BMJ  2006;333:203 (22 July), doi:10.1136/bmj.333.7560.203

Obituary

Ronald E Cranford

Bioethicist-neurologist who helped define vegetative state and later stood up to a president

In the late 1960s American medicine was becoming aware of the dilemmas arising from its therapeutic successes. Intensive care technology prolonged life, but doctors began asking, "At what cost?" Antibiotics saved lives of the young and vital, but also prolonged the lives of the frail and demented. Heart transplantation demanded a precise definition of death in order for hearts to be removed from patients who were dead.

Credit: HENNEPIN COUNTY MEDICAL CENTER

 

It was also a time when newly trained doctors were drafted en masse and sent to Vietnam to witness the agony of young soldiers brought wounded from the battlefield. One of those doctors was Ron Cranford.

Upon his return to the United States in 1968, he entered neurology and simultaneously became enamoured with the writings of the theologian-philosopher Joseph Fletcher. Fletcher's seminal book Situation Ethics proposed a pragmatic approach to ethical behaviour based on the "primary principle of acting in the most loving way." Fletcher argued, "Love is not something we have or are, it is something we do." Cranford embraced that argument deeply and eventually used the principle to challenge medical paternalism, right wing extremists, the US courts, and ultimately the US Congress and president.

He settled into practice at Hennepin County Medical Center in Minneapolis. The hospital was a trauma centre, and with transplantation services burgeoning at the nearby University of Minnesota, he soon became interested in brain death.

Taking the aphorism that "none of us is as wise as all of us," he formed a multidisciplinary thanatology committee to deal with controversies around brain death. Later, as moral dilemmas became more common owing to the tension between "what we can do" and "what we should do," he expanded the committee to become one of the first hospital clinical ethics committees.

Soon after, he became an adviser to the President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. The commission published a landmark book that both defined brain death and proposed that patients and families had rights to forgo life sustaining treatment, which was not a universally held belief among American doctors and courts at the time.

"Right now," he told a reporter, "we are beginning to realise that our wonderful medical advances enable us to prolong the dying process. The first question is, `Should we?' And then come all the others: `Who lives?' `Who dies?' `How do you decide?' `When do you decide?' `Who decides?'"

By the late 1970s, end-of-life controversies turned to those who were not dead, and Cranford's work became focused on the persistent (later permanent) vegetative state (PVS). He became the United States' foremost authority on the condition.

His humour, pragmatic ethics, logical arguments, and lifelong commitments to patients brought notoriety and trust among American neurologists, biomedical ethicists, and jurists. A lifelong Democrat whose extroversion brought him to thousands of podiums, he once said, "It helps a lot that I look like a Republican."

Cranford was introduced to the American public as a result of his work on behalf of the parents of Nancy Cruzan, a young woman who entered a vegetative state in 1983 as a result of trauma from a car crash. When her parents finally accepted after four years that she would not regain consciousness, they sought to have her feeding tube removed. The doctors refused, and the case reached the US Supreme Court, which declared that patients do have the right to refuse any medical intervention, including artificial nutrition and hydration. Cranford remained close to Cruzan's parents during and long after their ordeal, and he used the media to describe the facts of Nancy Cruzan's case and to educate the public on PVS and the rights of patients and families.

The high point of his career came in a case whose outcome surprised even Cranford, who had often derided politicians for entering discussions that he (and most jurists) believed belonged to patients, families, and physicians—and to the courts only as a last resort.

Terri Schiavo was a young woman in Florida who had a cardiac arrest in 1990 and was left in a vegetative state from anoxia. For eight years, her husband, Michael, and her parents worked together to try to rehabilitate her to consciousness. Finally, her husband accepted that she would not regain consciousness, and he sought to have her feeding tube removed. Her parents sought to keep it. The case became a cause célèbre for the "right to life" community. Despite unanimous judicial rulings on behalf of the husband, Florida governor Jeb Bush, the Florida legislature, and later President George W Bush and the US Congress all entered the debate and sought to block the courts' orders (BMJ 2005;330: 687[Free Full Text]). Cranford, who had become one of Schiavo's neurologists in 2002, bluntly and frequently chastised the politicians for injecting themselves into what he called a "horribly painful but ultimately private decision."

Terri Schiavo died on 31 March 2005, 13 days after her feeding tube was removed finally at the court's order. As was his usual practice, Cranford stayed close by during her last days to bear witness and to offer comfort. Throughout the debate, he was excoriated by his opponents. "They call me Dr Death," he said. "I would prefer `Dr Humane Death' or `Dr Caring Death'."

Ronald E Cranford, former professor of neurology University of Minnesota (b Peoria, Illinois, 1940; q University of Illinois College of Medicine, Chicago, 1965), died from complications of renal cancer on 31 May 2006.

[ Joanne Roberts ]
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