Petitioner Nancy Cruzan is in a persistent vegetative state after sustaining severe injuries in an automobile accident. She is currently in a Missouri state hospital, where the state is covering her care costs. Her parents requested the termination of her artificial nutrition and hydration, which would result in her death. Hospital employees refused to comply without court approval. A state trial court authorized the termination, citing a fundamental right under the State and Federal Constitutions to refuse death-prolonging procedures. The court found that Cruzan’s past statements suggested she would not wish to continue living in her current condition. However, the State Supreme Court reversed this decision.
The State Supreme Court recognized a right to refuse treatment under the common-law doctrine of informed consent but questioned its applicability in this case. The court declined to interpret the State Constitution as supporting an unrestricted right to refuse treatment and expressed doubt that the Federal Constitution embodied such a right. The court decided that the State Living Will statute strongly favored the preservation of life and found Cruzan’s statements unreliable for determining her intent. It concluded that no person could assume the choice for an incompetent individual without the formalities required by the Living Will statute or clear and convincing evidence of the patient’s wishes.
The United States Supreme Court held that the Constitution does not forbid Missouri from requiring clear and convincing evidence of an incompetent’s wishes regarding the withdrawal of life-sustaining treatment. Most state courts have based the right to refuse treatment on the common law right to informed consent or on both that right and a constitutional privacy right. State courts have also turned to state statutes for guidance. However, these sources are not available to the Supreme Court, where the question is whether the Federal Constitution prohibits Missouri from choosing its rule of law.
A competent person has a liberty interest under the Due Process Clause in refusing unwanted medical treatment. However, whether that constitutional right has been violated must be determined by balancing the liberty interest against relevant state interests. It is assumed that a competent person would have a constitutionally protected right to refuse lifesaving hydration and nutrition. This does not mean that an incompetent person should possess the same right, as they cannot make an informed and voluntary choice. Missouri has recognized that, under certain circumstances, a surrogate may act for the patient in electing to withdraw hydration and nutrition, but it has established a procedural safeguard to ensure the surrogate’s action conforms to the patient’s wishes while competent.
Missouri’s application of a clear and convincing evidence standard is appropriate when the individual interests at stake are particularly important and more substantial than mere loss of money. Missouri has a general interest in the protection and preservation of human life and other particular interests. It may seek to safeguard the personal element of an individual’s choice between life and death and guard against potential abuses by surrogates. The state may also consider that a judicial proceeding regarding an incompetent’s wishes may not be adversarial, with the added guarantee of accurate fact-finding that the adversary process brings. Missouri may properly decline to make judgments about the “quality” of an individual’s life and assert an unqualified interest in the preservation of human life to be weighed against the constitutionally protected interests of the individual.
The clear and convincing evidence standard serves as a societal judgment about how the risk of error should be distributed between the litigants. Missouri may place the increased risk of an erroneous decision on those seeking to terminate life-sustaining treatment. An erroneous decision not to terminate results in maintaining the status quo, with the potential that a wrong decision will eventually be corrected or its impact mitigated by an event such as an advancement in medical science or the patient’s unexpected death. However, an erroneous decision to withdraw such treatment is not susceptible to correction. Although Missouri’s proof requirement may have frustrated the effectuation of Cruzan’s not-fully-expressed desires, the Constitution does not require general rules to work flawlessly.
The State Supreme Court did not commit constitutional error in concluding that the evidence at trial did not amount to clear and convincing proof of Cruzan’s desire to have hydration and nutrition withdrawn. The trial court had not adopted a clear and convincing evidence standard, and Cruzan’s observations that she did not want to live life as a “vegetable” did not deal in terms with the withdrawal of medical treatment or hydration and nutrition.
The Due Process Clause does not require a State to accept the “substituted judgment” of close family members without substantial proof that their views reflect the patient’s. The decision upholding a State’s favored treatment of traditional family relationships may not be turned into a constitutional requirement that a State must recognize the primacy of these relationships in such a situation. Nor may a decision upholding a State’s right to permit family decision-making be turned into a constitutional requirement that the State recognize such decision-making. Nancy Cruzan’s parents would be qualified to exercise such a right of “substituted judgment” if required by the Constitution. However, for the same reasons that Missouri may require clear and convincing evidence of a patient’s wishes, it may also choose to defer only to those wishes rather than confide the decision to close family members.
Source: Supreme Court of the United States
