Court Lets States Place Limits on the Right to Die

The Supreme Court, in its first decision on the “right-to-die” issue, ruled Monday that the parents of a comatose woman do not have an automatic right under the U.S. Constitution to insist that hospital workers stop feeding her.

Although a conscious patient has a right to reject all medical treatment, the high court said, the patient’s family may not automatically invoke that right if the patient cannot speak for herself. Rather, a state is entitled to require that the family prove by “clear and convincing evidence” that the patient would wish to die, the court said.

The 5-4 decision means that a 32-year-old Missouri woman, Nancy Cruzan, will continue to be kept alive in a hospital.

More broadly, the ruling means that some sensitive issues involving what has come to be called the right to die will continue to be decided on a state-by-state basis.

For Californians, the impact of Monday’s high court ruling should be minimal. Chief Justice William H. Rehnquist, the court’s foremost proponent of states’ rights, said that state legislatures and state courts may use their own constitutions and laws to decide under what circumstances a life may be ended.

In a 1988 decision cited by Rehnquist, the California courts said that a patient not only has a right to die but that a family member or legal guardian may make that final decision on behalf of a comatose or terminally ill patient. Because that state court ruling is based on state law, it is unaffected by Monday’s high court ruling interpreting the U.S. Constitution, the chief justice said.

“The real message of this decision is: Make your choices known and they will be respected,” said Alexander Capron, a USC professor of law and medicine.

Even in Missouri, the state judges would have let Nancy die if she had spoken to her doctor on the subject or signed a “living will” expressing her views, Capron said.

Monday’s ruling, far from answering all the questions on the right-to-die issue, ensures that it will continue to be debated in hospitals, legislatures and state courts.

And for good reason. Thanks to recent advances in medical technology, most Americans now face the likelihood that they--or someone else--will make decisions affecting when they die.

About 2 million Americans die each year. About 80% of those deaths take place in a hospital or nursing home. And, in nearly every such death, a crucial decision is made at some point by a doctor, the patient or a relative on whether to stop, start or continue a potentially life-prolonging course of medical treatment.

Since 1976, when New Jersey teen-ager Karen Ann Quinlan lapsed into a coma, state courts have struggled to set rules on when medical treatment, life support and even food and water may be cut off from a still-living patient.

A legal consensus had developed since then. At least 27 state courts have upheld a right to die for patients who have no hope of recovery, according to the Society for the Right to Die in New York.

The Supreme Court had stood aside until now. It let stand a number of state court rulings upholding a right to die but refused to say whether any such right is included in the U.S. Constitution.

But, two years ago, the Missouri Supreme Court departed from the consensus by ruling that the state’s interest in “the right to life” outweighs the parents’ assertion of their daughter’s right to die. In a 4-3 decision, the Missouri court pointed out that Nancy Cruzan was not in pain, was not terminally ill and had not stated a clear view on whether she would want to die. Therefore, the state court said, it would “err on the side of life” and reject the parents’ request to end her life.

On the night of Jan. 11, 1983, Nancy Cruzan was driving alone on an icy road, lost control of her car and was seriously injured. After being rushed to a hospital by paramedics, she was kept alive but never regained consciousness. Her family initially agreed to have a tube implanted in her stomach for food and water. Now, she is classified, like an estimated 10,000 Americans, as being in a “persistent vegetative state.”

In the years before the accident, Nancy had told a friend that she would not want to live as a “vegetable.” Based on that evidence, a judge in Missouri had granted a request by Joe and Joyce Cruzan, Nancy’s parents, to order the hospital to stop feeding her.

But Missouri Atty. Gen. William Webster appealed to the state Supreme Court. Because the parents could not furnish “clear and convincing evidence” that Nancy would wish to die, she must be kept alive, the state court ruled.

The Cruzans then appealed to the U.S. Supreme Court.

“We hold there is nothing in the U.S. Constitution that prohibits Missouri from requiring clear and convincing proof” that a patient would have wanted her life ended, Rehnquist said in announcing Monday’s ruling (Cruzan vs. Missouri Department of Health, 88-1503).

He pointed out that the “risk of an erroneous decision” could cause judges to be cautious. As was noted in several friend-of-the-court briefs filed in the case, families of comatose patients sometimes stand to inherit large amounts of money if the relative dies.

Although Rehnquist’s opinion is a setback for the right-to-die movement, it is not a total loss. In a roundabout way, the chief justice endorsed the notion that a competent person has a constitutional right to reject all medical treatment, including food and water.

The 14th Amendment says that a state may not “deprive any person of . . . liberty . . . without due process of law.” This clause, Rehnquist said, establishes “the principle that a competent person has a constitutionally protected liberty interest in refusing unwanted medical treatment.”

This right includes, he added, “a constitutionally protected right to refuse life-saving hydration and nutrition.”

However, in a footnote, the chief justice said that this right to reject medical treatment does not stem from a general constitutional “right of privacy,” a point that has been the focus of the abortion fight. His opinion was joined by Justices Byron R. White, Sandra Day O’Connor, Anthony M. Kennedy and Antonin Scalia.

Rehnquist focused on the broad picture, but the dissenters focused on Nancy Cruzan and concluded that she should be allowed to die. She “has dwelt in a twilight zone for six years. She is oblivious to her surroundings and will remain so,” said Justice William J. Brennan Jr. Also dissenting were Justices Thurgood Marshall, Harry A. Blackmun and John Paul Stevens.