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



When Lester and Joyce Cruzan commenced this declaratory judgment proceeding to compel the Mount Vernon State Hospital to discontinue life-sustaining nutrition and hydration support from their daughter Nancy, the courts of Missouri were presented with a host of factual and legal questions:

-- Did Nancy, prior to becoming incompetent, clearly indicate what she would have wanted done under the circumstances? [The Missouri Supreme Court concluded that she had not: "statements attributed to Nancy in this case are... unreliable for the purpose of determining her intent." 760 S.W.2d at 424.)

-- How invasive, painful and burdensome is Nancy's nutrition and hydration support? [Not significantly, found the Missouri Supreme Court:

"Nancy's care requirements, while total, are not burdensome to Nancy. The evidence at trial showed that the care provided did not cause Nancy pain. Nor is that care particularly burdensome for her, given that she does not respond to it." Id.]

-- What is the nature of Missouri's state interest in this case? [Drawing upon principles of common law and Missouri's restrictive "living will" statute, the Missouri Supreme Court held that the state had a strong interest in both the preservation and sanctity of human life: "`The concern for preservation of the life of the patient normally involves an interest in the prolongation of life'... The state's interest in prolonging life is particularly valid in Nancy's case. Nancy is not terminally ill.... The state's concern with the sanctity of human life rests on the principle that life is precious and worthy of preservation without regard to its quality." Id. at 419 (citation and emphasis omitted).]

-- Does the common law recognition of a patient's right generally to refuse medical treatment require the hospital to terminate Nancy's nutrition and hydration at her parent's request? [No, ruled the Missouri Supreme Court: "The common law right to refuse treatment is not absolute. It too must be balanced against the state's interest in life... Nor do we believe that the common law right to refuse treatment -- founded in personal autonomy -- is exercisable by a third party absent formalities." Id. at 421, 425.]

-- Does the Missouri state constitution guarantee the right to refuse life-sustaining treatment? [The Missouri Supreme Court held that it does not: "We... find no unfettered right of privacy under our constitution that would support the right of a person to refuse medical treatment in every circumstance." Id. at 417.]

-- Does the federal constitution demand that the hospital discontinue Nancy's nutrition and hydration under the circumstances of this case? [No, said the Missouri Supreme Court: "Based on our analysis of the right to privacy decisions of the Supreme Court, we carry grave doubts as to the applicability of privacy rights to decisions to terminate the provision of food and water to an incompetent patient... [H]owever, even if we recognize such a broadly sweeping right of privacy, a decision by Nancy's co-guardians to withdraw food and water under these circumstances cannot be sustained." Id. at 418 (footnote omitted).]

At this stage of the proceeding, however, the issues have narrowed considerably. It is axiomatic that in reviewing cases like this, the United States Supreme Court does not consider whether the state court correctly evaluated the evidence or correctly determined issues of state policy or law. See, e.g., Murdock v. Memphis, 87 U.S. (20 Wall.) 590 (1874). Accordingly, the only issue before the Court at this point is the final one mentioned above -- whether the federal constitution precludes Missouri from continuing to provide Nancy with life-sustaining nutrition and hydration.

To find that Missouri is so precluded, the Court must reach two discrete legal conclusions. First, the Court must conclude that a state's interest in the preservation and sanctity of human life is not sufficiently compelling to override a non-terminal patient's right to refuse life-sustaining medical intervention. Second, the Court must conclude that third parties have the constitutional authority to assert that right on behalf of an incapacitated patient even in the absence of clear and convincing evidence that the patient herself would have exercised the right.

Both of these legal conclusions are prerequisites to a reversal of the decision below. However, as demonstrated in Points II and III infra, neither conclusion is compelled by constitutional precedent -- and either conclusion would break troublesome new moral ground.

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