The U.S. Supreme Court’s Ruling
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.