Cruzan v. Director of Missouri Department of Health
Supreme Court of the United States (1989)

I. It is axiomatic that the Court here has no occasion to review the Missouri Supreme Court's findings on issues of fact or rulings on issues of state law. Accordingly, the Court's analysis should proceed on the assumption that Nancy Cruzan never clearly indicated whether she would want life-sustaining nutrition and hydration discontinued under her current medical circumstances; that the continued provision of nutrition and hydration is neither painful nor burdensome to her; that Missouri's statutory and common law demonstrate its great interest in the preservation of human life and the sanctity of human life, both of which are present in this case to a substantial degree; and that neither Missouri's common law nor its state constitution compel the hospital to discontinue the patient's life support.

The sole issue for the Court to determine, then, is whether the federal constitution would compel the hospital to comply with the patient's parents' request to terminate nutrition and hydration. To reach an affirmative conclusion on that question, and reverse the ruling of the Missouri Supreme Court, the Court would have to hold that a state's asserted interest in protecting human life -- its preservation and its sanctity -- is not sufficiently compelling to override any liberty/privacy right a non-terminal patient may have to decline or discontinue life-sustaining intervention including nutrition and hydration. The Court would further have to hold that states may not insist that third parties who seek to assert the right to refuse life-sustaining measures on behalf of an incapacitated patient must present clear and convincing evidence that the patient herself would have exercised the right. As demonstrated in Points II and III, neither of those holdings would be consistent with settled constitutional jurisprudence.

II. As to the first point -- the strength of a state's interest in the preservation and sanctity of human life vis-a-vis an individual patient's right to decline life-sustaining intervention -- American society has long operated on the premise that protecting human health and human life is one of the most basic of all governmental purposes. This premise has found its expression in longstanding proscriptions against suicide and euthanasia; and in several contexts of the law in which even fundamental constitutional rights have been held subservient to the state interest in life. Accordingly, even if an individual's desire to refuse medical intervention rises to the level of a "fundamental" constitutional right, the state's interest in the preservation and sanctity of human life as defined by the Missouri Supreme Court is an interest of the highest order, sufficiently compelling to justify abridgment of the liberty/privacy right under the circumstances of this case.

III. As to the second point -- the constitutional authority of a third party to assert the patient's right to refuse life-sustaining intervention when the patient is incapacitated -- any constitutionally grounded liberty/privacy right to refuse such intervention is inherently personal to the patient. Its assertion by third parties is capable of serious abuse, intended and unintended. States should thus be free to insist that a third party who seeks to assert that right on behalf of an incapacitated patient must present the highest caliber of evidence that the patient would have asserted it were he or she competent to do so. Accepting (as the Court must) the Missouri Supreme Court's factual finding that no such evidence is present here, Missouri should be permitted to maintain the patient on her feeding tubes.