222 Cruzan v Dir.

Missouri
Date: June 25, 1990 No. 88-1503 Rehnquist, J.
Substantive Due Process Rica Aggabao
Petitioners: Nancy Cruzan Respondents: Director, Missouri Dept of
Health
Doctrine: Informed Euthanasia
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1. 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 husband’s 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.
2. After it had become apparent to Cruzan’s parents that recovery of mental faculties is
virtually nil, they requested termination of life support – which would no doubt cause
Cruzan’s death. This was refused by hospital employees, absent a showing of court
approval.
3. 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.
4. The Missouri Supreme Court reversed the State Trial Court’s ruling. While it
recognized a person’s 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 Cruzan’s parents were entitled to order the
termination of life support, absent the formalities under Missouri’s “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
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.

5. The question interposed to the court is if the U.S. Constitution grants the ‘right to die’
Issue/s: Ruling:
1. Whether or not Nancy Cruzan, being in a vegetative state, has 1. No
rights under the U.S. Constitution, which would require the 2. No
hospital to withdraw life support 3. No
2. Whether or not Missouri State’s 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.

Rationale/Analysis/Legal Basis:
1. ‘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 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. 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 standard (ex.
Via will) before the State can assent to their request.

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