Safatul Islam

AP Government

Cruzan v. Director, Missouri Department of Health

          The latter half of the 20^th century was a period of rapid technological advancements. With this came increased developments in the medical realm. People were exposed to better surgical methods and new tools that aided the recovery of individuals. The ability to keep a patient on artificial support also became possible. It is precisely this new feature in medicine that led to the Cruzan v. Director, Missouri Department of Health case. On January 11, 1983, Nancy Cruzan, a young lady in her twenties, was involved in a serious rollover when she lost control of her car. During the impact, Cruzan was thrown out of her vehicle and landed in a ditch outside. Although paramedics revived her breathing and heartbeat, she remained in a coma for three weeks. Doctors also projected that during the accident, Cruzan was without oxygen for 12-14 minutes – over twice as long as needed to cause permanent brain damage. It was no surprise, then, that when she recovered some more abilities (such as a small degree of oral feeding), she remained incapable of “significant cognitive function.” Her status was deemed to be in a “persistent vegetative state” (PVS) – a condition where a patient shows some signs of motor reflexes but nothing else. She was completely dependent to the hospital’s care.

            After observing Cruzan in this state for over three years and realizing that although she could stay alive for thirty more years, she would never be able to revive her other senses, Cruzan’s family decided to ask the hospital to take their daughter off the medical feeding and hydration procedures. This would inevitably lead to the patient’s death. As per Missouri law, the state was obligated to receive “clear and convincing” evidence that Nancy Cruzan would have agreed to allow the termination of the hospital services. The petitioner’s family did provide evidence, particularly a conversation with her roommate in which Nancy stated that she would never want to be kept alive in a situation resembling that of a persistent vegetative state. The trial court at Missouri accepted this evidence, but the state Supreme Court did not. It was under these circumstances that this case reached the US Supreme Court on the grounds of whether the state could impose such extensive laws regarding a person’s liberty (and right to die and refuse medical treatment) ^[1].

            The Court at this time was under the guidance of William Rehnquist and, as during all the Rehnquist courts, was mostly conservative. In this instance, that meant the court was a bit more partial to the state side, denying the petitioner privacy and the right to essentially terminate her life – an action of suicide. Still, the uncertain nature of how far individual liberties exist and the state’s ability to regulate that allowed for much debate because a few justices, such as O’Connor, were only moderately biased. In fact, the decision was made on a close 5-4 vote, with two concurring opinions.

            The fundamental question before the Supreme Court regarded whether the state’s actions in rejecting Nancy’s pleas was constitutional; this inevitably brought personal liberties to question. The Constitution states, under the 14^th amendment, that no state shall “deprive any person of life, liberty, or property, without due process of law.” ^[2] This clause necessitated the discussion of whether the state’s requirement of “clear and convincing evidence” fell under “due process” and whether Nancy even had a right to die. Addressing the second point, the Court mentioned am identical case in New Jersey, In re Quinlan (1976). Here, the New Jersey Supreme Court ruled that a person did have the right to terminate medical treatment even if they were incompetent for the decision (meaning family or close persons represent the patient). Also, the subsequent death would not be considered homicide or medical malpractice. This decision was upheld in a vast majority of state courts, all of who recognized that guardians of unconscious patients could make these decisions for them, and citizens did have a right to refuse treatment ^[3].

            The US Supreme Court, however, overturned this ruling. The majority opinion made use of Jacobson v. Massachusetts (1904) where the Court decided that the state could impose treatment (in this case a smallpox vaccination) in situations where it felt necessary. The opinion argued that Missouri had every right to require “clear and convincing” evidence before terminating medical treatment because it would lead to Cruzan’s death. In fact, five of the justices agreed that the requested action should be considered homicide or suicide, and the Missouri government should protect her citizens from such actions in order to preserve life. Also, the Supreme Court decided that a citizen is indeed guaranteed under the liberties granted in the Constitution to have the right to refuse medical treatment. However, the patient must be fully competent (not in a coma) to make such a decision. The majority opinion argued that this is an imperative qualification because sometimes the family may not have the best interests of the patient at heart. Thus, in this situation, the Missouri Department of Health was constitutionally sound in their jurisdiction – they felt that the evidence was not convincing so they were not bound to allow the termination of medical treatment to Nancy Cruzan as requested by her parents ^[4].

            This decision had major rivets in the realm of individual liberty. The dissenting opinions, particularly that of Justice Stevens, argued that this was a circumstance of personal privacy. The decision to refuse treatment is very similar to having an abortion in that it is a private matter. However, the Court rejected both of these issues (the latter in Roe v Wade) and stated that the state government could step in if necessary to preserve life. Justice Stevens then argued of the extent to which the state government could intervene in such a decision. Naturally, there was a value question at hand: did the state or Cruzan’s parents care more for her well-being? Furthermore, how much “clear and convincing” evidence was needed to reserve the State Court’s decision? Their law was unnecessarily vague and thus cannot be held superior. Stevens, and the other dissenting justices (and Justice O’Connor to some degree in her concurring opinion), realized that this decision would have consequences in personal liberties. They wanted to clarify that, in this modern era of advanced technology, citizens could still decide how they were to be treated. This right essentially interprets the “liberty” term in the 14th amendment to be more important than the “life” term ^[5]. The question of whether the Missouri courts set the barrier of evidence too high was more haughtily debated. Whereas the majority opinion stated the laws were constitutional, the dissenters asserted that this was not even a decision for the States to make because of the interference it could and did cause with personal liberties. Thus, this decision did hamper individuals’ right to privacy. Just as in abortion, the decision stated that the States could be the final judge regarding medical proceedings, and the patients were subservient to state law.

            Due to the strong ramifications on individual liberty, I do not agree with the Court’s decision. Although I do believe that it is fine, and indeed necessary, for the state to have some sort of evidence when it comes to terminating medical treatment, the Supreme Court allowed these precautions to be taken at an extreme level. To say that the state had the better interest of a patient than her own parents is a ridiculous assumption. Undoubtedly, there exist unfortunate cases where a family does ill to one of its members, but to use a few outlying examples to make such a broad statement was incorrect. In fact, there are far more instances of states being unfair to patients. Thus, I agree with Justice Stevens that case such as this, which involves the most personal medical decisions, should be kept private and not be made the State’s decision. Moreover, the probable death of Nancy Cruzan without treatment cannot be considered suicide or homicide because it does not involve the death of even a partially competent individual. Cruzan suffered permanent mental damage and, as Dr. Fred Plum stated, could never regain her senses to recognize her surroundings. All that she was able to do is perform internal bodily procedures, like digesting food. Her life was essentially lost. It should be also be realized that Cruzan was not “terminally ill,” so her situation is different from those that are afflicted with diseases or genetic mutations. The fact that there was even evidence that Cruzan never wanted to live in such a state should be further grounds for her treatment to be terminated; she had made a prior, sensible decision. The Missouri State should have been required to lower their barriers, or perhaps resort them to the hospital’s jurisdiction, and allow as much privacy and freedom as possible. The Cruzan family would know best in this circumstance because they, not the state, had raised and taken care of the patient. As a fitting testament to this, the Cruzan family found more evidence of their daughter’s wishes after the trial and Nancy was taken off treatment (and passed away) in December of 1990 ^[6].