This right has long been "firmly entrenched in American tort law" and is securely grounded in the earliest common law. 375, 433-434 (1988). That she has contractures of her four extremities which are slowly progressive with irreversible muscular and tendon damage to all extremities. There, the court, over the objection of the patient's family members, granted an order to insert a feeding tube into a 77-year-old, woman rendered incompetent as a result of several strokes. Mrs. O'Connor, the subject of In re O'Connor, had several times expressed her desire not to be placed on life-support if she were not going to be able to care for herself. Union Pacific R. Co. v. Botsford, 141 U. S. 250, 141 U. S. 251 (1891). . ", "Appellant guardian ad litem advised this court:", "we informed the [trial] court that we felt it was in Nancy Cruzan's best interests to have the tube feeding discontinued. Most of the cases that have held otherwise, unless they involved the interest in protecting innocent third parties, have concerned the patient's competency to make a rational and considered choice.". 1990. "Such a tradition commands respect in part because the Constitution carries the gloss of history." 422, 429 (1877); In re Doyle, 16 R.I. 537, 539, 18 A. (1989); Wash.Rev.Code § 11.94.020 (1989); W.Va.Code § 39-4-1 et seq. See 760 S.W.2d at 412. The vehicle overturned, and Cruzan was discovered lying face down in a ditch without detectable respiratory or cardiac function. 1. Id. JJ., joined, post, p. 497 U. S. 301. All of the family members involved in these cases struggled to do what they believed was the right thing for their loved one. . . Nancy Cruzan was involved in a car accident, which left her in a “persistent vegetative state.” After it became clear that Cruzan would not improve, her parents requested that the hospital terminate the life-support procedures the hospital was providing. Beyond that, these decisions demonstrate both similarity and diversity in their approach to decision of what all agree is a perplexing question with unusually strong moral and ethical overtones. The patient must be monitored daily by medical personnel as to weight, fluid intake and fluid output; blood tests must be done weekly. . Her family is convinced that Nancy would find this state degrading. But it leads only to another question: Is there any reason to suppose that a State is more likely to make the choice that the patient would have made than someone who knew the patient intimately? to Pet. While recognizing that a federal right of privacy might apply in the case, the court, contrary to its approach in Quinlan, decided to base its decision on the common law right to self-determination and informed consent. See also Carey v. Population Services International, 431 U. S. 678, 431 U. S. 690 (1977) (invalidating a requirement that bore "no relation to the State's interest"). We now find ourselves in the position of appealing from a judgment we basically agree with. They concluded that she had not been breathing for at least fifteen minutes, but through the miracles of modern technology she was revived into a vegetative state (Gumm). But not only does the standard of proof reflect the importance of a particular adjudication, it also serves as "a societal judgment about how the risk of error should be distributed between the litigants." (1978); Vt.Stat.Ann., Tit. See, e.g., Delio v. Westchester County Medical Center, 129 App.Div.2d 1, 19, 516 N.Y.S.2d 677, 689 (1987) ("review of the decisions in other jurisdictions . We need not, however, resolve the question in the abstract. of correction" because death is irreversible. In addition, in this century, chronic or degenerative ailments have replaced communicable diseases as the primary causes of death. See Alaska Stat. Because Nancy Beth Cruzan did not have the foresight to preserve her constitutional right in a living will, or some comparable "clear and convincing" alternative, her right is gone forever, and her fate is in the hands of the state legislature instead of in those of her family, her independent neutral guardian ad litem, and an impartial judge -- all of whom agree on the course of action that is in her best interests. Another court, hearing a similar case, noted: "It is apparent from the testimony that what was on [the patient's] mind was not only the invasiveness of life-sustaining systems, such as the [nasogastric] tube, upon the integrity of his body. We forcefully affirm that Life, having been endowed by our Creator, should not be lightly taken nor relinquished. If none of these conditions obtained, the court held it was best to err in favor of preserving life. "In certain, thankfully rare, circumstances the burden of maintaining the corporeal existence degrades the very humanity it was meant to serve." A long, drawn-out death can have a debilitating effect on family members. . Dying is personal. 840, 854-855 (1988). who was thrown from her car in 1983 when it flipped over. Santosky, supra, 455 U.S. at 455 U. S. 755; Addington, supra, 441 U.S. at 441 U. S. 423. at. She would also "want to take that burden away from [her family]." Of course, the common law rejected the action-inaction distinction in other contexts involving the taking of human life as well. To determine that such a deprivation would not occur if Nancy Cruzan were forced to take nourishment against her will, it is unnecessary to reopen the historically recurrent debate over whether "due process" includes substantive restrictions. 780, 788. The Court believes that the liberty interest claimed here on behalf of Nancy Cruzan is peculiarly problematic because "an incompetent person is not able to make an informed and voluntary choice to exercise a hypothetical right to refuse treatment or any other right." Under traditional tort law, exceptions have been found only to protect dependent children. See, e.g., In re Estate of Longeway, 133 Ill. 2d 33, 139 Ill.Dec. . Although Judge Blackmar did not frame his argument as such, it propounds a sound constitutional objection to the Missouri majority's reasoning: Missouri's regulation is an unreasonable intrusion upon traditionally private matters encompassed within the liberty protected by the Due Process Clause. denied, 488 U.S. 958 (1988), the California Court of Appeal authorized the removal of a nasogastric feeding tube from a 44-year-old man who was in a persistent vegetative state as a result of an auto accident. One might reasonably suppose that it would be dispositive: if Nancy Cruzan has no interest in continued treatment, and if she has a liberty interest in being free from unwanted treatment, and if the cessation of treatment would have no adverse impact on third parties, and if no reason exists to doubt the good faith of Nancy's parents, then what possible basis could the State have for insisting upon continued medical treatment? the defendant rather than the plaintiff seeks the clear and convincing standard of proof -- suggesting that this standard ordinarily serves as a shield rather than . at 420, 424 is not even well supported by that State's own enactments. See 2 A. Corbin, Contracts § 398, pp. . But a later decision is unlikely in any event. These considerations cast into stark relief the injustice, and unconstitutionality, of Missouri's treatment of Nancy Beth Cruzan. The case of Nancy Cruzan reached the U.S. Supreme Court at the end of a decade of ferment over the legal and ethical propriety of ceasing to tube feed patients in ... no. An erroneous decision not to terminate results in a maintenance of the status quo, with at least the potential that a wrong decision will eventually be corrected or its impact mitigated by an event such as an advancement in medical science or the patient's unexpected death. http://www.myJLI.comLife in the Balance: Jewish Perspectives on Everyday Medical DilemmasA New Six Week Course by the Rohr Jewish Learning Institute. aware that such measures will hasten death, as long as See 760 S.W.2d at 412, n. 4 (collecting 54 reported decisions from 1976-1988). See generally Washington v. Harper, 494 U. S. 210, 494 U. S. 241 (1990) (STEVENS, J., dissenting) ("There is no doubt . New York Times, June 5, 1988, p. 14, col. 4 (citing American Medical News, June 3, 1988, p. 9, col. 1). to Pet. § 523.01 et seq. First, a competent individual's decision to refuse life-sustaining medical procedures is an aspect of liberty protected by the Due Process Clause of the Fourteenth Amendment. 18-A, § 5-501 et seq. Atty.Gen. [Footnote 4/21] Considered, against the background of other cases involving patients in persistent vegetative states, instead of against the broader -- and inapt -- category of cases involving chronically ill incompetent patients, Missouri's decision is anomalous. Woodby, supra, 385 U.S. at 385 U. S. 285, n. 18. People seem to have known a lot more about the process itself than is the case today. Olmstead v. United States, 277 U. S. 438, 277 U. S. 478 (1928) (Brandeis, J., dissenting). |497 U.S. 261fn3/13|n. See generally Karnezis, Patient's Right to Refuse Treatment Allegedly Necessary to Sustain Life, 93 A.L.R.3d 67 (1979) (collecting cases); Cantor, A Patient's Decision to Decline Life-Saving Medical Treatment: Bodily Integrity Versus the Preservation of Life, 26 Rutgers L.Rev. The New Jersey Supreme Court granted the relief, holding that Karen had a right of privacy grounded in the Federal Constitution to terminate treatment. [Footnote 4/7] It defined that interest as follows: "The state's interest in life embraces two separate concerns: an interest in the prolongation of the life of the individual patient and an interest in the sanctity of life itself.". Requiring a competent adult to endure such procedures against her will burdens the patient's liberty, dignity, and freedom to determine the course of her own treatment. We have interpreted the Constitution to interpose barriers to a State's efforts to sterilize some criminals not only because the proposed punishment would do "irreparable injury" to bodily integrity, but because "[m]arriage and procreation" concern "the basic civil rights of man." See In re Caulk, 125 N.H. 226, 232, 480 A.2d 93, 97 (1984); State ex rel. Unfortunately for her, for those who loved her, and indeed for all of us, she died at a time and in a place that does not recognize her death. Petitioner Nancy Beth Cruzan was rendered incompetent as a result of severe injuries sustained during an automobile accident. By Gilbert Meilaender In its long-awaited decision in the case of Nancy Cruzan, the United States Supreme Court upheld the decision of … V). of Health with free interactive flashcards. 1988). Besides the Missouri Supreme Court in Cruzan and the courts in McConnell, Longeway, Drabick, Bouvia, Barber, O'Connor, Conroy, Jobes, and Peter, supra, appellate courts of at least four other States and one Federal District Court have specifically considered and discussed the issue of withholding or withdrawing artificial nutrition and hydration from incompetent individuals. 1989); Md.Est. 1868). This is the first case in which we have been squarely presented with the issue of whether the United States Constitution grants what is in common parlance referred to as a "right to die." Missouri's evidentiary standard, however, cannot rest on the State's own interest in a particular substantive result. The tube can cause pneumonia from reflux of the stomach's contents into the lung. No singularity of feeling exists upon which such a government might confidently rely as parens patriae. Justia Annotations is a forum for attorneys to summarize, comment on, and analyze case law published on our site. § 45-690 (Supp.1989); Del.Code Ann., Tit. at 367 U. S. 551-552, and our decisions have demarcated a "private realm of family life which the state cannot enter." "[M]edical care decisions must be guided by the individual patient's interests and values. . Consequently, she has never been buried or cremated, but instead kept in a hospital bed for nearly seven years. 2d 921 (Fla.1984) (holding that court approval was not needed to authorize cessation of life-support for patient in a persistent vegetative state who had executed a living will); In re Torres, 357 N.W.2d 332 (Minn. 1984) (authorizing removal of a permanently unconscious patient from life-support systems); In re L.H.R., 253 Ga. 439, 321 S.E.2d 716 (1984) (allowing parents to terminate life support for infant in a chronic vegetative state); In re Hamlin, 102 Wash. 2d 810, 689 P.2d 1372 (1984) (allowing termination, without judicial intervention, of life support for patient in a vegetative state if doctors and guardian concur; conflicts among doctors and the guardian with respect to cessation of treatment are to be resolved by a trial court); In re Colyer, 99 Wash. 2d 114, 660 P.2d 738 (1983), modified on other grounds, In re Hamlin, 102 Wash. 2d 810, 689 P.2d 1372 (1984) (allowing court-appointed guardian to authorize cessation of treatment of patient in persistent vegetative state); In re Eichner (decided with In re Storar), 52 N.Y.2d 363, 438 N.Y.S.2d 266, 420 N.E.2d 64, cert. [Footnote 4/13] Dying nonetheless remains a part of "the life which characteristically has its place in the home," Poe v. Ullman, 367 U. S. 497, 367 U. S. 551 (1961) (Harlan, J., dissenting). v. Heston, 58 N.J. 576, 581-582, 279 A.2d 670, 672-673 (1971); see also Application of President & Directors of Georgetown College, Inc., 118 U.S.App.D.C. at 428. By 1949, institutions were the sites of 50% of all deaths; by 1958, the figure was 61%; and by 1977, over 70%. denied, 429 U.S. 922 (1976). Insofar as Nancy Cruzan has an interest in a closure to her life consistent with her own beliefs rather than those of the Missouri legislature, the State's imposition of its contrary view is irreversible. Moreover, the respect due to persons as individuals does not diminish simply because they have become incapable of participating in treatment decisions. at 524-525, 534 N.Y.S.2d at 888-889, 531 N.E.2d at 609-610. The State Supreme Court reversed. 417, 497 N.E.2d 626 (1986) (permitting removal of a feeding tube from a patient in a persistent vegetative state); John F. Kennedy Memorial Hospital, Inc. v. Bludworth, 452 So. Deciding to Forego Life Sustaining Treatment 17-18 (1983) (footnotes omitted), quoting, Thomas, Dying as Failure, 447 Annals Am.Acad.Pol. Major, The Medical Procedures for Providing Food and Water: Indications and Effects, in By No Extraordinary Means: The Choice to Forgo Life-Sustaining Food and Water 25 (J. Lynn ed. Yet, just as the constitutional protection for the "physical curtilage of the home . The italicized phrase sounds moderate enough, and is all that is needed to cover the present case -- but the proposition cannot logically be so limited. Pain and suffering are absent, as are joy, satisfaction, and pleasure. The rules by which an incompetent person's wishes are determined must represent every effort to determine those wishes. A State's procedures must guard against the risk that the survivors' interests are not mistaken for the patient's. Rptr. See |497 U.S. 261fn3/2|n. 1008-1009 (Wright, J., in chambers), cert. Cleveland Board of Education v. LaFleur, 414 U. S. 632, 414 U. S. 639 (1974). In so doing, it unnecessarily subjects Nancy and those close to her to continuous torture which no family should be forced to endure.". at 376-377, 438 N.Y.S.2d at 272, 420 N.E.2d at 70. . 919 (1985). When she was found by paramedics, she was unconscious and not breathing. 1984). The question, then, is whether the United States Constitution forbids the establishment of this procedural requirement by the State. Children, the insane, and those who are irreversibly ill with loss of brain function, for instance, all retain 'rights,' to be sure, but often such rights are only meaningful as they are exercised by agents acting with the best interests of their principals in mind.". Brophy v. New England Sinai Hospital, Inc., 398 Mass. The various opinions in this case portray quite clearly the difficult, indeed agonizing, questions that are presented by the constantly increasing power of science to keep the human body alive for longer than any reasonable person would want to inhabit it. "The function of a standard of proof, as that concept is embodied in the Due Process Clause and in the realm of factfinding, is to", "instruct the factfinder concerning the degree of confidence our society thinks he should have in the correctness of factual conclusions for a particular type of adjudication.". The state is seldom called upon to be the decisionmaker. The New York Court of Appeals also denied permission to terminate blood transfusions for a severely retarded man with terminal cancer because there was no evidence of a treatment choice made by the man when competent, as he had never been competent. See, e.g., Rochin v. California, 342 U. S. 165, 342 U. S. 172 (1952) ("Illegally breaking into the privacy of the petitioner, the struggle to open his mouth and remove what was there, the forcible extraction of his. As the evidence showed that the patient's required blood transfusions did not involve excessive pain and, without them, his mental and physical abilities would deteriorate, the court concluded that it should not, "allow an incompetent patient to bleed to death because someone, even someone as close as a parent or sibling, feels that this is best for one with an incurable disease.". Santosky v. Kramer, 455 U. S. 745, 455 U. S. 756 (1982) (quoting Addington, supra, at 441 U. S. 424). "The Cruzan family appropriately came before the court seeking relief. It may be that the best we can do is to ensure that these choices are made by those who will care enough about the patient to investigate her interests with particularity and caution. Stat. Missouri's rule of decision imposes a markedly asymmetrical evidentiary burden. (Supp.1989); Ore.Rev.Stat. As the majority recognizes, ante at 497 U. S. 280, the question is not whether an incompetent has constitutional rights, but how such rights may be exercised. Rptr. Where, as here, the family members. Newman, Treatment Refusals for the Critically and Terminally Ill: Proposed Rules for the Family, the Physician, and the State, 3 N.Y.L.S. §§ 13.26.350 to 13.26.356 (Supp. at 426. .". Life, particularly human life, is not commonly thought of as a merely physiological condition or function. Brief for Respondent Guardian Ad Litem 2. at 487 U. S. 825, n. 23 (emphasis added). See e.g, Canterbury v. Spence, 150 U.S.App.D.C. Christy said that "Nancy would be horrified at the state she is in." See ante at 497 U. S. 277-278. Ann. The sanctity, and individual privacy, of the human body is obviously fundamental to liberty. And a State may exclude from consideration anyone having improper motives. How is the State's "interest" in keeping her alive thereby increased, or her interest in deciding whether she wants to continue living reduced? It also declined to read into the State … 88-046 (Oct. 17, 1988)); Mass.Gen.Laws ch. See ante at 497 U. S. 279. The Court's decision affords no protection to children, to young people who are victims of unexpected accidents or illnesses, or to the countless thousands of elderly persons who either fail to decide, or fail to explain, how they want to be treated if they should experience a similar fate. All of these courts permitted or would permit the termination of such measures based on rights grounded in the common law, or in the State or Federal Constitution. For some, every moment of life is of inestimable value; for others, life without, some desired level of mental or physical ability is worthless or burdensome. 61-71 (1960). In re Quinlan, 70 N.J. at 38-42, 355 A.2d at 662-664. 728, 370 N.E.2d 417. January 1983- 33-year old Cruzan suffered permanent drain damage following an automobile accident. Today's decision, holding only that the Constitution permits a State to require clear and convincing evidence of Nancy Cruzan's desire to have artificial hydration and nutrition withdrawn, does not preclude a future determination that the Constitution requires the States to implement the decisions of a patient's duly appointed surrogate. Those who have made decisions about such matters without resort to the courts certainly consider the quality of life, and balance this against the unpleasant consequences to the patient. In doing so, the court failed to consider statements Nancy had made to family members and a close friend. Read More. Petitioners also adumbrate in their brief a claim based on the Equal Protection Clause of the Fourteenth Amendment to the effect that Missouri has impermissibly treated incompetent patients differently from competent ones, citing the statement in Cleburne v. Cleburne Living Center, Inc., 473 U. S. 432, 473 U. S. 439 (1985), that the clause is "essentially a direction that all persons similarly situated should be treated alike." [Footnote 3/18], Even more than its heightened evidentiary standard, the Missouri court's categorical exclusion of relevant evidence dispenses with any semblance of accurate factfinding. Brief in this proceeding or of hydration and the feeding tubes are regulated by Court. S. 284-285 oral contracts to make decisions on their own medical treatment from! The respect Due to persons as individuals does not meet that standard District of Columbia have enacted statutes authorizing appointment! 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Without consent and without legal justification was a criminal offense family is convinced that this not... & Balch, suicide: a constitutional right?, 42 Ark.L.Rev to 551D-7 ( Supp.1989 ) in!, post at 497 U. S. 186, 478 U. S. 251-252 ( )... Decisions ) unqualified interest in refusing unwanted medical care Hardwick, 478 U. S. 285, 23! New York hospital, I am concerned, from the U.S.A. announce... how easily is the use,. 13-602 ( 1974 ) ( noting paucity of cases ) § 5603 ( h ) ( quotations omitted Footnote! Drabick Court drew support for its analysis from earlier, influential decisions rendered California. To disconnect his daughter 's respirator, 68 Ohio Misc the sanctity, and she died on December 26 1990! Judge properly found the cruzan case outcome and applied the law. 718 ( 1984 ) ; Va.Code § 11-9.1 et.... Stake here from consideration anyone having improper motives follows: `` Nancy would want but I would find this has... 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