Whether a person has a right to refuse medical treatment?
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
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.
- Incompetent persons are not able to make an informed choice
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.
Such a right must be exercised for her, if at all, by some sort
Procedural safeguards - For Surrogates that elect to remove life
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and nutrition withdrawn in such a way as to cause death, but it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
Missouri requires that evidence of the incompetent's wishes as
to the withdrawal of treatment be proved by clear and convincing
Whether the United States Constitution forbids the establishment
of this procedural requirement by the state.
We hold that it does not.
Missouri relies on its interest in the protection and
preservation of human life, and there can be no gainsaying this
State has more particular interests at stake.
The choice between life and death is a deeply personal decision
of obvious and overwhelming finality.
- Heightened evidentiary requirements
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
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.
Not all incompetent patients will have loved ones available to
serve as surrogate
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
state is entitled to guard against potential abuses in such
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.
- Permissible adoption of clear and convincing standard
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.
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
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
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
Our cases do not support this claim.
No doubt is engendered by anything in this record but that Nancy
Cruzan's mother and father are loving and caring parents.
If the State were required by the Constitution to repose a right
of "substituted judgment" with anyone, the Cruzans would surely
But we do not think the Due Process Clause requires the State to
repose judgment on these matters with anyone but the patient
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
Concurring - Justice OConnor
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
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
In my view, such a duty may well be constitutionally required to
protect the patient's liberty interest in refusing medical
Few individuals provide explicit oral or written instructions
regarding their intent to refuse medical treatment should they
Dissent - Justice Brennan
Unwanted Medical Treatment: States cannot outweigh rights of
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
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.
The only state interest asserted here is a general interest in
the preservation of life.
No legitimate Interest
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.
This is not to say that the state has no legitimate interest to
As the majority recognizes, Missouri has a
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
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
May impose requirements that enhance the accuracy of
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
The Missouri safeguard that the Court upholds today does not
meet this standard.
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
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
Must bear a reasonable relationship to a legitimate state end
To be constitutionally permissible, Missouri's intrusion upon
these fundamental liberties must, at a minimum, bear a
reasonable relationship to a legitimate state end.
Missouri asserts that its policy is related to a state interest
in the protection of life.
In my view, however, it is an effort to define life, rather than
protect it, that is at the heart of Missouri's policy.
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.