NANCY CRUZAN V. DIRECTOR, MISSORI DEPT.

OF HEALTH
497 U.S. 261 (1990)
JUNE 25, 1990
Specific constitutional provision/s cited: Substantive Due Process; Informed Euthanasia

FACTS:

Petitioner Nancy Cruzan sustained severe injuries as a result of a car accident on January 11, 1983.
She remained in a coma for 3 weeks, during which feeding tubes were inserted with her husbands
consent. Her condition progressed into an unconscious state and she now (as of time of case) lies in
a Missouri state hospital in a persistent vegetative state (no indication of cognitive function), with
the State of Missouri bearing the cost of her care.

After it had become apparent to Cruzans parents that recovery of mental faculties is virtually nil,
they requested termination of life support which would no doubt cause Cruzans death. This was
refused by hospital employees, absent a showing of 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). Additionally, the court found that at 25 years old, Nancy expressed that she would not
wish to continue her life unless she could live at least halfway normally to her roommate.

The Missouri Supreme Court reversed the State Trial Courts ruling. While it recognized a persons
right to refuse treatment as embodied in the common law doctrine of Informed Consent, it
expressed doubt on its applicability on the case at bar, It rejected the argument that Cruzans parents
were entitled to order the termination of life support, absent the formalities under Missouris
Living Will statue (document which list end-of-life preferences should the patient be unable to
communicate), This statute requires clear and convincing evidence of the incompetents 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:

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

2. Whether or not Missouri States procedural requirement of clear and convincing evidence
violates U.S. Constitution

3. Whether Missouri must accept the substituted judgment of close family members, absent
substantial proof that their views reflect the views of the patient.

HELD:

1. NO
Bodily integrity (right and control of own person) is carefully guarded under US Common Law.
This 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
Prepared by: Graciella S. Fernandez
refuse medical treatment. Jurisprudence has demonstrated that this doctrine encompasses the right
of a competent individual to refuse medical treatment. The Fourteenth Amendment states that no
State shall deprive any person of life, liberty or property without due process of law.

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. NO

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 persons 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 Cruzans parents are required to present evidence of such
a standard (ex. Via will) before the State can assent to their request.

3. NO

The Due Process Clause does not require the State to place judgment on matters such as the case at
bar with the incompetents guardians. There is no automatic guarantee that the view of close family
members will reflect the patients.

WHEREFORE, the judgment of the Supreme Court of Missouri is Affirmed

Notes:
Decision was 5-4

Prepared by: Graciella S. Fernandez