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The Right to Die:

The Broken Road from Quinlan to Schiavo

Annette E. Clark*

I. INTRODUCTION

On the thirtieth anniversary of the Quinlan case,1 it seems appropriate to go back in time and revisit the decision that started us down the road to developing what is now a large and complex body of right-to-die jurisprudence in this country. As a longtime bioethics professor, this opportunity to reacquaint myself with one of the seminal cases, to read it in something other than the edited and abbreviated form in which it appears in casebooks, has been an education in and of itself. It is a reminder that we should not lose sight of our beginnings when we try to understand where the path of right-to-die law has taken us and to anticipate where it will lead us next.

The life and death of Karen Ann Quinlan and the Chancery Court and New Jersey Supreme Court decisions that flowed from her sad story provide a remarkable introduction to the right-to-die issues that have developed over the ensuing thirty years.2 Quinlan also provides a useful measure of the law’s progress over the last thirty years.3 The United States Supreme Court’s decision in the Cruzan case, which occurred approximately midway through this thirty-year period, and the

1. In re Quinlan, 348 A.2d 801, 806 (N.J. Super. Ct. Ch. Div. 1975), modified and remanded, 355 A.2d 647 (N.J. 1976).

2. Those issues include: Whether the law should distinguish between the withdrawal of ordinary and extraordinary medical treatment? What is the proper role of religion and religious beliefs in the withdrawal of life-sustaining treatment? What is the best method to determine the wishes of an incompetent individual regarding medical treatment? Should the courts, the medical profession, or loved ones and family members be empowered to make life-and-death decisions for incompetent individuals? Should the law err on the side of sustaining life if we cannot discern what the now-incompetent individual would have chosen, or should courts turn to a best interests analysis? Is the right to refuse treatment a fundamental right protected by the federal Constitution, and if so, does that right continue after an individual becomes incompetent?

3. Evaluating the developments since Quinlan helps to determine whether the law and society have continued down the road established in Quinlan, found a better path, or become lost somewhere along the way.

384 Loyola University Chicago Law Journal [Vol. 37

very recent developments in the Schiavo case provide some enlightening, and perhaps distressing, insights into the question of whether the law and society have moved forward in our right-to-die jurisprudence.4 This article consequently reviews the Quinlan decisions and issues raised in those cases.5 It also discusses the seminal developments in right-to-die law following Quinlan.6

II. THE CASE OF KAREN ANN QUINLAN

On April 15, 1975, Karen Ann Quinlan, for reasons still unknown, stopped breathing for two fifteen-minute periods.7 The lack of oxygen (anoxia) produced significant brain damage, leaving the twenty-one- year-old first in a coma and then in a persistent vegetative state, dependent upon a respirator to breathe.8 The Quinlan family first authorized the treating neurologist, Dr. Morse, to do everything he could to keep Karen alive.9 After three months without improvement in her neurological condition and with little hope that she would ever regain any level of cognitive function, however, Karen’s parents consulted their local parish priest, who advised them that the Roman Catholic Church’s teachings would permit withdrawal of extraordinary medical treatment under these circumstances.10 Mr. and Mrs. Quinlan then approached hospital officials and sought to have the respirator removed, knowing that doing so would likely result in their daughter’s death.11 To effectuate their decision, Karen’s parents signed the following statement:

4. Cruzan v. Dir., Mo. Dep’t of Health, 497 U.S. 261 (1990); In re Schiavo, 780 So. 2d 176 (Fla. Dist. Ct. App.), reh’g denied (Feb. 22, 2001), review denied, 789 So. 2d 348 (Fla. 2001).

5. See infra Part II (discussing the issues and opinions of the Quinlan case). 6. See infra Parts III, IV (analyzing two seminal right-to-die cases post-Quinlan: Cruzan and

Schiavo). 7. In re Quinlan, 348 A.2d 801, 806 (N.J. Super. Ct. Ch. Div. 1975), modified and remanded,

355 A.2d 647 (N.J. 1976). Some commentators, however, have expressed the belief that Ms. Quinlan had been overcome by an ingestion of a combination of alcohol and tranquilizer pills. Robert D. McFadden, Karen Ann Quinlan, 31 Dies: Focus of the ‘76 Right to Die Case, N.Y. TIMES, June 12, 1985, at A1.

8. Quinlan, 348 A.2d at 809–12. Karen’s physicians described this as a neurological condition consisting of irreversible brain damage with a total lack of any cognitive or cerebral functioning, but with a partially functioning lower brain (brainstem). Id. at 811–12. The brainstem continued to regulate such “vegetative” functions as Karen’s body temperature, blood pressure, heart rate, and sleep-wake cycles. Id. at 812.

9. Id. 10. Id. at 813. The family consulted with Monsignor Trapasso, who explained to the family

that a declaration by Pope Pius XII clarified that the family had no obligation to sustain life when there is no realistic hope of recovery. McFadden, supra note 7, at A1.

11. Quinlan, 348 A.2d at 813. Efforts had been made to wean Karen from the respirator, but these attempts to have her breathe on her own were unsuccessful, leading her physicians to

2006] The Road from Quinlan to Schiavo 385

We authorize and direct Doctor Morse to discontinue all extraordinary measures, including the use of a respirator for our daughter Karen Quinlan. We acknowledge that the above named physician has thoroughly discussed the above with us and that the consequences have been fully explained to us. Therefore, we hereby RELEASE from any and all liability the above named physician, associates and assistants of his choice, Saint Clare’s Hospital and its agents and employees.12

Even with this authorization and release from liability, Dr. Morse expressly declined to withdraw the respirator, asserting that to do so would deviate from standard medical practice and would require making a “quality of life” determination, which he would not do.13

A. The Chancery Court Decision

In response to the doctor’s refusal to withdraw Karen’s respirator, Mr. Quinlan sought judicial assistance. He petitioned the chancery court to appoint him legal guardian of Karen’s person and property because of her incompetency, and asked that the court grant “the express power of authorizing the discontinuance of all extraordinary means of sustaining the vital processes of his daughter.”14

The chancery court judge placed this case within the framework of equity,15 with Mr. Quinlan’s petition invoking the parens patriae power of the court to aid and protect the incompetent Karen Ann Quinlan, and to act in her best interests.16 In Judge Muir’s view, the power of equity called upon the court to do justice in the particulars of this case according to the dictates of societal morality and judicial conscience.17 Interestingly, he directly equated this judicial conscience and morality, which would ultimately determine whether it was appropriate to authorize the removal of the respirator, with the role of the physician in society and the duty owed by physicians to their patients.18 In rather noble terms, he anointed the medical profession as the guardian of morality in life-and-death decision making, charged by society to “do all within [its] human power to favor life against death.”19 Furthermore,

conclude that she would likely be unable to sustain her breathing without the mechanical assistance provided by the respirator. Id. at 809.

12. Id. at 813–14. 13. Id. at 814. 14. Id. at 806. 15. Id. at 816 (stating that morality and conscience dictates the framework of the case). 16. Id. 17. Id. at 816–17. 18. Id. at 818. 19. Id.

386 Loyola University Chicago Law Journal [Vol. 37

the court held Dr. Morse up as a shining example of the profession, attaching great significance to the fact that this “man who demonstrated strong empathy and compassion, a man who has directed care that impressed all the experts” had concluded that medical tradition would not justify the withdrawal of the respirator. 20

Judge Muir then took up the question of whether or how Karen’s own views on the subject of withdrawal of life-sustaining treatment, expressed prior to her incompetency, should factor into the court’s determination.21 If Dr. Morse’s views were entitled to instant respect and deference, Karen’s prior statements were not. As to testimony that Karen had said at the age of twenty in various conversations with friends and family that she would not want to be kept alive through artificial means, Judge Muir concluded that her statements were merely theoretical, not the expression of a personal choice made under circumstances where her death was a distinct choice (such as would be the case with a living will). Thus, her statements were not sufficiently probative to persuade the court that Karen would elect, if competent, to terminate the respirator.22

In the end, Judge Muir concluded that the decision whether Karen should be removed from the respirator was a medical decision, not a judicial one, and that parents, whose own best interests might conflict with the best interests of the incompetent, could concur in the medical treatment decision but could not control it.23 Furthermore, he held that to the extent that the court played any role as parens patriae, protecting Karen’s best interests could not include permitting her to die, since life in the sense of biological existence was all that she had remaining to her.24 Finally, the court concluded that the constitutional right to privacy claimed by Karen’s parent on her behalf was weaker than, and trumped by, both the medical profession’s duty to provide life-giving care and the judicial obligation to act in Karen’s best interests by choosing her life over her death.25 The court ultimately denied Mr. and Mrs. Quinlan any role in medical decision making for their daughter on the grounds that their anguish and inner conflicts would be magnified by having to be involved in the day-by-day medical decisions necessary for her care.26 Thus, rather than appointing either of the parents, the

20. Id. at 819. 21. Id. 22. Id. 23. Id. 24. Id. at 819–20. 25. Id. at 821–22. 26. Id. at 824.

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court chose a virtual stranger as guardian to protect the interests of the person of Karen Ann Quinlan.27

B. The New Jersey Supreme Court Decision

The chancery court’s decision was obviously the product of a time when the medical profession held great sway. The court’s view of physicians as god-like figures who controlled and protected society’s morality and conscience through their life-and-death decision-making for their patients is a rather remarkable example of the strength and reach of medical paternalism only three decades ago.28

Nevertheless, if the chancery court’s opinion was tradition-bound and backward looking, the New Jersey Supreme Court decision only one year later was strikingly prescient and forward-looking. This difference in approach is immediately apparent in the way the state’s highest court framed the issue before it:

The matter is of transcendent importance, involving questions related to the definition and existence of death, the prolongation of life through artificial means developed by medical technology undreamed of in past generations of the practice of the healing arts; the impact of such durationally indeterminate and artificial life prolongation on the rights of the incompetent, her family and society in general; the bearing of constitutional right and the scope of judicial responsibility, as to the appropriate response of an equity court of justice to the extraordinary prayer for relief of the plaintiff. Involved as well is the right of the plaintiff, Joseph Quinlan, to guardianship of the person of his daughter.29

Before turning to the transcendent questions and constitutional and legal issues alluded to above, Justice Hughes extensively reviewed the evidence of Karen’s medical condition and prognosis, and, unlike the chancery court, emphasized the fact that, within the bounds of medical certainty, Karen would never regain cognitive or sapient life.30 The

27. Id. The court appointed Daniel Coburn, Esq., who had acted on Karen’s behalf during the guardianship hearing. Id. As is typical with guardians ad litem, Mr. Coburn likely had no knowledge of Karen Quinlan prior to this proceeding. Id.

28. See S. Elizabeth Wilborn Malloy, Beyond Misguided Paternalism: Resuscitating the Right to Refuse Medical Treatment, 33 WAKE FOREST L. REV. 1035, 1067–68 (1998) (arguing that the court’s deference to physicians stems from a misplaced appreciation of medical professionals and their ability to save lives); Alicia R. Ouellette, When Vitalism is Dead Wrong: The Discrimination Against and Torture of Incompetent Patients By Compulsory Life-Sustaining Treatment, 79 IND. L.J. 1, 3 (2004) (noting the shift in the past thirty years from medical paternalism to patient autonomy).

29. In re Quinlan, 355 A.2d 647, 652 (N.J.), cert. denied sub nom. Garger v. New Jersey, 429 U.S. 922 (1976).

30. Id. at 655.

388 Loyola University Chicago Law Journal [Vol. 37

court also explored the factual foundation regarding Mr. Quinlan’s suitability as a guardian for his daughter, finding that he was a loving father, a deeply religious man, and a person of unquestioned moral character.31

Turning next to the legal questions before it, the court dispensed quickly with Mr. Quinlan’s constitutional claims of free exercise of religion and cruel and unusual punishment, finding neither to be applicable in this case.32 The New Jersey Supreme Court gave careful and prolonged consideration to the constitutional right of privacy the Quinlans claimed. The court imagined a scenario where Karen Ann Quinlan miraculously regained competence for a time, but with the same grim prognosis of irreversible and permanent brain damage without hope of a cognitive existence. The court had no difficulty reaching the conclusion that, under these hypothetical circumstances, Karen, if competent, would have the right to decide to discontinue the respirator even if the decision resulted in her death, and that no State interest could compel her continued vegetative existence against her will.33

It is perhaps not surprising that the court centered this legal right in the developing federal constitutional right to privacy. Citing Eisenstadt v. Baird,34 Griswold v. Connecticut,35 and Roe v. Wade,36 the latter of which had been decided just three years earlier, the New Jersey

31. Id. at 657. The court described in some detail the Roman Catholic Church’s position on the question of withdrawal of life-sustaining treatment, as reflected in a position statement by Bishop Lawrence B. Casey, spokesperson for the New Jersey Catholic Conference, which was contained within the Conference’s amicus brief. Id. at 658–60. Justice Hughes emphasized that the purpose of this exposition of the Catholic Church’s position was only to explore the impact it had on Joseph Quinlan’s motivation and purpose in seeking guardianship of his daughter rather than to establish precedent for the court’s decision. Id. at 660.

32. Id. at 661–62. As to the free exercise of religion claim, the court stated that the right to act in accordance with religious beliefs is not free from governmental restraint, that the State’s interest in the preservation of human life would outweigh any constitutional right claimed here, and that there existed no independent parental right of religious freedom to support the relief Mr. Quinlan was requesting. Id. The court also concluded that the Eighth Amendment protection against cruel and unusual punishment was relevant only to penal sanctions and had never been extended to the correction of societal ills or injustices. Id. at 662.

33. Id. at 663. Justice Hughes analogized this scenario to that of a competent, terminally ill patient suffering from cancer and in great pain, whose right to refuse resuscitation or a respirator was unquestioned. Id.

34. 405 U.S. 438 (1972) (holding that the right to privacy gives an individual the right to be free from unwarranted governmental intrusion into the decision whether to bear a child).

35. 381 U.S. 479 (1965) (holding that the penumbra of the Bill of Rights protects an individual’s privacy interests from governmental intrusion).

36. 410 U.S. 113 (1973) (holding that the constitutional right of privacy is broad enough to include a woman’s right to terminate her pregnancy).

2006] The Road from Quinlan to Schiavo 389

Supreme Court stated that the constitutional right of privacy existing in the penumbra of the Bill of Rights was surely broad enough to encompass an individual’s decision to decline medical treatment under certain conditions.37 The court buttressed this conclusion by articulating that the State’s legitimate interest in the preservation of human life necessarily weakens and the individual’s right to privacy grows as the extent of bodily invasion occasioned by the medical treatment increases and the patient’s prognosis dims.38 Given Karen Quinlan’s extremely poor prognosis, at least in terms of cognitive functioning, the high degree of bodily invasion involved in twenty-four hour nursing care, and the use of the respirator and feeding tube, the court asserted that the federal right to privacy would vindicate her choice, were she competent to make it, to choose not to have her life prolonged by extraordinary medical treatment.39

The extension of the right to privacy to the realm of refusing life- sustaining medical treatment was an important development in the law, but the New Jersey Supreme Court went one critical step further. It is a step that still reverberates today. The court acknowledged the difficulty of effectuating Karen’s right to choose in circumstances where she had been rendered incompetent and where her choice could not be adequately discerned from prior conversations with friends and family.40 The justices might have concluded that Karen’s privacy right could be honored only under circumstances where there was some degree of legal certainty regarding the choice she would have made were she competent, a path that many courts have taken in the intervening years.41 Instead, the court held that:

The only practical way to prevent destruction of the right is to permit the guardian and family of Karen to render their best judgment . . . as to whether she would exercise it in these circumstances. If their conclusion is in the affirmative this decision should be accepted by a society the overwhelming majority of whose members would, we

37. Quinlan, 355 A.2d at 663. The court also referenced but did not discuss the right of privacy that is contained within Art. I, paragraph 1, of the New Jersey Constitution. Id.

38. Id. at 664. 39. Id. 40. The N.J. Supreme Court concurred in the chancery court’s conclusion that Karen’s prior

statements regarding withdrawal of extraordinary treatment were too remote and impersonal and thus lacked sufficient probative weight to be given legal effect. Id. at 653, 664.

41. See, e.g., Matter of Visbeck, 510 A.2d 125, 131 (N.J. Super. Ct. Ch. Div. 1986) (holding that unless the patient, while competent, clearly indicates a personal desire to do so, treatment may not be withheld); In re A.C., 573 A.2d 1235, 1247 (D.C. 1980) (holding that whenever possible, the judge should attempt to speak to the patient and ascertain her wishes).

390 Loyola University Chicago Law Journal [Vol. 37

think, in similar circumstances, exercise such a choice in the same way for themselves or for those closest to them.42

Thus, lacking a sufficient factual basis to make the legal determination of what choice Karen would have made regarding the withdrawal of the respirator, the court ceded its parens patriae power to Karen Ann Quinlan’s family, and more specifically to Joseph Quinlan, her father and now legal guardian.43 This decision is exactly one hundred eighty degrees from that of the chancery court, which ceded decision-making power entirely to the medical profession.44

In reaching this very different outcome, the New Jersey Supreme Court adopted a contrary view of the medical profession, one somewhat less deferential and slightly more realistic. In addressing the “medical factor,” the court ultimately rejected the chancery court judge’s proposition that societal morality rests in the hands of physicians, finding instead that the courts have a “nondelegable judicial responsibility” to decide matters before them and to reexamine underlying human rights and values when faced with new questions wrought by advances in medical technology.45 Furthermore, the court stated that judicial decisions must pay attention not only to current medical standards and practices but also to the common moral judgment of the community.46 Thus, the court accepted that then-existing medical standards supported Dr. Morse’s decision to refuse to withdraw Karen’s respirator, but questioned whether physicians sometimes failed to achieve a proper balance between curing the sick and prolonging the dying process for their patients who were being kept alive indefinitely by advances in life-sustaining technology.47

Justice Hughes postulated that physicians continued to provide medical treatment to those patients with irreversible conditions and poor prognoses both because of the enormity of the ethical decisions they were called upon to make and also out of concern for potential civil or criminal liability should withdrawal of treatment lead to a patient’s death.48 The New Jersey Supreme Court sought to assist the medical profession with these concerns, by first proposing that hospital ethics

42. Quinlan, 355 A.2d at 664. 43. See id. at 669 (holding that Quinlan’s right to privacy would be vindicated by her

guardian, her father). 44. In re Quinlan, 348 A.2d 801, 819 (N.J. Super. Ct. Ch. Div. 1975), modified and remanded,

355 A.2d 647 (N.J. 1976). 45. In re Quinlan, 355 A.2d 647, 665 (N.J. 1976). 46. Id. 47. Id. at 667. 48. Id. at 668.

2006] The Road from Quinlan to Schiavo 391

committees could share the responsibility in an advisory capacity for difficult ethical decisions.49 Second, the court reassured physicians that withdrawal of life-sustaining treatment in aid of an individual’s privacy right was lawful and could not, therefore, subject the physician to criminal prosecution or liability.50

Having completed its constitutional and philosophical exegesis, the court finally took up the question of whether the chancery court had erred in refusing to appoint Mr. Quinlan to be the legal guardian of his daughter’s person.51 Noting that the guardianship statute created an initial presumption in favor of next of kin, Justice Hughes swiftly concluded that Joseph Quinlan’s strength of character and purpose made him eminently suited for the position.52 Rather than directly authorizing the withdrawal of life support, however, the court expressly reserved that power to Mr. Quinlan, as guardian, and Karen’s family, as long as the attending physicians and hospital ethics committee agreed that there was no reasonable probability that Karen would ever return to a cognitive, sapient state.53 In a strange and sad twist of fate, when the respirator was withdrawn at Mr. Quinlan’s request following the court’s decision, Karen Ann Quinlan survived for an additional nine years, remaining throughout that time in a persistent vegetative state without self-awareness or awareness of her surroundings.54

The New Jersey Supreme Court’s decision in Quinlan was remarkably forward-looking on four grounds. First, it acknowledged that families and health-care providers had regularly been withholding or withdrawing life-sustaining treatment in accord with the express or implied wishes of patients without the sanction of civil law.55

49. Id. at 668–69. Justice Hughes articulated several grounds upon which Ethics Committee consultation would be useful in cases such as Quinlan: (1) shared and diffused responsibility with regard to difficult ethical decisions; (2) the addition of diverse views of other professionals such as social workers, theologians, and attorneys to those of physicians; and (3) the likelihood that new courses of action in aid of dying patients could be undertaken with less concern about liability and societal censure if the Ethics Committee stood behind the decision. Id.

50. Id. at 669–70. 51. Id. at 670. The court also held that termination of treatment would not be a criminal act

because “the ensuing death would not be homicide but rather expiration from existing natural causes.” Id.

52. Id. at 670–71 (“[W]hile Mr. Quinlan feels a natural grief, and understandably sorrows because of the tragedy which has befallen his daughter, his strength of purpose and character far outweighs these sentiments and qualifies him eminently for guardianship of the person as well as the property of his daughter.”).

53. Id. at 671–72. 54. McFadden, supra note 7, at A1. 55. Quinlan, 355 A.2d at 659–60 (citing with approval from Bishop Casey’s statement

regarding the gap in the law regarding cases such as Karen Quinlan’s).

392 Loyola University Chicago Law Journal [Vol. 37

Second, it recognized that the federal constitutional right to privacy was broad enough to encompass an individual’s decision to decline medical treatment, even if that decision would lead to the individual’s death.56

Third, it refused to rest the decision whether to withdraw life- sustaining treatment exclusively in the hands of the medical profession, holding rather that an incompetent individual’s right of privacy could be asserted on her behalf by a guardian, even under circumstances where the court could not discern her wishes based on prior statements while competent.57

Finally, it emphasized that in making the decision whether to withdraw treatment in circumstances such as these, the critical inquiry turned not on an individual’s chance for mere biological existence but rather on whether there existed a reasonable medical probability that the person could return to a cognitive and sapient life.58

III. THE CASE OF NANCY BETH CRUZAN

Had courts followed the path laid down in 1976 by the New Jersey Supreme Court in Quinlan, the road over the ensuing three decades might have been a bit smoother. Instead, the United States Supreme Court took up the Cruzan case59 in 1990 and took us down a different and even more difficult path to life-and-death decision making for incompetent individuals.

Nancy Beth Cruzan was a young adult in 1983 when she lost control of her car and was thrown into a ditch, where she lay without respiratory or cardiac function for some twelve to fourteen minutes.60 Paramedics were able to restore her breathing and heartbeat at the accident site and transported her to the hospital, where she remained in a coma for three weeks, “progressed to an unconscious state in which she was able to orally ingest some nutrition,” and then regressed into a persistent vegetative state in which she would remain for the rest of her life.61 Nancy was able to breathe on her own62 but required the surgical

56. Id. at 663; see, e.g., Griswold v. Connecticut, 381 U.S. 479 (1965) (finding an constitutional right to privacy exists in the penumbra of the specific guarantees of the Bill of Rights); Roe v. Wade, 410 U.S. 113 (1993) (holding the right of privacy to be broad enough to include a woman’s decision to terminate a pregnancy in some circumstances).

57. Quinlan, 355 A.2d at 664. 58. Id. at 669. 59. Cruzan v. Dir., Mo. Dep’t of Health, 497 U.S. 261 (1990). 60. Id. at 266; see also William H. Colby, LONG GOODBYE: THE DEATHS OF NANCY CRUZAN

7–9 (2002) (summarizing the events leading to Nancy Cruzan’s vegetative state). 61. Cruzan, 497 U.S. at 266.

2006] The Road from Quinlan to Schiavo 393

insertion of a gastrostomy tube to receive adequate nutrition an

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Description:

Total Possible Score: 6.00

Distinguished – Thoroughly describes one’s personal worldview.

Proficient – Describes one’s personal worldview. Minor details are missing.

Basic – Minimally describes one’s personal worldview. Relevant details are missing.

Below Expectations – Attempts to describe one’s personal worldview; however, significant details are missing.

Non-Performance – The description of one’s personal worldview is either nonexistent or lacks the components described in the assignment instructions.

Distinguished – Comprehensively explains how elements of the personal worldview could positively influence one’s perception of the problem.

Proficient – Explains how elements of the personal worldview could positively influence one’s perception of the problem. The explanation is slightly underdeveloped.

Basic – Minimally explains how elements of the personal worldview could positively influence one’s perception of the problem. The explanation is underdeveloped.

Below Expectations – Attempts to explain how elements of the personal worldview could positively influence one’s perception of the problem; however, the explanation is significantly underdeveloped.

Non-Performance – The explanation of how elements of the personal worldview could positively influence one’s perception of the problem is either nonexistent or lacks the components described in the assignment instructions.

Distinguished – Thoroughly, clearly, and accurately examines the worldview for existing or potential biases that may negatively impact one’s perception of the problem or potential solutions.

Proficient – Examines the worldview for existing or potential biases that may negatively impact one’s perception of the problem or potential solutions. Minor details are missing, slightly unclear, or inaccurate.

Basic – Minimally examines the worldview for existing or potential biases that may negatively impact one’s perception of the problem or potential solutions. Relevant details are missing, unclear, and/or inaccurate.

Below Expectations – Attempts to examine the worldview for existing or potential biases that may negatively impact one’s perception of the problem or potential solutions; however, significant details are missing, unclear, and inaccurate.

Non-Performance – The examination of the worldview for existing or potential biases that may negatively impact one’s perception of the problem or potential solutions is either nonexistent or lacks the components described in the assignment instructions.

Distinguished – Thoroughly describes at least two ways in which biases can be prevented.

Proficient – Describes at least two ways in which biases can be prevented. Minor details are missing.

GEN499.W2A1.09.2023

Describes One’s Personal Worldview Total: 1.00

Explains How Elements of the Personal Worldview Could Positively Influence One’s Perception of the Problem

Total: 1.00

Examines the Worldview for Existing or Potential Biases That May Negatively Impact One’s Perception of the Problem or Potential Solutions

Total: 1.00

Describes At Least Two Ways in Which Biases Can Be Prevented Total: 1.00

Basic – Minimally describes at least one way in which biases can be prevented. Relevant details are missing.

Below Expectations – Attempts to describe at least one way in which biases can be prevented; however, significant details are missing.

Non-Performance – The description of at least two ways in which biases can be prevented is either nonexistent or lacks the components described in the assignment instructions.

Distinguished – Displays meticulous comprehension and organization of syntax and mechanics, such as spelling and grammar. Written work contains no errors and is very easy to understand.

Proficient – Displays comprehension and organization of syntax and mechanics, such as spelling and grammar. Written work contains only a few minor errors and is mostly easy to understand.

Basic – Displays basic comprehension of syntax and mechanics, such as spelling and grammar. Written work contains a few errors which may slightly distract the reader.

Below Expectations – Fails to display basic comprehension of syntax or mechanics, such as spelling and grammar. Written work contains major errors which distract the reader.

Non-Performance – The assignment is either nonexistent or lacks the components described in the instructions.

Distinguished – Demonstrates methodical application of organization and presentation of content. The purpose of the writing is evident and easy to understand. Summaries, quotes, and/or paraphrases fit naturally into the sentences and paragraphs. Paper flows smoothly.

Proficient – Demonstrates sufficient application of organization and presentation of content. The purpose of the writing is, for the most part, clear and easy to understand. There are some problems with the blending of summaries, paraphrases, and quotes. Paper flows somewhat smoothly.

Basic – Demonstrates a limited understanding of organization and presentation of content in written work. The purpose of the writing is somewhat evident but may not be integrated throughout the assignment. There are many problems with the blending of summaries, paraphrases, and quotes. Paper does not flow smoothly in all sections.

Below Expectations – Organization and presentation of content are extremely limited. The purpose of the writing is unclear. There is little or no blending of summaries, paraphrases, and quotes. Paper does not flow smoothly when read.

Non-Performance – The assignment is either nonexistent or lacks the components described in the instructions.

Distinguished – Accurately uses APA formatting consistently throughout the paper, title page, and reference page.

Proficient – Exhibits APA formatting throughout the paper. However, layout contains a few minor errors.

Basic – Exhibits limited knowledge of APA formatting throughout the paper. However, layout does not meet all APA requirements.

Below Expectations – Fails to exhibit basic knowledge of APA formatting. There are frequent errors, making the layout difficult to distinguish as APA.

Non-Performance – The assignment is either nonexistent or lacks the components described in the instructions.

Distinguished – Uses more than the required number of scholarly sources, providing compelling evidence to support ideas. All sources on the reference page are used and cited correctly within the body of the assignment.

Proficient – Uses the required number of scholarly sources to support ideas. All sources on the reference page are used and cited correctly within the body of the assignment.

Basic – Uses less than the required number of sources to support ideas. Some sources may not be scholarly. Most sources on

Written Communication: Control of Syntax and Mechanics Total: 0.50

Written Communication: Context of and Purpose for Writing Total: 0.50

Written Communication: APA Formatting Total: 0.50

Written Communication: Resource Requirement Total: 0.50

the reference page are used within the body of the assignment. Citations may not be formatted correctly.

Below Expectations – Uses an inadequate number of sources that provide little or no support for ideas. Sources used may not be scholarly. Most sources on the reference page are not used within the body of the assignment. Citations are not formatted correctly.

Non-Performance – The assignment is either nonexistent or lacks the components described in the instructions.

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Module 2 Learning Outcomes

In this module, you will consider how your personal experiences and knowledge gained through your postsecondary general education courses inform your analysis and understanding of problems. After reading this module, you should be able to

ሁ Compare the limitations and functional benefits of a lens as a means of interpreting truth. ሁ Reflect on your individual cultural lens and the ways in which it impacts your understanding of

phenomena. ሁ Articulate how using a theoretical lens can focus and enhance your problem-solving efforts. ሁ Evaluate theories to determine their relevancy to a problem of interest.

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Part 4Module 2 Introduction

Module 2 Introduction In 1799, George Washington, the first president of the United States, died in his Mount Vernon bedroom after doctors had extracted nearly 40% of his blood volume while attempting to cure a throat infection. His wife, Martha, purportedly shared her concerns about this method of treatment, but Washington had requested it, believing it had cured him of past illness. While Washington’s exact diagnosis is unknown, he died within a day of his first complaints (Wallenborn, 1997). Modern physicians might infer that it was the bloodletting treatment that led to his rapid decline, but it would be inappropriate to criticize the doctors who admin- istered a method of care considered to be standard best practice for nearly 3,000 years (Greenstone, 2010).

The medical treatment of bloodletting was based on an understanding of disease theorized by Greek physician Hippocrates (approximately 460–370 BC) well prior to the discovery of molds and bacteria in the mid – to late-1600s (Nouri, 2011). Because germs were unknown in Hippocrates’ time, he believed disease to be the result of an imbalance of four bodily elements called humors: blood, phlegm, black bile, and yellow bile. Bloodletting via small cuts and scraping was thought to restore that bal- ance and offer a cure. Leeches, a predatory worm, were added to the practice in the early 19th century (Greenstone, 2010).

As science has advanced, medical practice has also evolved. Hippocrates’ theory of bodily humors has been replaced by a modern understanding of anat- omy and medicine, and bloodletting is no longer a standard treatment. It is easy to reflect in hindsight on the errors of past thinking and practice (recall hindsight bias from Module 1), but imagine yourself as a mediaeval physician or as one of Washington’s doctors; you would have had to act on what you understood as truth.

Ask the ancient Greeks who first countered com- mon knowledge of a flat earth with a spherical hypothesis; truth, as it turns out, is a tricky thing. By definition, truth is based on proven fact or com- monly accepted reality. Ironically, this definition reveals truth’s flaws. First is the issue of “proven.” To offer proof, evidence must be produced accord- ing to an agreed upon method. Experts are often called upon to establish standard methods and to evaluate the accuracy of evidence. Therefore, proof is subject to expert opinion. Expert opinion is based on the wisdom and knowledge of the era—hence, bloodletting. Similarly, truth that is based on “commonly accepted reality” requires the shared subjective experience that something is true.

“A medical practitioner administers leeches” by Wellcome Trust is licensed under CC BY 4.0.

ሁ As our understanding of anatomy and medicine has evolved, so too has the way doctors treat patients. In the early 19th century, leeches were used for bloodletting, which was believed to cure various illnesses and restore balance to a sick patient’s body.

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Part 1Establishing a Lens of Understanding

Although an objective reality may exist that is not subject to human experience and interpre- tation, when discussing truth, humans are limited to what we have experienced either col- lectively or individually. In other words, objective truth may exist, but it may be unknowable. This module introduces how you might view the circumstances of a problem through the subjective lens of truth, noting that this lens is both a limitation and a potential advantage in bringing focus to complex issues. As you read this module, you are encouraged to reflect on your own lens of understanding, how it is informed by your strengths and preferences, and how you might apply this lens as you set out to analyze and solve problems.

Part 1: Establishing a Lens of Understanding With so much uncertainty about the nature of truth, it may seem unlikely that humans agree on anything, especially as each person views phenomena through their own lens of under- standing that serves as a filter through which information is perceived and interpreted. A basis for common understanding is formed through education. In primary and secondary school, students are often taught highly evidenced, basic facts. Examples include math facts like multiplication tables, the varying energetic intensity of clouds in producing storms, and witnessed historical facts, such as the order of the presidents of the United States. Education also provides students with fundamental skills for differentiating fact from opinion. Facts are defined as something that can be supported by evidence, whereas opinion is based on

2 Developing

a lens of understanding

4 Finding

solutions and gaining support

f02.00_UN_GEN499.ai

1 Identifying

and defining problems

3 Collecting

and considering data

5 Taking

action and leading change

 Self-reflect on your cultural lens and personal beliefs.  Map concepts related to the problem.  Conduct research to find relevant theories or existing models.

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Part 1Establishing a Lens of Understanding

subjective beliefs that may vary from person to person. For a fact to be a fact, it must be unaf- fected by what an individual thinks or feels about it. Students might list state capitals as fact, for example, but offer opinion as to whether each capital is a desirable vacation destination.

Discerning fact from opinion is key in analyzing the quality of a source. This is yet another skill that students hone throughout their education, but it can be a confusing effort. Students may find that different sources argue over the logical soundness of evidence used to support facts. Or some sources may offer evidence that directly conflicts with another’s statement of fact. As students develop information literacy, they learn specific strategies to evaluate such conflicts. Researching a source’s credentials, potential biases, and motivations can help in determining their credibility, or trustworthiness. However, it may still occur that equally cred- ible experts in a field disagree on the truth of a matter, each providing seemingly sound evi- dence to bolster their counterpoints. In these instances, a student might compare the experts’ varied worldviews, their individual experiences, and the theoretical lens through which they view phenomena. Often, an individual will be most inclined to believe or to agree with those whose “lens” is most aligned with their own.

Defining “Lens” In photography, the role of the camera lens is to adjust focus and depth of the field of view with the aim of drawing attention to specific subjects. There is more at play when compar- ing camera lens types and exploring creative pos- sibilities, but at a basic level the lens sheds light on what the photographer wants to see and influences the quality of that image. It is the tool used to deter- mine not only what is in the picture, but also what is excluded.

“Lens” in the figurative sense is much like the pho- tographic tool. It is a perceptual and cognitive tool through which information is filtered and inter- preted. Learned through both experience and edu- cation, your lens of understanding is the unique perspective through which you view the world. This perspective is informed by any number of demographic factors, including your gender, age, where you live, work, or go to school, who you inter- act with, and so on. Your lens helps you determine what you see as normal, right, or good. It is your truth-o-meter when truth is hard to measure. It is important to acknowledge that your lens is not the only way to see things, and that what you consider to be normal or right may seem strange or even wrong through someone else’s lens. You may also be completely unaware of your own lens, despite recognizing when your viewpoints differ from others’. Problem solvers, like trained researchers, make a conscious effort to examine their ingrained and adopted lenses. This awareness allows them to

“Pushing the Leaning Tower of Pisa – 3” by Barney Moss is marked with CC BY 2.0.

ሁ This tourist photo of the Leaning Tower of Pisa provides a further reminder that what is captured through a lens may be more a matter of perspective than reality.

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Part 1Establishing a Lens of Understanding

check their own biases, assess the validity of other perspectives, and note when their lens has limited their focus to the wrong thing.

Lens as a Potential Limitation Your lens may also be described as your worldview. Worldview is a philosophical term refer- ring to your conception of the world and humanity’s role within it. It is “a collection of atti- tudes, values, stories and expectations” that informs your thoughts, behaviors, interactions, and judgments of others (Gray, 2011, p. 58). Certain fundamental beliefs form the core of your worldview, such as beliefs about the nature of reality, the origins of man and the universe, the meaning and purpose of life, and the nature of values. Unlike the practice of bloodlet- ting, the philosophical debates related to these beliefs often transcend time and elude sci- ence—despite humanity’s best efforts to resolve them. In the absence of definitive evidence, it is impossible to conclude that one belief is entirely accurate while the opposite is entirely wrong.

While a worldview isn’t necessarily limiting, it has the potential to limit how you see the world. The beliefs that stem from your worldview are so central to your understanding that they may be taken for granted. You may find yourself arguing with others about something that seems quite obvious to each of you, only to discover that your differences aren’t in the validity of your reasoning, but in your respective worldviews. The failure to recognize these funda- mental differences can limit your ability to understand and solve problems. This is especially the case when you’re unable to identify your own interpretative lens and instead assume that your beliefs are undeniable truth. In lacking this awareness, you may fail to understand oth- ers’ experiences and perspectives. Recalling the photography analogy in this instance, your lens may define more of what you do not see, rather than providing further clarity and focus.

This limitation is also self-perpetuating. Because we view new experiences through our pre- existing lens, our interpretations of these experiences tend to validate and justify what we already believe. Confirmation bias, the psychological tendency to actively seek information and evidence that supports existing beliefs, also contributes to unchallenged worldviews. Understanding these tendencies can help you to appreciate why others might deny certain facts of a situation, or why you may also struggle to see another’s point of view.

Just as all lenses can be limiting, all lenses can be useful, too. Your worldview offers an impor- tant foundation to identify and examine issues in your life and helps form the basis of your opin- ions and perspectives. It is only when you close yourself off from learning and considering new information, and hearing others’ views, that your worldview is purely limiting. To ensure that your lens is not limiting, spend time reflecting on your beliefs, but also ponder possible alterna- tives. Actively seek to learn about other perspectives. Be open to feedback from others. Be will- ing to listen, and humbly seek truth in what others have to say, even if you ultimately disagree.

Lens as a Tool While a narrowed view of the world can be a limitation, when acknowledged, a lens can actu- ally serve a functional purpose. Being open to limitless possibilities may sound like a noble social ideal. The pursuit of lifelong learning may even lead you down many different intellec- tual paths. In the interest of being politically correct, some people even fear committing to a certain viewpoint. But there is a difference between considering all perspectives and accept- ing all possibilities as truth. Some views will always be mutually exclusive, wherein two or

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Part 1Establishing a Lens of Understanding

more possibilities conflict to the extent that they cannot coexist or be simultaneously true. To move forward with purpose and action, you must be willing to commit to a particular way of viewing or examining a problem.

As noted in the opening of the section, education offers students a common understanding of basic phenomena. In college or university studies, students begin to unpack the differences in their perspectives on these phenomena. Such differences may be found in relation to their peers, their instructors, and the scholars whose work they read. Rather than simply evaluate the credibility of a source, college students are asked to evaluate the quality of the source’s ideas. Critical evaluation of others’ competing claims for truth is a necessary step in a college student’s journey toward asserting their own claims. Guided by their instructors in the evalu- ation of others’ arguments, students are also encouraged to reflect critically on their own viewpoints. These efforts lead students to the goal of establishing a framework to test their own ideas (Perry, 1999). In other words, college students are led to assess the worldview inherited from their childhood experiences and develop an intentional lens—one that is still anchored in their values but informed by a deeper understanding of self and the world.

To understand how a lens could be used as a tool, consider the function of another device that makes use of literal lenses: the telescope. Attributed to physicist Galileo Galilei (1564–1642), the telescope is a device that enables astronomers to see objects at great distances, such as the Messier 51 galaxy that is located 31 million light-years from Earth (Garner, 2021; Macha- mer & Miller, 2021).

Hubble Space Telescope, a satellite telescope residing outside of Earth’s atmosphere, captures images from as far as 13.4 billion light-years away (Vogel, 2022). Telescopes use perfectly engineered optics, often a combination of mirrors and lenses, to concentrate light on regions of the night sky that an astronomer wishes to explore in greater detail (NASA Science, 2021). If an observer were to view the night sky without a telescope, they may only identify the faint stars of the constellation, Canes Venatici, where the Messier 51 galaxy resides.

“Hubble image of M51, the ‘Whirlpool Galaxy’” by dsleeter_2000 is licensed under CC BY 2.0.

“CanesVenaticiCC.jpg” by Till Credner is licensed under CC BY-SA 3.0.

ሁ Note the differences in these two images of the Messier 51 galaxy. The photo on the left was taken with the Hubble Space Telescope and the one on the right was taken without a telescope.

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Part 2Examining Cultural Lenses

Without a telescope, an observer sees the broader picture of many stars and galaxies from Earth’s viewpoint. With the telescope, the observer gathers a much more detailed image and understanding of a galaxy of interest. Similarly, by applying the lens of your worldview to a specific phenomenon, you’re able to see and analyze that issue in more refined detail. When you then consider other perspectives, you may lose that refinement, but see more of the larger context of possibilities.

For your lens to serve as a tool, rather than a limitation, you must regularly reflect on it. It is necessary to become critically self-aware of both your assumptions and those things you might be excluding from sight in favor of the clarity of narrowed focus. This module provides more detail in this regard in the sections that follow.

Part 2: Examining Cultural Lenses The ancient Greek philosophers Plato and Aristotle were the first to explore—or at least the first to document—ideas of worldview and individual perspective (Marshall, 1995). Their findings formed the basis for considering how individuals experience and make sense of their world. Philosopher Immanuel Kant was the first to describe these organizing structures of the mind as schemas (Kant, 1781–1787/1929). He theorized that individuals rely on prior experiences to categorize new information. As they encounter new information, people draw intuitive relationships, assigning categories as a means of intellectual efficiency (Pendlebury, 1995). In other words, when an individual encounters something new, they make sense of it through the lens of what they already know.

In his 1932 publication Remembering: A Study in Experimental and Social Psychology, psychol- ogist Frederic Bartlett adopted the term schema, introducing this theory to the field of psy- chology. Schemas, he reasoned, are the building blocks for learning, memory, and decision- making processes. They are the mental models that serve as the lens of individual experience. So to understand how an individual lens is formed, the influences that shape it, and to evalu- ate its malleability, it’s necessary to turn to the field of psychology where schemas have not only been theorized but demonstrated via empirical study and brain scans.

Schema Development As part of investigating the formation of schemas, cognitive psychologists have conducted experiments in which they presented research participants with a combination of previously familiar and previously unfamiliar sensory information in the form of video or pictures (Bal- dassano et al., 2018; Webb & Dennis, 2020). They then asked participants to view images

Part 1 Knowledge Check

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