CRUZAN v.
DIRECTOR, MISSOURI
DEPARTMENT OF HEALTH
U.S. SUPREME COURT
1990
CRUZAN
QUESTION AND DECISION
• QUESTION
– WHETHER THE U.S. CONSTITUTION PROHIBITS
MISSOURI FROM CHOOSING THE RULE OF DECISION
THAT IT DID [I.E., CLEAR AND CONVINCING EVIDENCE
MUST BE PRESENT BEFORE THE TERMINATION OF
LIFE-SUSTAINING TREATMENT FOR AN INCOMPETENT].
• DECISION
– THE U.S. CONSTITUTION DOES NOT FORBID MISSOURI
FROM REQUIRING THAT EVIDENCE OF AN
INCOMPETENT’S WISHES AS TO THE WITHDRAWAL OF
LIFE-SUSTAINING TREATMENT BE PROVIDED BY THE
CLEAR AND CONVINCING EVIDENCE STANDARD.
CRUZAN
GROUNDS AND ASSUMPTIONS
• INFORMED CONSENT DOCTRINE
• 14TH AMENDMENT LIBERTY INTEREST
– “. . . NOR SHALL ANY STATE DEPRIVE ANY
PERSON OF LIFE, LIBERTY, OR PROPERTY,
WITHOUT DUE PROCESS OF LAW.”
• PATIENT HAS A LIBERTY INTEREST IN REFUSING
LIFE-SUSTAINING TREATMENT WHICH CAN BE
OUTWEIGHED BY THE STATE’S INTEREST IN
PRESERVING LIFE
• MEDICALLY ADMINISTERED NUTRITION AND
HYDRATION ARE MEDICAL TREATMENT
CRUZAN
POWERS OF THE PATIENT, I
• COMPETENT PATIENTS CAN
REFUSE ANY AND ALL TREATMENT.
• PATIENTS ARE ENCOURAGED TO
EXPRESS THEIR WISHES ABOUT
LIFE-SUSTAINING TREATMENT IN
ADVANCE OF DECISIONAL
INCAPACITY.
• SUBSTITUTED JUDGMENT
STANDARD IS STRENGTHENED.
STANDARDS FOR SURROGATE
DECISION MAKING
SUBSTITUTED JUDGMENT
• SURROGATE ATTEMPTS TO REPLICATE FAITHFULLY THE
DECISION THAT THE INCAPACITATED PERSON WOULD
MAKE IF HE/SHE WERE ABLE TO MAKE A CHOICE
• SURROGATE LOOKS AT THE DECISION THROUGH THE
“VALUE EYES” OF THE INCAPACITATED PERSON
• GROUNDED IN THE PRINCIPLE OF AUTONOMY
• BASED UPON
– DIRECT STATEMENTS BY PATIENT
– INFERENCES FROM VALUE CHOICES OF PATIENT
• SUBSTITUTED JUDGMENT STANDARD IS PREFERABLE
BUT BEST INTEREST STANDARD IS PERMITTED AND
OFTEN NECESSARY
STANDARDS FOR SURROGATE
DECISION MAKING
BEST INTERESTS
• SURROGATE MAKES THE DECISION, FROM AN OBJECTIVE
STANDPOINT, WHICH APPEARS TO PROMOTE A PATIENT’S
GOOD WITHOUT REFERENCE TO THE INCAPACITATED
PATIENT’S ACTUAL OR SUPPOSED PREFERENCES
• WEIGHING BENEFITS AND BURDENS FROM THE
STANDPOINT OF A “REASONABLE” PERSON LOOKING AT
THE CLINICAL OUTCOMES
– “REASONABLE” = SELF-REFLECTIVE, RELATIVELY
UNBIASED, ATTEMPTING FACT-BASED OBJECTIVITY,
SETTING ASIDE SELF-INTEREST
• GROUNDED IN THE PRINCIPLE OF BENEFICENCE
CRUZAN
POWERS OF THE PATIENT, II
• IMPORTANCE OF INFORMED CONSENT IS
UNDERSCORED AND BROADENED TO INCLUDE
DISCUSSION RELEVANT FOR ADVANCE
DIRECTIVES.
• EXPRESSED WISHES OF THE INCOMPETENT
PATIENT MUST BE HONORED BARRING AN
OUTWEIGHING STATE INTEREST.
• ADVANCE DIRECTIVES, WHEN SPECIFIC WITH
REGARD TO CONDITION AND TREATMENT, ACT
AS CLEAR AND CONVINCING EVIDENCE.
CRUZAN
LIMITATIONS ON DECISION MAKING
• BEST INTEREST TEST DOES NOT QUALIFY AS CLEAR AND
CONVINCING EVIDENCE.
• FAMILY MEMBERS DO NOT HAVE AN AUTOMATIC RIGHT TO
BE DECISION MAKERS IN A CONTEXT OF CLEAR AND
CONVINCING EVIDENCE STANDARD.
• CLEAR AND CONVINCING EVIDENCE MAY REQUIRE
EXPLICIT STATEMENTS FROM THE PATIENT, EXCLUDING
MERE INFERENCES.
• STATE MAY IGNORE “QUALITY OF LIFE CONSIDERATIONS”
AND MAY ASSERT AN UNQUALIFIED INTEREST IN
PRESERVING LIFE BALANCED AGAINST THE
CONSTITUTIONAL PROTECTIONS OF INDIVIDUALS.