Cruzan v. Director, Missouri Department of Health

Brief Fact Summary.

Cruzan was made incompetent due to severe injuries sustained during an automobile accident. Her parents requested a court to order the withdrawal of their daughter’s artificial feeding and hydration equipment when Cruzan had virtually no chance of recovering her cognitive faculties.

Synopsis of Rule of Law.

A State is entitled to guard against potential abuses in unfortunate situations in which family members will not act to protect a patient.

Facts.

In 1983, Nancy Cruzan lost control of her car. The vehicle overturned, and Cruzan was discovered lying face down in a ditch without detectable respiratory or cardiac function. Paramedics were able to restore her breathing and she was transported to a hospital. An attending neurosurgeon diagnosed her as having sustained probable cerebral contusions compounded by lack of oxygen. The Missouri trial court found that permanent brain damage generally results after 6 minutes in an anoxic state; and it was estimated that Cruzan was deprived of oxygen from 12 to 14 minutes. She remained in a coma for approximately three weeks and then progressed to an unconscious state. Subsequent rehabilitative efforts proved unavailing. She now lies in a Missouri state hospital in what is commonly referred to as a persistent vegetative state. Her parents asked hospital employees to terminate the artificial nutrition and hydration procedures. The employees refused to honor the request without court approval.

Issue.

Can a state court refuse to allow individuals to terminate their life?

Held.

No, here Missouri has in effect recognized that under certain circumstances a surrogate may act for the patient in electing to have hydration and nutrition withdrawn in such a way as to cause death, but it m established a procedural safeguard to assure that the action of the surrogate conforms as best it may to the wishes expressed by the patient while competent. The United States Constitution does not forbid the establishment of this procedural requirement by the State.

Dissent.

Justice Stevens

To be constitutionally permissible, Missouri’s intrusion upon fundamental liberties must, at a minimum, bear a reasonable relationship to a legitimate state end. Missouri asserts that its policy is related to a state interest in the protection of life, but it is an effort to define life, rather than to protect it, that is at the heart of Missouri’s policy.

Justice Brennan

Freedom from unwanted medical attention is unquestionably among those principles so rooted in the traditions and conscience of our people as to be ranked as fundamental. No material distinction can be drawn between the treatment to which Nancy Cruzan continues to be subject – artificial nutrition and hydration – and any other medical treatment. The State here has no legitimate general interest in someone’s life, completely abstracted from the interest of the person living that life, that could outweigh the person’s choice to avoid medical treatment.

Concurrence.

Justice Scalia

The federal courts have no business in this field; that American law has always accorded the State the power to prevent, by force if necessary, suicide – including suicide by refusing to take appropriate measures necessary to preserve one’s life; that the point at which life becomes worthless, and the point at which the means necessary to preserve it become extraordinary or inappropriate, are neither set forth in the Constitution nor known to the Supreme Court any better than they are known to nine people picked at random from the Kansas City telephone directory. Thus, even when it is demonstrated that a patient no longer wishes certain measures to be taken to preserve his life, it is up to the citizens of Missouri to decide, through their elected representatives, whether that wish will be honored.

Discussion.

Missouri relies on its interest in the protection and preservation of human life, and there can be no gainsaying this interest. Missouri may legitimately seek to safeguard the personal element of the state choice through the imposition of heightened evidentiary requirements. Not all incompetent patients will have loved ones available to serve as surrogate decision-makers. Even where family members are present, there will be some unfortunate situations in which family members will not act to protect a patient. A State is entitled to guard against potential abuses in such situations. Similarly, a State is entitled to consider that a judicial proceeding to make a determination regarding an incompetent’s wishes may very well not be an adversarial one, with the added guarantee of accurate factfinding that the adversary process brings with it. Also, a State may properly decline to make judgments about the quality of life that a particular individual may enjoy, and simply assert an unqualified interest in the preservation of human life to be weighed against the constitutionally protected interests of the individual.