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Cruzan v. Director, Missouri Department of Health, 497 U.S. 261 |
Supreme Court of the United States |
1990 |
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Chapter |
6 |
Title |
Implied Fundamental Rights |
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Page |
927 |
Topic |
Due Process Clause: Protect life and refusing medical life support treatment |
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Quick Notes |
Nancy Cruzan suffered severe brain damage in an automobile accident. She was in a vegetative state. Nancy's parents asked the hospital to end the artificial nutrition and hydration procedures. Everyone agreed that she would die if these procedures were terminated. But the hospital refused to do this without a court order.
Parents Argument - Fourteenth Amendment due process right to refuse medical treatment o Nancy's parents claimed in court that Nancy had a Fourteenth Amendment due process right not to be kept alive by unwanted medical procedures, and that before her accident she had told friends that she would not want to be kept alive in such a comatose condition.
Missouri - No Clear and Convincing Proof of Nancys intentions o But the Missouri Supreme Court, interpreting the state's "living will" statute, concluded that even if Nancy had such a Fourteenth Amendment right, the right could be exercised under state law only by "clear and convincing" evidence that Nancy would not have wanted the life-sustaining procedures used here. The court concluded that such clear and convincing evidence was not present, and it thus denied Nancy's parents' claim.
Rule o The due process clause protects an interest in life as well as an interest in refusing life-sustaining medical treatment, and a state may legitimately seek to safeguard the personal element of this choice for incompetent persons through the imposition of heightened evidentiary requirements. o States may assert an unqualified interest in the preservation of human life.
Court - Holding o In sum, all of the previous discussion for allowing Missouri to require clear and convincing evidence of the patient's wishes leads us to conclude that the State may choose to defer only to those wishes, rather than confide the decision to close family members.
Cruzan establishes two major propositions (1) A competent adult has a constitutionally-protected Fourteenth Amendment liberty interest in declining unwanted medical procedures. (2) Where the patient is incompetent, the state may constitutionally refuse to allow these medical procedures to be terminated except where there is "clear and convincing evidence" that this is what the patient would have wanted. |
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Book Name |
Constitutional Law : Stone, Seidman, Sunstein, Tushnet. ISBN: 978-0-7355-7719-0 |
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Issue |
o Whether a person has a right to refuse medical treatment? Yes. o Whether a state can require that those who want to cease medical treatment for a person in a persistent vegetative state bring forth evidence of that person's similar intent before permitting such an action? Yes, but in Missouris case, it has to be clear and convincing. |
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Procedure |
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Missouri |
o Supreme Court of Missouri which denied their petition for a court order directing the withdrawal of their daughter's artificial feeding and hydration equipment |
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Supreme |
o The United States Supreme Court affirmed. o It said that the Due Process Clause, U.S. Const. amend. XIV, did not require the state to repose [to place in someones control] judgment on matters concerning the right to refuse treatment with anyone but the patient herself. o The Court held that a state could choose to defer only to the patient's wishes rather than confide the decision to close family members. |
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Facts/Cases |
Discussion |
Key Phrases |
Rules/Laws |
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Pl - Cruzan Df - Director, Missouri Department of Health
Accident o On January 11, 1983, Nancy Cruzan entered a vegetative coma as a result of an automobile accident. Three Week Coma o She remained in a coma for approximately three weeks until she entered an unconscious state in which she was able to orally ingest some nutrition. Feeding Tube o In order to ease feeding and further her recovery, surgeons implanted a gastrostomy feeding and hydration tube into her body, doing so with the consent of her then husband. Vegetative State o Subsequent rehabilitative efforts proved unavailing, and Cruzan remained in a persistent vegetative state, a condition in which a person exhibits motor reflexes but evinces no indications of significant cognitive function, for the next seventeen years. Parents Removal Request o After it had become apparent that she had no chance of regaining her mental faculties, Cruzan's parents asked hospital employees to terminate the artificial nutrition and hydration procedures. o All agree that such a removal would cause her death. Hospital Refused o The employee's refused to honor the request without court approval |
Justice Rehnquist
Whether a person has a right to refuse medical treatment?
Informed Consent o The common law doctrine of informed consent is viewed as generally encompassing the right of a competent individual to refuse medical treatment.
Parents Claim - Incompetent has same right as competent o The parents assert that an incompetent person should possess the same right in this respect as is possessed by a competent person, as in, the right to refuse treatment.
Court - Incompetent persons are not able to make an informed choice o The difficulty with the parents' claim is that in a sense it begs the question whether an incompetent person is not able to make an informed and voluntary choice to exercise a hypothetical right to refuse treatment or any other right. o Such a right must be exercised for her, if at all, by some sort of surrogate.
Procedural safeguards - For Surrogates that elect to remove life support o Here, Missouri has recognized that under certain circumstances a surrogate may act for a patient in electing to have hydration and nutrition withdrawn in such a way as to cause death, but it has established a procedural safeguard to assure that the action of the surrogate conforms as best it may to the wishes expressed by the patient while competent.
Clear and Convincing Evidence o Missouri requires that evidence of the incompetent's wishes as to the withdrawal of treatment be proved by clear and convincing evidence.
Whether the United States Constitution forbids the establishment of this procedural requirement by the state. o We hold that it does not. o Missouri relies on its interest in the protection and preservation of human life, and there can be no gainsaying this interest.
A State has more particular interests at stake. o The choice between life and death is a deeply personal decision of obvious and overwhelming finality.
Court - Heightened evidentiary requirements o We believe Missouri may legitimately seek to safeguard the personal element of its choice through the imposition of heightened evidentiary requirements.
DPC - Protect the interest of life, Protect interest in refusing life support o 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.
Safeguard situations o Not all incompetent patients will have loved ones available to serve as surrogate decision-makers. o And even where family members are present, there will be some unfortunate situations in which family members will not act to protect a patient.
State is entitled to guard against abuses o A state is entitled to guard against potential abuses in such situations. o A state may also properly decline to make judgments about the quality of life that a particular individual may enjoy, and simply assert an unqualified interest in the preservation of human life to be weighed against the constitutionally protected interest of the individual.
Court - Permissible adoption of clear and convincing standard o In our view, Missouri has permissibly sought to advance these interests through the adoption of a clear and convincing standard of proof to govern such proceedings. o The Supreme Court of Missouri held that in this case the testimony adduced at trial did not amount to clear and convincing proof of the patient's desire to have hydration and nutrition withdrawn. o Based on the facts, we cannot say that the Missouri Supreme Court committed constitutional error in reaching the conclusion that it did.
Parents contend - Must accept substituted judgment of close family members o Missouri must accept the substituted judgment of close family members even in the absence of substantial proof that their views reflect the views of the patient.
Court - DPC deals only with the wishes of the individual (Clear and Convincing) o Our cases do not support this claim. o No doubt is engendered by anything in this record but that Nancy Cruzan's mother and father are loving and caring parents. o If the State were required by the Constitution to repose a right of "substituted judgment" with anyone, the Cruzans would surely qualify. o But we do not think the Due Process Clause requires the State to repose judgment on these matters with anyone but the patient herself. o In sum, all of the previous discussion for allowing Missouri to require clear and convincing evidence of the patient's wishes leads us to conclude that the State may choose to defer only to those wishes, rather than confide the decision to close family members.
Affirmed.
Concurring - Justice OConnor o I agree that a protected liberty interest in refusing unwanted medical treatment may be inferred from our prior decisions, and that the refusal of artificially delivered food and water is encompassed within that liberty interest.
Surrogate decision-maker rights not decided o I write separately to emphasize that the Court does not today decide the issue whether a State must also give effect to the decisions of a surrogate decision-maker.
Liberty in refusing treatment if there is explicit oral or written instructions o In my view, such a duty may well be constitutionally required to protect the patient's liberty interest in refusing medical treatment. o Few individuals provide explicit oral or written instructions regarding their intent to refuse medical treatment should they become incompetent.
Dissent - Justice Brennan
Unwanted Medical Treatment: States cannot outweigh rights of individuals o Although the right to be free of unwanted medical intervention may not be absolute, no state interest could outweigh the rights of an individual in Nancy Cruzan's position.
What good is obtained by remaining on life support o Whatever a state's possible interests in mandating life-support treatment under other circumstances, there is no good to be obtained here by Missouri's insistence that Nancy Cruzan remain on life-support systems if it is indeed her wish not to do so. o The only state interest asserted here is a general interest in the preservation of life.
No legitimate Interest o 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. o This is not to say that the state has no legitimate interest to assert here.
parens patriae interest o As the majority recognizes, Missouri has a parens patriae interest in providing Nancy Cruzan, now incompetent, with as accurate as possible a determination of how she would exercise her rights under these circumstances.
Safeguarding Accuracy of determination o But until Nancy's wishes have been determined, the only state interest that may be asserted is an interest in safeguarding the accuracy of that determination. Accuracy, therefore, must be our touchstone.
May impose requirements that enhance the accuracy of determination o 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.
Does not meet standard o The Missouri safeguard that the Court upholds today does not meet this standard. o The Court adverted to no evidence supporting its decision, and it failed to consider statements Nancy had made to family members and a close friend.
Failed to consider testimony o It also failed to consider testimony from Nancy's mother and sister that they were certain that Nancy would want to discontinue the artificial nutrition and hydration, even after finding that Nancy's family was loving and without malignant motive.
Must bear a reasonable relationship to a legitimate state end o To be constitutionally permissible, Missouri's intrusion upon these fundamental liberties must, at a minimum, bear a reasonable relationship to a legitimate state end. o Missouri asserts that its policy is related to a state interest in the protection of life. o In my view, however, it is an effort to define life, rather than protect it, that is at the heart of Missouri's policy. o This is not a legitimate end. In short, there is no reasonable ground for believing that Nancy Cruzan has any personal perpetuation of what the state has decided is her life. |
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Rules |
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Rule o The due process clause protects an interest in life as well as an interest in refusing life-sustaining medical treatment, and a state may legitimately seek to safeguard the personal element of this choice for incompetent persons through the imposition of heightened evidentiary requirements. o States may assert an unqualified interest in the preservation of human life.
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Class Notes |
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