Caseflicks

Supreme Court of the United States • 1990

Cruzan Ex Rel. Cruzan v. Director, Missouri Department of Health

497 U.S. 261 | 110 S. Ct. 2841 | 111 L. Ed. 2d 224 | 1990 U.S. LEXIS 3301 | 58 U.S.L.W. 4916

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Takeaway

In short, Cruzan permits States to require clear and convincing evidence of an incompetent patient's own wishes before life-sustaining treatment may be withdrawn, while recognizing—at least by assumption—a competent person's liberty interest in refusing unwanted medical care.

Background

Nancy Cruzan suffered severe brain damage after a 1983 automobile accident deprived her brain of oxygen for an estimated 12 to 14 minutes. She entered a persistent vegetative state: she retained certain reflexes and could breathe on her own, but showed no meaningful cognitive function and could not swallow food or water. A surgically implanted gastrostomy tube supplied artificial nutrition and hydration. Doctors concluded that she had virtually no prospect of recovering her mental faculties.

Nancy's parents and co-guardians asked the state hospital to remove the feeding tube, knowing that its removal would cause her death. Hospital employees refused without a court order. The Missouri trial court authorized withdrawal, finding that Nancy had a fundamental right to refuse death-prolonging procedures and that her prior statements to a roommate suggested she would not want to live unless she could live at least “halfway normally.”

The Supreme Court of Missouri reversed. It recognized a common-law right to refuse treatment but held that Nancy's informal statements did not provide clear and convincing evidence of her own wish to discontinue artificial nutrition and hydration. It also declined to let her parents make the decision through substituted judgment without the required proof of Nancy's wishes. The U.S. Supreme Court affirmed.

Issues

Issue #1

Whether the Fourteenth Amendment protects a competent person's liberty interest in refusing life-sustaining medical treatment, including artificial nutrition and hydration.

Holding

The Court assumed, without definitively deciding, that a competent person has a constitutionally protected liberty interest in refusing lifesaving hydration and nutrition.

Reasoning

The Court located the claimed interest in the Due Process Clause's protection of liberty, rather than in a broad constitutional right of privacy. Common-law doctrines of bodily integrity and informed consent strongly recognize that a competent adult generally controls what is done to her body, including the decision to refuse medical treatment.

Prior decisions involving compulsory vaccination, involuntary medication, bodily searches, and medical confinement supported the proposition that unwanted bodily intrusions implicate important liberty interests. The Court therefore accepted, for purposes of resolving this case, that forced life-sustaining treatment would burden a competent person's protected liberty interest.

That premise did not itself resolve Nancy Cruzan's case. Nancy was incompetent and could not make an informed, voluntary choice; the central constitutional question was instead what procedures Missouri could require before a surrogate could exercise a treatment-refusal decision on her behalf.

Issue #2

Whether the Due Process Clause forbids Missouri from requiring clear and convincing evidence of an incompetent patient's own wishes before permitting withdrawal of artificial nutrition and hydration.

Holding

No. Missouri could constitutionally require clear and convincing evidence that an incompetent patient would have chosen to withdraw life-sustaining treatment.

Reasoning

Missouri had legitimate interests in preserving human life, safeguarding the deeply personal choice between life and death, and protecting incompetent patients from error or abuse. The State could decline to make a quality-of-life judgment and could instead give substantial weight to the preservation of life.

A heightened evidentiary standard was an appropriate procedural safeguard because the decision to withdraw nutrition and hydration was final: an erroneous decision to terminate treatment could not be corrected. By contrast, an erroneous decision to continue treatment maintained the existing condition and left open the possibility of new evidence about the patient's wishes, medical advances, legal changes, or death from other causes.

Clear and convincing evidence is regularly used where individual and societal interests are especially important, including civil commitment, denaturalization, deportation, and termination of parental rights. Missouri could permissibly place the heightened risk of error on those seeking to end an incompetent person's life-sustaining treatment.

The Missouri Supreme Court did not commit constitutional error by finding Nancy's statements inadequate under that standard. Her comments about not wishing to live as a “vegetable” did not specifically address withdrawal of medical treatment or artificial nutrition and hydration.

Issue #3

Whether the Constitution requires Missouri to accept the substituted judgment of close family members when there is not clear and convincing evidence of the incompetent patient's own wishes.

Holding

No. The Due Process Clause does not require a State to give family members authority to make that decision in the absence of sufficiently reliable evidence of the patient's wishes.

Reasoning

The Court rejected the parents' reliance on cases recognizing that States may allow family decisionmaking. A constitutional decision permitting a State to rely on parents or family members does not create a constitutional requirement that every State must do so.

Even loving family members may not necessarily make the choice the patient herself would have made. Their understandable interests in avoiding the suffering of watching a loved one remain alive in a hopeless condition may overlap with, but are not automatically identical to, the patient's own preferences.

Missouri could choose to honor only the patient's own demonstrated wishes rather than confer an independent substituted-judgment power on relatives. The Court reserved the distinct question whether a State might have to honor a surrogate specifically appointed by the patient to make health-care decisions.

Concurrences

Justice O'Connor

Reasoning

Justice O'Connor agreed that Missouri could require clear and convincing evidence of Nancy Cruzan's wishes, but wrote to underscore that the liberty interest at stake plainly includes the refusal of artificially delivered food and water. Such feeding requires physical intrusion and restraint, whether through a tube passed through the nose and throat or a tube surgically implanted in the stomach.

For her, the decisive constitutional principle was bodily integrity and self-determination. Forcing a competent person to undergo artificial feeding, like compelling other medical interventions, can make that person captive to medical machinery and therefore burdens liberty protected by the Due Process Clause.

She stressed the narrowness of the Court's holding. The decision did not resolve whether States may be constitutionally required to honor decisions by a patient-appointed health-care proxy, nor did it foreclose States from developing procedures that better protect incompetent patients' treatment preferences.

Justice Scalia

Reasoning

Justice Scalia joined the Court's judgment but would have gone further. In his view, the federal Constitution provides no substantive right to refuse life-preserving treatment, so federal courts should leave these difficult questions entirely to state legislatures and state law.

He reasoned that the Nation's legal tradition allowed States to prevent suicide, including by force if necessary. In his view, refusing food, water, or treatment with the purpose of ending one's life does not become constitutionally distinct from suicide merely because it is characterized as an omission rather than an affirmative act.

Justice Scalia rejected judicial balancing between an individual's interest in self-determination and the State's interest in preserving life because neither the Constitution's text nor historical tradition supplied a judicially enforceable line between ordinary care and excessive or extraordinary treatment. Humane limits may be appropriate, he concluded, but elected representatives—not federal judges—must establish them.

Dissents

Justice Brennan

Reasoning

Justice Brennan, joined by Justices Marshall and Blackmun, viewed the right to refuse unwanted medical treatment, including artificial nutrition and hydration, as a fundamental liberty interest rooted in bodily integrity and the common-law doctrine of informed consent. In his view, Nancy's incompetence did not eliminate that right; it required a reliable means of exercising it through others.

He concluded that Missouri's unqualified interest in preserving life could not outweigh Nancy's personal interest in avoiding treatment that could offer her no recovery, awareness, comfort, or meaningful benefit. The State's interest in life, he argued, cannot be separated from the interests of the person whose life is being sustained.

Justice Brennan maintained that Missouri's clear-and-convincing rule was improperly tilted toward continued treatment. From the patient's perspective, an erroneous decision to continue treatment is also irrevocable because it prolongs an existence the patient may have rejected and cannot later undo the resulting loss of dignity, suffering to family, or interference with self-determination.

He also criticized Missouri for discounting evidence from Nancy's close friend, relatives, and guardian ad litem. Formal directives such as living wills are uncommon, and conversations with family and friends may be the best available evidence of what an incompetent patient would choose. States may use procedural protections, he reasoned, but those procedures must genuinely seek to discover and effectuate the patient's own wishes rather than systematically favor treatment.

Justice Stevens

Reasoning

Justice Stevens argued that the Constitution required the State to respect Nancy Cruzan's best interests as established by the trial court, her parents, and the guardian ad litem. Nancy had no prospect of recovery or consciousness, her continued treatment served no interest of innocent third parties, and no party questioned her parents' good faith.

He rejected the majority's premise that Missouri could assert an abstract and undifferentiated interest in preserving Nancy's biological existence against her own interests. For a permanently unconscious person with no chance of recovery, he reasoned, treating mere bodily persistence as “life” effectively lets the State impose its own contested definition of life rather than protect the life and liberty of the individual.

Justice Stevens agreed that clear proof may be appropriate, but he believed the critical question was what facts should control once established. The patient's best interests, particularly when supported by family, a neutral guardian, and medical evidence, should prevail over a general state policy that ignores those interests.

He warned that allowing the State to define life independently of the person creates a dangerous theory: a State favoring preservation of life could compel treatment, while another State favoring a particular view of quality of life could withhold treatment. The Constitution, he maintained, protects the personhood and liberty of incompetent individuals against either form of state appropriation.