The American judicial system, which has supported the concept of brain death as described earlier, also has been instrumental in shaping public attitudes and social policy in the area of withholding or withdrawing support from patients who are not brain dead. In the process, the courts have underscored the importance of privacy and the right to refuse treatment. They have also contributed to the concept that human life is more than a biologic process, defined how therapies may or may not benefit patients, argued against a distinction between withholding and withdrawal of support, and established guidelines for how support may be withheld or withdrawn.

Perhaps the best known judicial decision regarding withholding and withdrawal of life support occurred in the case of Karen Quinlan (1975), in which the father of a girl who was in a persistent vegetative state petitioned the court to appoint him her guardian with the power to remove her from mechanical ventilation. The lower court denied the petition, but the New Jersey Supreme Court reversed the decision. In doing so, the court reasoned that patients generally would accept or refuse medical treatment based on its ability to support sentient life as distinguished from mere biologic existence. Having concluded that Ms. Quinlan would have decided to forgo life-prolonging therapy were she not in a persistent vegetative state, the court decided that her right to privacy would be abrogated if it prevented the exercise of this right on her behalf. The court therefore granted the fathers petition, allowing him to exercise “substituted judgment” for his daughter, and stated that life support can be withdrawn if physicians and a hospital ethics committee agreed that such support would not alter Ms. Quinlans underlying condition. there
Three subsequent cases furthered the concept of “substituted judgment” articulated in the Quinlan decision. In Superintendent of Belchertown State School v Saikewicz (1977), the Massachusetts Supreme Court upheld a lower courts decision that treatment for acute myeloblastic leukemia should not be administered to a mentally retarded ward of the state whose guardian and physicians had argued that the treatment would be painful, poorly understood by the patient, and unlikely to produce a cure. In In the Matter of Dinnerstein (1978), the Appeals Court of Massachusetts supported the family of a 67-year-old widow with Alzheimer’s disease who had petitioned the court for a declaratory judgment that a do-not-resuscitate (DNR) order could be written in her medical record without judicial approval. And in Eichner v Dillon (1981), the New York Court of Appeals agreed that the director of a Catholic religious order could direct removal of a colleague from a mechanical ventilator because the patient, while competent, had stated that he did not want to have his life prolonged by medical means and his physician believed he had no reasonable chance of recovery from a persistent vegetative state.