497 U.S. 261, 277 (1990)
On the night of January 11, 1983, Nancy Beth Cruzan lost control of her car as she traveled down Elm Road in Jasper County, Missouri.1 The vehicle overturned, and Cruzan was discovered lying face down in a ditch without detectable respiratory or cardiac function.2 Paramedics were able to restore her breathing and heartbeat at the accident site, and she was transported to a hospital in an unconscious state.3 An attending neurosurgeon diagnosed her as having sustained probable cerebral contusions compounded by significant anoxia.4 The Missouri trial court found that permanent brain damage generally results after six minutes in an anoxic state, and it was estimated that Cruzan was deprived of oxygen from twelve to fourteen minutes.5
She remained in a coma for approximately three weeks and then progressed to an unconscious state in which she was able to orally ingest some nutrition.6 Surgeons implanted a gastrostomy feeding and hydration tube in Cruzan with the consent of her then husband.7 Subsequent rehabilitative efforts proved unavailing.8 She now lies in a Missouri state hospital in what is commonly referred to as a persistent vegetative state in which a person exhibits motor reflexes but evinces no indications of significant cognitive function.9 The State of Missouri is bearing the cost of her care.10
After it had become apparent that Nancy Cruzan had virtually no chance of regaining her mental faculties, her parents Lester and Joyce Cruzan, who serve as coguardians, asked hospital employees to terminate the artificial nutrition and hydration procedures.11 All agree that such a removal would cause her death.12 The employees refused to honor the request without court approval.13 The parents then sought and received authorization from the state trial court for termination.14 The trial court found that a person in Nancy's condition had a fundamental right under the State and Federal Constitutions to refuse or direct the withdrawal of death prolonging procedures.15 The court also found that Nancy's expressed thoughts at age twenty-five in conversation with a housemate friend suggested that given her present condition she would not wish to continue on with her nutrition and hydration.16
The Supreme Court of Missouri reversed by a divided vote.17 The court recognized a right to refuse treatment embodied in the common-law doctrine of informed consent but expressed skepticism about the application of that doctrine in the circumstances of this case.18 The court found that Cruzan's statements to her roommate regarding her desire to live or die under those conditions were unreliable for determining her intent and thus insufficient to support the coguardians' claim to exercise substituted judgment on Nancy's behalf.19 It rejected the argument that Cruzan's parents were entitled to order the termination of her medical treatment, concluding that no person can assume that choice for an incompetent in the absence of the formalities required under Missouri's Living Will statutes or the clear and convincing inherently reliable evidence absent here.20
The Supreme Court granted certiorari to consider the question whether Cruzan has a right under the United States Constitution which would require the hospital to withdraw life-sustaining treatment from her under these circumstances.21
Whether Cruzan has a right under the United States Constitution which would require the hospital to withdraw life-sustaining treatment from her under these circumstances?22
The Fourteenth Amendment provides that no State shall deprive any person of life, liberty, or property, without due process of law. The principle that a competent person has a constitutionally protected liberty interest in refusing unwanted medical treatment may be inferred from our prior decisions. We assume that the United States Constitution would grant a competent person a constitutionally protected right to refuse lifesaving hydration and nutrition. It is not necessary to decide the precise contours of the right to refuse treatment because whatever right Nancy Cruzan has to refuse treatment is outweighed by the State's legitimate interests.23
No. Nancy Cruzan was rendered incompetent as a result of severe injuries sustained in an automobile accident on January 11, 1983, when her vehicle overturned on Elm Road in Jasper County, Missouri. Paramedics restored her breathing and heartbeat at the scene, but she suffered anoxia depriving her brain of oxygen for twelve to fourteen minutes. She progressed from a coma to a persistent vegetative state with no cognitive function after surgeons implanted a gastrostomy tube. Her parents Lester and Joyce Cruzan, as coguardians, sought termination of artificial nutrition and hydration, which all agree would cause her death.
The only evidence offered was the testimony of one former roommate regarding statements Nancy made approximately a year before the accident. The Missouri Supreme Court found this evidence insufficient under the clear and convincing standard. Therefore any liberty interest is outweighed by Missouri's interests in preserving life and guarding against erroneous decisions that cannot be corrected.24
Cruzan does not have a constitutional right that would require the hospital to withdraw life-sustaining treatment under these circumstances because any such interest is outweighed by the State's interests and the evidentiary standard has not been met.25
Whether the United States Constitution forbids Missouri to require that evidence of an incompetent's wishes as to the withdrawal of life-sustaining treatment be proved by clear and convincing evidence?26
Missouri may permissibly place an increased risk of an erroneous decision on those seeking to terminate an incompetent individual's life-sustaining treatment. An erroneous decision not to terminate results in a maintenance of the status quo with the possibility of subsequent developments that could correct or mitigate a wrong decision. An erroneous decision to withdraw life-sustaining treatment is not susceptible of correction. The clear and convincing evidence standard is a constitutionally permissible procedural protection to assure that the withdrawal of life-sustaining treatment from an incompetent person is consistent with the wishes of that person, if those wishes are known.27
No. The Supreme Court of Missouri correctly found that the clear and convincing evidence standard was a constitutionally permissible procedural protection. In this case only the testimony of one witness, Nancy's former roommate, was offered to show that Nancy would not wish to continue her life in a persistent vegetative state after the January 11, 1983 accident that left her with irreversible cerebral cortical atrophy. The court found this evidence insufficient to satisfy the clear and convincing evidence standard. Missouri's policy advances its interest in the protection and preservation of human life by requiring heightened proof before allowing surrogates to exercise substituted judgment.
The standard properly allocates the risk of error to those seeking termination because an erroneous decision to withdraw cannot be corrected. Maintenance of the status quo preserves the possibility of future correction through medical advances or new evidence.28
The United States Constitution does not forbid Missouri to require that evidence of an incompetent's wishes as to the withdrawal of life-sustaining treatment be proved by clear and convincing evidence.29
Related opinions on this issue
Justice O’Connor agreed that a protected liberty interest in refusing unwanted medical treatment may be inferred from prior decisions and that the refusal of artificially delivered food and water is encompassed within that interest. She wrote separately to emphasize that the State's imposition of medical treatment on an unwilling competent adult involves restraint and intrusion that burdens liberty interests. She noted that artificial feeding cannot readily be distinguished from other forms of medical treatment because it involves intrusion and restraint.30
Justice O’Connor stressed that the Constitution requires States to protect this liberty interest through narrowly tailored regulations.
Justice Scalia joined the Court's opinion but would have preferred a clearer announcement that federal courts have no business in this field. He argued that American law has always accorded the State the power to prevent suicide, including by refusing life-preserving measures. He contended that the point at which life becomes worthless or treatment extraordinary is not set forth in the Constitution and is not known better by the Justices than by ordinary citizens.31
Justice Scalia maintained that even when clear and convincing evidence shows a patient no longer wishes measures to preserve life, it is up to the citizens of Missouri through their elected representatives to decide whether that wish will be honored.32
Joined by Marshall And Blackmun, Jj.
Justice Brennan dissented on the ground that Nancy Cruzan has a fundamental right to be free of unwanted artificial nutrition and hydration that is not outweighed by any state interest. He argued that the right to refuse medical treatment is deeply rooted in the Nation's traditions as a logical extension of the right to bodily integrity. Justice Brennan contended that Missouri's clear and convincing evidence requirement impermissibly burdens that right by making it impossible in most cases for a person in Nancy Cruzan's condition to exercise the right.33
He maintained that the State's general interest in life must accede to Nancy Cruzan's particularized interest in self-determination.34
Justice Stevens dissented on the ground that the Constitution requires the State to care for Nancy Cruzan's life in a way that gives appropriate respect to her own best interests. He argued that Missouri's policy is an effort to define life rather than to protect it by equating her life with the biological persistence of her bodily functions. Justice Stevens maintained that the State's insistence on continued treatment subordinates Nancy's body, her family, and the lasting significance of her life to the State's own interests.35
He concluded that the best interests of the individual must prevail over any general state policy that ignores those interests.36