17. CRUZAN V.

DIRECTOR, MISSOURI DEPARTMENT OF HEALTH

497 U.S. 261 | June 25, 1990

DOCTRINE:

A State may apply a clear and convincing evidence standard in proceedings where a guardian
seeks to discontinue nutrition and hydration of a person diagnosed to be in a persistent
vegetative state.

FACTS:

Nancy Cruzan was involved in a car accident, which left her in a “persistent vegetative state.” In
order to feed her and to facilitate her recovery, surgeons implanted into her a gastronomy feeding
and hydration tube. After it had become apparent to Cruzan’s parents that recovery of mental
faculties is virtually nil, they requested termination of life support. The State hospital employees
refused to honor this request without court approval. The parents went to the Missouri State Trial
Court to request termination. The Trial Court granted the request and recognized that a vegetative
person has rights protected by State and Federal Constitutions, ‘to refuse or direct the withdrawal
of death-prolonging procedures’ (right to refuse treatment).

The Missouri Supreme Court rejected the argument that Cruzan’s parents were entitled to order
the termination of life support, absent the formalities under Missouri’s Living Will statute. This
statute requires clear and convincing evidence of the incompetent’s will to terminate life support.
The Court found that Cruzan's statements to her roommate regarding her desire to live or die
under certain conditions were unreliable for the purpose of determining her intent.

The question interposed to the court is if the U.S. Constitution grants the ‘right to die’.

ISSUE/S:

1. Whether or not Nancy Cruzan, being in a vegetative state, has rights under the U.S.
Constitution, which would require the hospital to withdraw life support (NO)
2. Whether or not Missouri State’s procedural requirement of clear and convincing evidence
violates U.S. Constitution (NO)

RULING:

1. Bodily integrity or the right and control of own person is embodied in the Doctrine of
Informed Consent, where every person has a right to determine what shall be done with
is own body. Logically, with this comes the right not to consent, or to refuse medical
treatment.

US Jurisprudence involving the right to refuse life support has established an incompetent
person retains the same rights as a competent individual. The right of self-determination
is not lost merely because an individual is unable to sense a violation of it. Right to refuse
treatment therefore is grounded in common law and guaranteed in the Constitutional right
 to privacy, among others.

Petitioners assert that an incompetent person should enjoy the same right in this respect
as a competent person. However, the incompetent is unable to make an informed and
voluntary choice to exercise this hypothetical right to refuse treatment or any other right.
Such right must be exercised for her by a surrogate. While incompetent persons have the
right to refuse treatment, as protected by the Due Process clause, they may cannot make
autonomous decisions for themselves and thus their rights are limited.

2. Individual rights must be balanced by compelling state interest. To see if this procedural
requirement by Missouri is in consonance with the U.S. Constitution, the State interest
sought to be protected must be established. The Due Process Clause seeks to protect
and preserve human life. This Court believes that Missouri may advance the protection of
this interest by intruding in the deeply personal choice of the right to die, through the
imposition of heighted evidentiary requirements.

This standard of evidence protects the State interest to preserve human life, as not all
incompetent patients will have loved ones available as surrogate decision-makers. It
seeks to protect those who may have family members who do not act to protect a patient.
The State is entitled to guard against abuse in such situations. This is also precaution
against the risk of erroneous decisions of surrogates seeking to terminate an incompetent
person’s life. The finality and irrevocability of the end result of a decision to discontinue
life support warrants the quantum of proof required in a proceeding to end artificial nutrition
and hydration procedures.

In sum, the Court concludes that the State may apply a clear and convincing standard of
evidence in proceedings where a guardian seeks to discontinue life support in patients
under a persistent vegetative state. In the case at bar, Nancy Cruzan’s parents are
required to present evidence of such a standard (ex. via will) before the State can assent
to their request.

HELD:

The judgment of the Supreme Court of Missouri is Affirmed.