis. Once again quoting Blackstone, Justice Scalia reiterated that
[starving oneself to death is no different from putting a gun to one's temple as far as the common-law definition of suicide is concerned; the cause of death in both cases is the suicide's conscious decision to 'pu[t] an end to his own existence.'"
110 S. Ct. at 2861. He insisted that imposing treatment on a patient who wished to die did not violate a person's bodily integrity and reminded us that, at common law, even a private person was justified in the use of force to prevent suicide. 110 S. Ct. at 2862. Justice Scalia concluded that although there exist limits that "ought not to be exceeded in requiring an individual to preserve his own life", such *691limits are not set out in the due process clause and, therefore, should not be set by the Court. 110 S. Ct. at 2863.
The majority opinion in Cruzan, along with Justice Scalia's concurrence, make it clear that the existence of the right to refuse nutrition and hydration under the federal constitution is a question open for debate. Further, it is clear that the creation of such a right is not the privilege of the Court. As Justice Scalia noted in his conclusion, his point was not that Nancy Cruzan should remain alive, even if knowledge of her wish to die were certain, but rather that the constitution had nothing to say on the subject and, therefore, the Court should not either.16
This Court need not, and has no authority to, inject itself into every field of human activity where irrationality and oppression may theoretically occur, and if it tries to do so it will destroy itself.
110 S. Ct. at 2863. The same reasoning is true and applies in Washington State.
Natural Death or Euthanasia?
Washington's Natural Death Act does not permit the removal of nutrition and hydration from terminally ill patients. Nothing in the Natural Death Act suggests that *692such basic treatment falls within the ambit of "life-sustaining procedure". In fact, upon close examination, the language of the Natural Death Act suggests the opposite.17
The concept of "natural death" itself suggests a death caused by neither act nor omission, but rather by the patient's own unimpeded illness. Under this reasoning, only the removal of treatment directly addressing a terminal condition could be congruent with the Natural Death Act. The provision of food and water, however, certainly does not combat a terminal affliction. The withdrawal of food and water causes a premature unnatural death. To say a person died naturally because of an inability to feed oneself is absurd. Such logic could support the withdrawal of treatment from unwanted babies, the handicapped or the developmentally disabled.
Using this reasoning, the New York Court of Appeals disallowed the termination of blood transfusions that were administered to a terminally ill, profoundly retarded patient. In re Storar, 52 N.Y.2d 363, 420 N.E.2d 64, 438 N.Y.S.2d 266 (1981). In Storar, the court found it "unrealistic to attempt to determine whether [the patient] would want to continue potentially life prolonging treatment if he were competent." Instead, the court likened the developmentally disabled patient's condition to that of an infant and held that a guardian "may not deprive a child of lifesaving treatment, however well intentioned." (Citations omitted.) 52 N.Y.2d at 380. The court further reasoned that the "transfusions were analogous to food—they would not cure the cancer, but they could eliminate the risk of death from another treatable cause." 52 N.Y.2d at 381. The Court of Appeals, therefore, reversed the lower court decision to *693withhold the blood transfusions. The Court of Appeals did, however, authorize the lower court's holding permitting the removal of artificial ventilation. 52 N.Y.2d at 381. In doing so, it implicitly recognized the difference between extraordinary care, such as ventilation, and basic care, such as the provision of food.18 This court should plainly recognize the same today, that the provision of food and water is simply the most basic care, the withdrawal of which would certainly not cause a "natural death."
It is openly accepted that "life-sustaining treatment" was not meant to include basic, ordinary medical care. What could be more basic than feeding a patient? Proponents of withholding nutrition and hydration often argue that physicians equate such treatment with extraordinary methods of life support such as ventilation. This statement, however, cannot speak for the medical profession as a whole. Many physicians reasonably and genuinely believe that nutrition and hydration are not life-sustaining treatment within the Natural Death Act, but rather typify the administration of intimate care necessary to maintain patient comfort, essential to the doctor-patient relationship.19 The fact is that artificial nutrition and hydration are different from other forms of treatment, just as eating and drinking are different from breathing or, for example, the blood-cleansing function of kidneys. Whereas, eating and drinking are voluntary functions, breathing and blood cleansing are reflexive, involuntary functions. At various times in our lives we are unable to feed ourselves. It is a fact of human life that we are fed as helpless, newborn infants and often as helpless invalids. The inability to breathe or cleanse blood, however, merits extraordinary or heroic measures such as artificial *694ventilation or kidney dialysis. The Legislature contemplated such heroic measures, which often only prolong the inevitable cessation of life, when it adopted the language "[l]ife-sustaining procedure" in the Natural Death Act.
The argument that artificial nutrition and hydration are withholdable because they are more intrusive than other forms of ordinary feeding is without merit. The most basic forms of patient care, such as ordinary bottle feeding and spoon feeding or catheterization, involve forced bodily intrusion to a degree sufficient to implicate a person's privacy interests. Because such treatment is necessary to maintain patient comfort, however, it is considered basic care. Artificial nutrition and hydration are objectively no different. Both forms of treatment involve forced bodily intrusion sufficient to implicate a privacy interest, and both are necessary to maintain patient comfort. Any attempt to differentiate artificial nutrition and hydration from other forms of basic care is based on emotion and confuses form with substance.
The Natural Death Act's evident concern for patient comfort further supports my belief that nutrition and hydration are not withholdable. The Natural Death Act expressly excludes the "administration of medication . . . necessary to alleviate pain." RCW 70.122.020(4). The text of the act, therefore, suggests that the Legislature did not sanction the removal of nutrition and hydration, which would inevitably cause pain.20
Legislative concern that terminally ill patients forgo pain or prolonged death is congruent with the philosophy of euthanasia. Webster's Third New International Dictionary (1963), at 786, defines euthanasia as, "the act or practice of painlessly putting to death persons suffering from incurable conditions or diseases". But bringing about a premature *695death by starvation and dehydration is profoundly inconsistent with even the philosophy of euthanasia. It would be less painful and, therefore, more humane, to administer lethal injection, an action which the Natural Death Act certainly does not condone.
The argument that the removal of nutrition and hydration is humane because incompetents have no sensation is equally unconvincing. If the patient cannot feel pain or contemplate death, then the purpose of terminating treatment to afford a death with dignity disappears. Such a patient will experience neither the indignity of a prolonged death caused by an unimpeded illness, nor the pain of a death caused by starvation and dehydration. If, however, an incompetent person maintains any awareness at all, then the manner of death does become a subject of concern. The Natural Death Act's exclusion of "medication . . . necessary to alleviate pain" suggests that the Legislature recognized an ever-present possibility that the patient might not be completely insensate. RCW 70.122.020(4). Nancy Cruzan, for example, was "oblivious to her environment except for reflexive responses to sound and perhaps painful stimuli" and her "highest cognitive brain function [was] exhibited by her grimacing . . . indicating the experience of pain . . .." 110 S. Ct. at 2845 n.l. Patients in such degenerated states will not be aware of lofty concepts such as dignity or the passage of time, but they will be aware of pain. Thus, for the barely sentient patient, a painless if lengthier death by an unimpeded illness is more merciful than a short but painful death by starvation.
Where a persistently vegetative patient is indeed completely insensate, this entire debate concerns not the feelings of the terminally ill and incompetent, but the feelings of family and friends of the unfortunate patient. I sympathize with the feelings of loved ones. I recognize that the pain of watching a loved one degenerate to a less than human state can be unbearable. I am certain that the cost of care can be financially crippling. Although the Legislature must have recognized the plight of loved ones, it did *696not enact the Natural Death Act so that loved ones could construe their own self-interest, rationalizing their actions as "in the patient's best interest," and then impose this will on the helpless invalid. Because such an interpretation of the Natural Death Act offends the senses, risking error and inviting abuse, I reject the majority's gloss.
Rather than charging off on an emotional crusade for the right to die, we should follow the United States Supreme Court's rationale in Cruzan and defer to the Legislature. First, legislative action will inevitably be more attuned to public opinion than any decision the judiciary could make. Secondly, that the Legislature has defeated every attempt to modify the Natural Death Act and establish nutrition and hydration as "life-sustaining treatment," signals the Legislature's intent that these basic forms of treatment do not fall within the Natural Death Act.21 Finally, the Legislature is currently addressing the issue. Initiative 119, currently before the Legislature, specifically allows "position assisted suicide,” which proposes medically assisted euthanasia for terminally ill patients. The failure of the Legislature to enact a law congruent with the ethical views of this court does not license us to venture into judicial policymaking and ultimately preempt the legitimate exercise of legislative authority.
Conclusion
In In re Colyer, supra, the court affirmed the right to refuse extraordinary medical treatment in Washington State. Hamlin extended the right to incompetent persons *697and Grant limited this right to the withdrawal of extraordinary care which did not include nutrition and hydration. In re Colyer, 99 Wn.2d 114, 660 P.2d 738 (1983); In re Hamlin, 102 Wn.2d 810, 689 P.2d 1372 (1984); In re Grant, 109 Wn.2d 545, 747 P.2d 445, 757 P.2d 534 (1987). Today the majority redefines "life-sustaining treatment" and its definition directly contradicts our decision in Grant. The court's action not only violates the doctrine of stare decisis, it also entangles the court in a web of complex philosophical issues. The United States Supreme Court, in Cruzan, questioned whether a federally protected right to forgo nutrition and hydration existed. The Cruzan Court confronted the same philosophical issues that we face today and wisely recognized and deferred to the Legislature's superior policymaking abilities. As was the case in Cruzan, our Legislature is far better equipped to evaluate this complex issue and should not have its power usurped by this court.
I dissent.

Brief of Appellant, at 28-35. Brief of Respondents, at 39-44.

 The original In re Grant slip opinion presented a 5-justice majority opinion yielding a 5-2-2 decision. The later, mandated decision, however, contained a 4-3-2 tally of justices after Justice Durham altered her stance and joined with Justice Andersen's concurrence/dissent.

 See H.R. Rep., 50th Legislature (1987), at 2. See also Senate and House versions of Engrossed Substitute Senate Bill 5401, 50th Legislature (1987), at 3, lines 10-12.

 In re Workmen's Circle Home & Infirmary for the Aged v. Fink, 135 Misc. 2d 270, 514 N.Y.S.2d 893, 895 (N.Y. Sup. Ct. 1987).

 Brophy v. New England Sinai Hosp., Inc., 398 Mass. 417, 497 N.E.2d 626 (1986).

 It is noteworthy that both parties in Cruzan interpreted Grant as clearly holding that nutrition and hydration removal is euthanasia and therefore illegal. See Petition for Writ of Certiorari to the Missouri Supreme Court, at 15-16 (Cruzan); Brief in Opposition, at 15-16 (Cruzan).

The Court then essentially allowed Missouri to restrict that right to competent persons.
Missouri has in effect recognized that under certain circumstances a surrogate may act for the patient in electing to have hydration and nutrition withdrawn in such a way as to cause death, but it has established a procedural safeguard to assure that the action of the surrogate conforms as best it may to the wishes expressed by the patient while competent. Missouri requires that evidence of the incompetent's wishes as to the withdrawal of treatment be proved by clear and convincing evidence. The question, then, is whether the United States Constitution forbids the establishment of this procedural requirement by the State. We hold that it does not.
110 S. Ct. at 2852. The Court reasoned that the most cautious approach would be to allow the patient to live until evidence was obtained proving the incompetent's wishes in accordance with the clear and convincing standard imposed by Missouri law.

 Justice Scalia compared Cruzan to the Court's recent decision in Webster v. Reproductive Health Servs., 492 U.S. 490, 106 L. Ed. 2d 410, 109 S. Ct 3040 (1989).
I am concerned, from the tenor of today's opinions, that we are poised to confuse that enterprise as successfully as we have confused the enterprise of legislating concerning abortion—requiring it to be conducted against a background of federal constitutional imperatives that are unknown because they are being newly crafted from Term to Term. That would be a great misfortune.
110 S. Ct. at 2859. Justice Scalia further asserted:
[I]t is up to the citizens of Missouri to decide, through their elected representatives, whether that wish will be honored. It is quite impossible (because the Constitution says nothing about the matter) that those citizens will decide upon a line less lawful than the one we would choose; and it is unlikely (because we know no more about "life-and-death" than they do) that they will decide upon a line less reasonable.
110 S. Ct. at 2859.

 Numerous scholarly articles address the subject of whether nutrition and hydration constitute withholdable, ordinary care or nonwithholdable heroic, extraordinary care. See Note, In re Grant: Where Does Washington Stand on Artificial Nutrition and Hydration?, 13 U. Puget Sound L. Rev. 197 (1989); Comment, Artificial Nutrition and the Terminally Ill: How Should Washington Decide?, 61 Wash. L. Rev. 419 (1986); Horan & Grant, The Legal Aspects of Withdrawing Nourishment, 5 J. Legal Med. 595 (1984).

The patient died of cancer before the case could be resolved, but the court found the underlying issue of overriding public importance and addressed the case despite its mootness. 52 N.Y.2d at 381.

 Seigler & Weisbard, Against the Emerging Stream: Should Fluids and Nutritional Support Be Discontinued?, 145 Archives Internal Med. 129, 130 (1985).

Justice Lynch, in his dissent in part from the majority in Brophy v. New England Sinai Hosp., Inc., 398 Mass. 417, 497 N.E.2d 626 (1986) recounted the particularly gruesome effects of death by starvation and dehydration.

 See House Bill 2465, 51st Legislature, Legislative Digest 664 (1990); House Bill 2681, 51st Legislature, Legislative Digest 733 (1990); House Bill 3005, 51st Legislature, Legislative Digest 826 (1990); Senate Bill 5628, 51st Legislature, Legislative Digest 297 (1989); Substitute Senate Bill 5401, 50th Legislature, Legislative Digest 202 (1987); House Bill 582, 50th Legislature, Legislative Digest 280 (1987); House Bill 1965, 50th Legislature, Legislative Digest 867 (1988); House Bill 206, 49th Legislature, Legislative Digest 93 (1985); Substitute Senate Bill 3228, 49th Legislature, Legislative Digest 94 (1985); House Bill 319, 47th Legislature, Legislative Digest 181 (1981); House Bill 1497, 46th Legislature, Legislative Digest 1300 (1979).