Chief Justice William Rehnquist wrote the majority opinion that establishes the
legal rule of the Cruzan case. Four additional justices joined in this opinion, and
four justices dissented. With the exception of Justice Antonin Scalia, all of the
justices were willing to agree, for the purpose of this case, that a competent
person has a right to refuse life-saving medical treatment. (When judges
assume something for the purpose of a case, it means that what they are
assuming is not critical to their decision and may be reevaluated in other
cases.) Justice Scalia refused to accept this assumption because he believed
that this would undermine the state’s authority to forbid suicide.
Both the majority and dissenting opinions accepted that the patient’s intentions
should be controlling if they are known. The majority found it proper for
Missouri to require these intentions be judged by a standard of clear and
convincing evidence, preferably through a living will or durable power of
attorney. The dissent found the requirement of such formality to be
unconstitutionally burdensome, arguing that the court hearing a termination of
life-support case should be bound by the testimony of the patient’s family and
friends. Although accepting such informal evidence would seem to ease the
resolution of these cases, it conflicts with the general rule disallowing oral
testimony:
It is also worth noting that most, if not all, States simply forbid oral
testimony entirely in determining the wishes of parties in transactions
that, although important, simply do not have the consequences that a
decision to terminate a person’s life does. At common law and by
statute in most States, the parole evidence rule prevents the variations
of the terms of a written contract by oral testimony. The statute of
frauds makes unenforceable oral contracts to leave property by will, and
statutes regulating the making of wills universally require that those
instruments be in writing. [
Cruzan by Cruzan v. Director, Mo. Dept. of
Health, 497 U.S. 261 (1990)
.]
The states prohibit oral testimony about wills because the person whose
intentions are being sought is dead and thus unavailable to contest the
testimony. This rule evolved as the courts found determining the wishes of
dead people to be an invitation to fraud and family conflict. Given that a
patient in a persistent vegetative state, is, for the purpose of contesting
testimony, equivalent to a dead person, the majority did not find it
unconstitutionally burdensome to require these same protections for
termination of life-support decisions.
There is a contentious debate between the majority and dissenting opinions
over the use of the clear-and-convincing standard for proving a patient’s
wishes. This debate is less important for its own merits than as a surrogate for
the fundamental disagreement between the majority and dissenting opinions
in Cruzan: Is Nancy Cruzan really dead? Justice Rehnquist’s majority opinion
and, more strongly, Justice Scalia’s concurring opinion treat Nancy Cruzan as a
living person with liberty interests that are entitled to constitutional protection.
The dissenting justices, led by now- retired Justice Brennan, treat Nancy
Cruzan as a dead person who has slipped through the cracks in the usual
medical tests for death.
The majority opinion specifically rejected a constitutional right of family
members to terminate care for patients whose wishes are not known. This
ruling is consistent with the Court’s previous cases protecting competent
patients from requirements that husbands have a voice in determining their
wives’ medical care. The Court ruled that states, through their legislative
processes, are empowered to establish guidelines for medical decision making
for incompetent patients who have not otherwise properly documented their
wishes. This ruling leaves existing state laws in place;
Cruzan did not require
any changes in established procedures to terminate life support.
