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Nancy Beth Cruzan and the Constitutional Right to Refuse Medical Treatment

by Professor Will Huhn on August 18, 2009

in Constitutional Law,Wilson Huhn

     The right to refuse lifesaving medical treatment as well as the wisdom of filling out advance directives was established in the case of Cruzan v. Director (1990).  This case is summarized below.

     In 1983 a young woman, Nancy Beth Cruzan, was seriously injured in an automobile accident and her brain was deprived of oxygen for several minutes.  Because she was in a comotose state the hospital inserted a gastrostomy tube into her stomach as a means of providing nutrition and hydration – a necessary step to take while physicians evaluated her condition.  Doctors eventually agreed that Nancy's higher brain functions had been destroyed and that there was no hope of recovery.  She was diagnosed as being in a "persistent vegetative state," a condition in which there is no possibility of conscious thought or even dreaming.  As a result her family requested that the gastrostomy tube should be removed so that Nancy could die, and they initiated a lawsuit on her behalf requesting a court order allowing the removal of the tube.  The Missouri trial court found that Nancy had a constitutional right to refuse medical treatment and that she would not have chosen to continue to leave the feeding tube in under these circumstances; it therefore ruled that the tube could be removed.  The decision was appealed by Nancy's guardian ad litem, and the Missouri Supreme Court reversed the decision of the trial court for two reasons: (1) The state supreme court expressed doubt that an individual has a constitutional right to refuse lifesaving medical treatment; and (2) the state supreme court ruled that under Missouri law the parents had the burden of producing "clear and convincing evidence" that Nancy would have chosen to discontinue treatment, and that the parents had failed to meet that standard in this case.

     The U.S. Supreme Court unanimously reversed the Missouri Supreme Court on the first point, but by a vote of 5-4 it upheld the right of the State of Missouri to require "clear and convincing" evidence of the patient's intent. 

      The U.S. Supreme Court began its analysis by reviewing the common law of "informed consent."  The Court noted that under tort law physicians are not only obligated to obtain a patient's consent to treatment, but must also inform their patients of the material consequences or accepting and refusing treatment.  The Court observed:

As these cases demonstrate, the common law doctrine of informed consent is viewed as generally encompassing the right of a competent individual to refuse medical treatment.

     The Court then reviewed its previous decisions such as Jacobson v. Massachusetts (1905) (upholding a state law requiring people to submit to smallpox vaccinations) and Vitek v. Jones (1980) (ruling that individuals have a right to a hearing before being involuntarily committed to a mental hospital), and concluded that the right to refuse medical treatment is a constitutional right:

The principle that a competent person has a constitutionally protected liberty interest in refusing unwanted medical treatment may be inferred from our prior decisions.

 The Court then noted that both the common law and previous decisions of the Supreme Court had indicated that this right to refuse unwanted medical treatment extends even to treatment that could save or extend the person's life:

Petitioners insist that, under the general holdings of our cases, the forced administration of life-sustaining medical treatment, and even of artificially-delivered food and water essential to life, would implicate a competent person's liberty interest. Although we think the logic of the cases discussed above would embrace such a liberty interest, the dramatic consequences involved in refusal of such treatment would inform the inquiry as to whether the deprivation of that interest is constitutionally permissible. But for purposes of this case, we assume that the United States Constitution would grant a competent person a constitutionally protected right to refuse lifesaving hydration and nutrition.

     Accordingly, the Court found that a competent person has a constitutional right to refuse lifesaving medical treatment.  The problem, of course, was that after the accident Nancy was no longer "competent" and was incapable of making this decision for herself.  The issue in the case was therefore whether there was sufficient evidence that Nancy had made the choice to refuse this treatment prior to the accident.  If Nancy had made out a living will her wishes would have been clear, or if she had filled out a durable power of attorney for health care she could have chosen someone to make this decision for her, but like most people – particularly young people – Nancy had never filled either of these documents out.  Nancy's friends and relatives testified generally about her active lifestyle and specifically about statements she had made about not wanting to live in this kind of condition, but the state supreme court had set a pretty high bar for proving that Nancy would have refused this medical treatment – "clear and convincing evidence" – and the U.S. Supreme Court upheld the finding of the Missouri Supreme Court that this standard had not been met in this case, and it affirmed the decision of the state supreme court.

     Later that year the family found additional witnesses who testified that Nancy would have wanted her medical treatment terminated, and the trial court ruled that there was now "clear and convincing evidence" to support the removal of the feeding tube.  This time there was no appeal, and Nancy died December 26, 1990, more than seven years after the accident.

     The lawsuits over Nancy's wishes would have been avoided if she had completed advance directives – a living will and a durable power of attorney for medical care.  A living will specifies what medical care you want and don't want, and a durable power of attorney for health care gives someone you trust the legal authority to make health care decisions for you.  Information about these documents and forms for a Living Will and Durable Power of Attorney for Health Care that satisfy the requirements of Ohio law are available here at a website that is maintained by several organizations including the Ohio State Medical Association and the Ohio State Bar Association.  You have a constitutional right to make these decisions, and these documents should assure that your wishes are respected.

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