The following is an edited transcript of an MDAdvantage podcast with Steve Adubato, PhD, and the Honorable Paul W. Armstrong, JSC (Ret.), recorded on January 25, 2023. Judge Armstrong previously served for 15 years as a New Jersey Superior Court Judge in Somerset, Hunterdon and Warren Counties in the Civil, Criminal and Family Divisions. He also served as the inaugural Drug Court Judge in both Somerset and Hunterdon counties. He is currently a Senior Policy Fellow and Judge in Residence for the Program in Health Administration at the Edward J. Bloustein School of Planning and Public Policy at Rutgers University. In this interview, Judge Armstrong discusses landmark New Jersey cases, including the Karen Ann Quinlan and Charles Cullen cases, the recent Dobbs case overturning Roe v. Wade, and the birth of bioethics in New Jersey.
ADUBATO: Judge Armstrong, you have been involved as a judge and as an expert in the field of law, notably, law dealing with medicine and healthcare. Of the many cases you’ve adjudicated, which one stands out as most important to the healthcare community?
JUDGE ARMSTRONG: I know that we both share admiration for the only individual to ever serve as both Governor of New Jersey and Chief Justice of the New Jersey Supreme Court, and that, of course, is Richard J. Hughes, who authored the Karen Ann Quinlan case. This case has been translated into 64 languages all over the world and was the first case to recognize that each of us has a fundamental right to make medical decisions at the end of life. As the Chief used to say, it’s not a “right to die” case. He pointed out that, unfortunately, all of us will eventually die, but this case is about the right to make fundamental decisions while you are dying. I have been to 43 states and seven countries teaching Chief Justice Hughes’s unanimous Karen Ann Quinlan decision.
ADUBATO: That is an important case. But you, yourself, presided over the State v. Cullen case—the one about the infamous serial killer nurse who admitted to murdering hundreds of patients. In fact, there are now two movies about Charles Cullen available on Netflix: The Good Nurse starring Jessica Chastain and Eddy Redmayne and a 2022 documentary called Capturing the Killer Nurse, in which you make a cameo appearance. This was a case that had great impact in so many areas of healthcare and medicine. Tell us about that.
JUDGE ARMSTRONG: That is another extraordinary case. We arrested Cullen in 2003, and I sentenced him in 2006 after the investigators determined that he had murdered 29 people in nine separate hospitals. He later admitted to killing more than 400 people. It’s extraordinary to think that where people go for care and treatment could be a place where they end up being murdered by a nurse. A lot of things developed from the case, including the responsibility of the institutions within which Charlie Cullen practiced as a nurse and murdered individuals. As a result of his being sentenced to 11 life sentences in New Jersey State Prison, the New Jersey Legislature passed the so-called Cullen Act (officially known as the Health Care Professional Responsibility and Reporting Enhancement Act), which requires institutions to notify law enforcement officials and the health department when they suspect that activities like this are taking place. Thirty-six other states followed by passing similar laws in their jurisdictions.
“Sooner or later, the things we hold sacred in America end up in an American courtoom.”
ADUBATO: The implications of the Cullen case, the Karen Ann Quinlan case, and so many others, have had a significant impact on healthcare in the State of New Jersey and in the nation. Do you think most people realize that?
JUDGE ARMSTRONG: Indeed. And we can’t leave out another one of New Jersey’s landmark cases—the Baby M custody case that became the first American court ruling on the validity of surrogacy. Sooner or later, the things we hold sacred in America end up in an American courtroom. That doesn’t happen in England, and France and Germany. The various codes of ethics for medicine in England, or France, or Germany or Italy are able to respond to the development of science. What happens in the U.S. is that we develop a new scientific modality. It’s then applied through medicine and then there’s a question of when we can use it and when we can stop using it. Then, rather than assume the responsibility, those questions end up in an American courtroom where they ask individual judges and ultimately, the State Supreme Court or the United States Supreme Court, to make the decision for them.
ADUBATO: Could you put bioethics and the judiciary in context?
JUDGE ARMSTRONG: Absolutely. The birth of bioethics began with the Quinlan case. Then more cases that raised moral and legal questions continued in other prominent New Jersey cases. The cases of Claire Conroy, Nancy Jobes, Hilda Peter and Kathleen Farrell all centered on the circumstances under which life-sustaining treatment may be withdrawn or withheld from individuals suffering from incurable and irreversible medical conditions. Then only after 37 states followed Chief Justice Hughes’ decision in the Quinlan case did we reach the United States Supreme Court, where I was privileged to represent the American Hospital Association in the landmark Nancy Beth Cruzan case, regarding a 25 year-old young adult. The issue in this case was whether a state could order a person to receive invasive medical treatment when that order is contrary to the wishes of the family. It was the first “right to die” case ever heard by the U.S. Supreme Court. Uniquely, the United States Supreme Court cited the New Jersey Supreme Court as precedent for its ultimate decision. Usually, we lower court judges cite the United State Supreme Court, but, in this instance, the wisdom and the insight of a man who was a governor and a chief justice and who understood the practical ramifications of the decisions, is the reason why we still look to the birth of bioethics in the Quinlan case.
ADUBATO: Your passion not just for the law but specifically for health- and medical-related law issues is very strong. Where does this dual passion come from?
JUDGE ARMSTRONG:
Actually, I studied premed. I figured maybe I would go to medical school or maybe I would go to law school, and I ended up going to the University of Notre Dame School of Law and New York University’s School of Law. Looking back, I realize that I’ve spent more time in hospitals than most physicians have for the last 50 years. It’s been a joy and a privilege to work closely with healthcare providers and patients.
