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Report No. 196

Chapter V

Leading Case Law and Statutes in United States of America

In this chapter, we shall refer to some leading judgments from USA and also refer to some of the pieces of legislation.

(A) USA (Federal):

(1) Cruzan vs. Director, MDH: (1990) 497 US 261 (dated 25th June 1990)

(Rehnquist CJ delivered the opinion, in which White, Sandra Day O'Connor, Scalia and Kennedy JJ joined. O'Connor and Scalia J filed cocurring opinions. Brennan J filed a dissenting opinion in which Marshall and Blackmun JJ joined. Stevens filed a separate dissenting opinion).

Nancy Cruzan met with a motor accident on January 11, 1983, while she lost control of her car, the vehicle overturned and went down Elm Road in Jaspar County, Missouri. She has been in Mission State Hospital, in a Persistent Vegetative State (PVS), where she only exhibits motor reflexes but evinces no indication of significant cognitive function. The State is bearing the cost of her care. Cruzan's parents requested for termination of her artificial nutrition and hydration but the hospital refused, since that would result in her death.

The State trial Court authorized termination but the State Supreme Court refused to so authorize. While recognizing a right, on part of a patient, to refuse treatment under common law doctrine of informed consent, the Court questioned applicability of the said principle to this case. It declined to read into the State Constitution a broad right to privacy that would support an unrestricted right to refuse treatment and expressed doubt if the Federal Constitution embodied such a right.

The Court then decided that the State's Living Will statute embodied a state policy strongly favouring the preservation of life and that Cruzan's statements to her housemate were unreliable for the purpose of determining her intent. It rejected the argument that the parents were entitled to order termination of her medical treatment. It concluded that no person can assume that choice for an incompetent person, in the absence of the formalities required by the Living Will Statute or in the absence of clear and convincing evidence of the patient's wishes.

The US Supreme Court affirmed the judgment and held that (1) the State of Missouri was competent to require that the incompetent's prior wish as to withdrawal of life sustaining treatment, should be proved by 'clear and convincing' evidence. (Here the plea about the patient's earlier words, while conscious, that she did not wish to live unless at least one half of normal life was assured by treatment, was not substantiated by clear and convincing evidence);

(2) Most State Courts in US have based a right to refuse treatment on the basis of the common law right to informed consent or on both that right and a constitutional privacy right. Courts have also turned to guidance from State statutes;

(3) A competent person is at liberty under Due Process Clause in refusing unwanted medical treatment (Jacobson vs. Massachusetts: 197 US 11). However, the question whether that constitutional right has been violated, must be determined by balancing the liberty interest against relevant State interests. For purposes of this case, it is assumed that a competent person would have a constitutionally protected right to refuse life-saving hydration and nutrition.

This does not mean that an incompetent person should possess the same right, since such a person is unable to make an informed and voluntary choice to exercise that hypothetical right or any other right. While State of Missouri has, in effect, recognized that, under certain circumstances, a surrogate may act for the patient in electing to withdraw hydration and nutrition and thus cause death, it has established a procedural safeguard to assure that surrogate's action conforms, as best as it may, to the wishes expressed by the patient while competent;

(4) It is permissible for the Missouri State, in its proceedings, to apply a 'clear and convincing' evidence standard, which is an appropriate standard when the individual interests at stake are both particularly important and more substantial than mere loss of money (Santosky vs. Kramer: 455 US 745). The State of Missouri has a general interest in the protection and preservation of human life, as well as other, more particular interests, at stake. It may legitimately seek to safeguard the personal element of an individual's choice between life and death. The State is also entitled to guard against potential abuses by surrogates who may not act to protect the patient.

(5) Similarly, the State is entitled to consider that a judicial proceeding regarding an incompetent's wishes may not be adversarial, with the added guarantee of accurate fact finding that the adversary process begins with it.

(6) The State may also decline to make judgments about the 'quality' of a particular individual's life, and simply assent an unqualified interest in the preservation of human life to be weighed against the constitutionally protected interests of the individual. The clear and convincing evidence standard also serves as a societal judgment about how the risk of error should be distributed between the litigants. Missouri State may permissibly place the increased risk of an erroneous decision on those seeking to terminate life-sustaining treatment.

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. However, an erroneous decision to withdraw such treatment is not susceptible of correction. Although the Missouri State's proof requirement may have frustrated the effectuation of Cruzan's not-fully expressed desires, the Constitution does not require general rules to work flawlessly.

(7) On facts, it was held that the State Supreme Court did not commit any constitutional error in concluding that the evidence adduced at the trial did not amount to clear and convincing proof of Cruzan's desire for withdrawal of hydration and nutrition. The trial Court had not adopted a 'clear and convincing' evidence standard, and Cruzan's observation that she did not want to live life as a 'vegetable' did not deal in terms with withdrawal of medical treatment or of hydration and nutrition.

(8) The 'Due Process' clause does not require a State to accept the 'substituted judgment' of close family members in the absence of substantial proof that their views reflect the patient's. The US Supreme Court's decision upholding the State's favoured treatment of traditional family relationships, Michael H vs. Gerald D 491 US 110, may not be turned into a constitutional requirement that a State must recognize the primacy of these relationships in a situation like this.

Nor may a decision upholding a State's right to permit family decision-making, Parham vs. J.R 442 US 584, be turned into a constitutional requirement that the State must recognize such decision-making. Cruzan's parents would surely be qualified to exercise such a right of 'substituted judgment', were it required by the Constitution. However, for the same reasons that Missouri State may require a clear and convincing evidence of the patient's wishes, it may also choose to defer only to those wishes, rather than confide the decision to close family members.

Medical Treatment to Terminally Ill Patients (Protection of Patients and Medical Practitioners) Back

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