The majority of people on Earth do not expect to find themselves in the situation of choosing how to die. However, the unlucky ones suffering from terminal illnesses sometimes make decisions to stop receiving any kind of medical treatment in order to depart peacefully. These people are very often unconscious, living in a persistent vegetative state with no hope of improvement or recovery. The matter is American laws allow people to say no to medical treatment. But do family members have the right to make the choice for the terminally ill person? The Cruzan Case was the first situation when the US Supreme Court issued its first decision in favor of the right to die. In this paper we will shed light on the story of Nancy Cruzan’s last years of life and death, Cruzan’s Case in the Court and its’ constitutional questions, as well as majority, concurring and dissenting judicial opinions concerning it.
Facts of the Case
On January 11, 1983, Nancy Cruzan was returning back home after work and got into a car accident. Her car was very old and had no seatbelts that is why she was thrown several feet away from it and damaged her head severely. When she was found by the people that lived nearby, she lied on the ground unconsciously, had no pulse and no heartbeat, but they were restored in the hospital. She overcame surgical operations and managed to survive them all, but fall into a coma. After an accident, Nancy’s brain did not receive oxygen for twelve to fourteen minutes and, because of this, there was almost no hope left that in the future it will regain its activity. Nancy was in a vegetative state and the only parts of her brain functioning were those, responsible for breathing, heartbeat and reflex movements (Donnelly, 7-46). Because his daughter could not eat by herself, Joe Cruzan signed a consent form to have a feeding tube surgically inserted into her stomach. Back then he did not know that, at the same time that he had given his permission to have the feeding tube implanted, he had lost the right to have it removed (Perl, 45).
Three years after the accident, realizing that Nancy’s condition will not improve, her parents asked doctors to discontinue tube feedings, but they refused and Cruzan family filed a lawsuit against Missouri Department of Health in order to defend their daughter’s right to die. The thing is a feeding tube was not considered a medical treatment that is why it was complicated to refuse Nancy in it from the standpoint of the law. Cruzan’s family lawyer Bill Colby tried to persuade the judge that it was indeed a form of medical treatment, as necessary as a respirator (Lo, 171-172). One of Nancy’s doctors, in order to support the parents that wanted peaceful departure of their daughter into the better world, explained the process of death in a PVS patient:
It is a peaceful one, that a person in a persistent vegetative state is incapable of experiencing pain, thirst, hunger. There is nothing left in their brain to experience these things. All they have is brain stem function which controls their reflexes (Perl, 80-83).
The trial Court decided that Nancy’s family had the right to remove the tube, because the person that is in a vegetative state for years is to have the right to remove his or her supporting system. However, Nancy did not write any will during her life, as well as she did not choose a person, who could make medical decisions for her, if she was physically unable to do this. Her family only provided the court with the information that Nancy once mentioned she would prefer not to live in a vegetative state. So, when the case was transferred to the Missouri Supreme Court for further consideration, the decision was changed. The Court viewed Nancy’s ideas about her possible future medical care as too general and too casual. As a result, it was summarized that there were no clear, convincing and reliable evidence of the fact that Nancy Cruzan would agree to terminate her life support being in such a condition (Levinson, 647).
Nancy Cruzan’s parents decided to appeal to the US Supreme Court in search of justice and peaceful departure of their daughter. Bill Colby tried to persuade the judges that forced medical treatment in the form of feeding tube is a violation of human liberty and freedom of choice, and, in a way, violation of the Fourteenth Amendment to the Constitution. The lawyer’s argument was also based on the fact that Nancy had a right on privacy, as well as her parents had the right to speak for her as her guardians. He tried to establish that had Nancy been able to speak for herself, she would not have wanted to live in a vegetative state. Right to life advocates argued that the removal of feeding tube was a criminal act similar to abortion. But Nancy was not a healthy fetus with all the possibilities of life open to her. She was already a thirty one year old woman, doomed to limited form of existence that was entirely dependent on artificial feeding and constant medical care (Perl, 57-63).
The Cruzan Case raised many questions, connected to the rightness of euthanasia and legality of allowing terminally ill patients to die. What rights did patients have if they were unable to speak for themselves? How could a person voice his or her desires? Was Nancy’s constitutional right to reject unwanted treatment violated? What about the constitutional question of self-starvation? Among other crucial questions, this case touched upon the right to die, informal refusal of treatment, constitutional standing of the guardians, patient’s best interests’ protection and quality of life exemption from the obligation to preserve life. It also aimed at figuring out whether there is a family’s right of sovereignty that overrides the State’s interest in preserving life. Nancy did not leave specific instructions to terminate life support, if she were in a comatose state. Who then should decide to withhold medical treatment: family, court or doctor?
The Cruzan Case for the first time was raising federal constitutional questions that reached the US Supreme Court. The judges decided that:
The choice of how and when to die is an aspect of liberty protected by the Due Process Clause of the Fourteenth Amendment so that it could focus instead on whether a state may constitutionally require clear and convincing evidence…that the decision to terminate life support is one the comatose patient would have made (Ducat, 791).
Because patients like Nancy Cruzan are not able to make such decision on their own, a family member or appointed guardian must make the decision for them.
When three new witnesses testified on Nancy’s stated desire not to continue life-sustaining medical treatment in this type of circumstances, the case was dismissed and the US Supreme Court granted permission for feeding tube to be removed. The need for patients to have written advance directives, or, in other words, Living Wills, was emphasized. It was a five-to-four Court decision: Justices Anthony Kennedy, Sandra Day O’Connor, Antony Scalia, Byron R. White and Chief Justice William H. Rehnquist concurred; Justices Harry A. Blackmun, William J. Brennan, Jr. Thurgood Marshall and John Paul Stevens dissented (Perl, 82-83).
The majority of the Court in the Cruzan Case decided that a guardian must provide clear and convincing evidence of the fact that the patient in a vegetative state wants to discontinue nutrition and hydration. When it comes to such important decision as ending a life, the Court pointed out that in a situation, when there is no Living Will and obvious expression of patient’s wish, clear and convincing evidence that a person expressed such wishes or general proof of what individual’s decision would have been are to be provided (Ducat, 791). The judge Sandra Day O’Connor expressed a concurring opinion that after the Cruzan Case the States are to implement the decisions of patient’s guardian appointed in a proper way (Kerridge, Lowe, and McPhee, 399).
The dissenters did not agree with the position of the majority. They considered that clear and convincing evidence rule was an intrusion into the patient’s right to privacy. Judge John Paul Stevens stated that determination of the State to prolong physical existence of the individual in a vegetative state is to be understood as an effort to define the meaning of life, not an attempt to preserve its sanctity. He continued that government should not limit liberties of the people by regulations created in order to establish the definition of life. Judge Stevens concluded that interests of the individual, supported by the interests of the third party, are to prevail over any kind of state policy that ignores such interests. To deny this means to call into question the fact that Nancy Cruzan has interests at all and to object her personhood in the name of life’s sanctity (Ducat, 791).
To conclude with, the Cruzan Case had a tremendous influence on the lives of terminally ill Americans. Most importantly, it stimulated the appearance of laws that allowed people to created Living Wills – documents signed before witnesses that indicated person’s wishes if they became catastrophically injured. After the Cruzan Case many states also adopted laws that allowed patients to appoint people, who would make decisions for them, when they themselves would not be able to do this.