Cruzan v. Director

In January 1983, Nancy Cruzan lost control of her car, which overturned. Found unconscious, she remained in a coma for three weeks, and eventually her condition progressed into what was termed a “persistent vegetative state,” where there are motor reflexes but no signs of cognition. She was able to survive when fed and hydrated artificially, but because there was “virtually no chance” of her recovering cognitive abilities, her parents requested that the hospital remove her feeding and hydration tubes, in order to allow her to die. The hospital refused, and the parents sought a court order.

The trial court granted the parents’ request, finding that an individual has the right under both the State and Federal Constitutions to refuse life-sustaining medical procedures or effectuate their withdrawal. The trial court also found that evidence from a prior conversation Nancy had with a friend showed that Nancy would not have wanted to continue in her current state.

However, the Supreme Court of Missouri reversed the trial court.  While the court recognized the right to refuse treatment, based on the right to informed consent, it rejected finding a broad right of privacy within the State Constitution and did not agree that such a right was necessarily in the Federal Constitution. The Court decided that the right to refuse treatment required in this scenario “clear and convincing” evidence of the intent of the incompetent person, and that no surrogate can make the choice for the incompetent without such evidence or a living will.

The Supreme Court of the United States granted certiorari to determine whether the petitioner has a right under the federal Constitution to refuse treatment in these circumstances and whether the decision of the Missouri supreme court violated that right.

The Court held that the federal Constitution does not prohibit Missouri from establishing a requirement of clear and convincing evidence as a procedural safeguard in the determination of an incompetent’s wishes to refuse treatment.

To determine whether the right to refuse treatment, which is encompassed in the right to due process of the Fourteenth Amendment of the Constitution, was violated, the Court employed a balancing test, balancing the state’s interest in protecting and preserving life, against the individual’s constitutionally protected rights. For the purposes of this case, the Court assumed that the Constitution grants a competent person the right to refuse lifesaving hydration and nutrition treatment. However, the Court did not agree with the petitioners that an incompetent person has the exact same right of refusal. The Court recognized that an incompetent person necessarily is unable to make an informed or voluntary decision, and as a consequence, their right to refuse is exercised by a surrogate. The Court found that Missouri was constitutionally permitted to require clear and convincing evidence of the incompetent’s wishes in order for the surrogate to act on behalf of the incompetent.

The Court also held that Missouri is not obligated to accept the “substituted judgment” of “close family members” as to the decision whether or not to prolong the life-sustaining treatment. The Court rejected petitioners’ reliance on previous cases, finding that those prior cases that permitted a state to rely on substituted judgment were not a constitutionally mandated requirement for a state to do so.

One concurrence distinguished this case from a right to commit suicide case and emphasize that this case does not mean that there is such a right.

Three Justices dissented, holding that the individual’s right to refuse unwanted treatment is fundamental and that a high level of scrutiny is required to show whether state interests are allowed to significantly interfere with that right. In this case, the dissent found that the “improperly biased procedural obstacles imposed by the Missouri Supreme Court impermissibly burden[ed] that right.”

“But in the context presented here, a State has more particular interests at stake. The choice between life and death is a deeply personal decision of obvious and overwhelming finality. We believe Missouri may legitimately seek to safeguard the personal element of this choice through the imposition of heightened evidentiary requirements. It cannot be disputed that the Due Process Clause protects an interest in life as well as an interest in refusing life-sustaining medical treatment.” (p. 281)

“If the State were required by the United States Constitution to repose a right of "substituted judgment" with anyone, the Cruzans would surely qualify. But we do not think the Due Process Clause requires the State to repose judgment on these matters with anyone but the patient herself. Close family members may have a strong feeling—a feeling not at all ignoble or unworthy, but not entirely disinterested, either—that they do not wish to witness the continuation of the life of a loved one which they regard as hopeless, meaningless, and even degrading. But there is no automatic assurance that the view of close family members will necessarily be the same as the patient's would have been had she been confronted with the prospect of her situation while competent.” (p. 286)

“The only state interest asserted here is a general interest in the preservation of life. But the State has no legitimate general interest in someone's life, completely abstracted from the interest of the person living that life, that could outweigh the person's choice to avoid medical treatment. "[T]he regulation of constitutionally protected decisions . . . must be predicated on legitimate state concerns other than disagreement with the choice the individual has made. . . . Otherwise, the interest in liberty protected by the Due Process Clause would be a nullity." . . . . Thus, the State's general interest in life must accede to Nancy Cruzan's particularized and intense interest in selfdetermination in her choice of medical treatment. There is simply nothing legitimately within the State's purview to be gained by superseding her decision.” (pp. 313-4, dissent)

“Missouri may constitutionally impose only those procedural requirements that serve to enhance the accuracy of a determination of Nancy Cruzan's wishes or are at least consistent with an accurate determination. The Missouri "safeguard" that the Court upholds today does not meet that standard. The determination needed in this context is whether the incompetent person would choose to live in a persistent vegetative state on life support or to avoid this medical treatment. Missouri's rule of decision imposes a markedly asymmetrical evidentiary burden. Only evidence of specific statements of treatment choice made by the patient when competent is admissible to support a finding that the patient, now in a persistent vegetative state, would wish to avoid further medical treatment. Moreover, this evidence must be clear and convincing. No proof is required to support a finding that the incompetent person would wish to continue treatment.” (p. 316, dissent)