cruzan director mdh argued december decided june petitioner nancy cruzan incompetent sustained severe injuries automobile accident lies missouri state hospital referred persistent vegetative state generally condition person exhibits motor reflexes evinces indications significant cognitive function state bearing cost care hospital employees refused without approval honor request cruzan parents copetitioners terminate artificial nutrition hydration since result death state trial authorized termination finding person cruzan condition fundamental right state federal constitutions direct refuse withdrawal procedures cruzan expression former housemate wish continue life sick injured unless live least halfway normally suggested wish continue nutrition hydration state reversed recognizing right refuse treatment embodied doctrine informed consent questioned applicability case also declined read state constitution broad right privacy support unrestricted right refuse treatment expressed doubt federal constitution embodied right decided state living statute embodied state policy strongly favoring preservation life cruzan statements housemate unreliable purpose determining intent rejected argument parents entitled order termination medical treatment concluding person assume choice incompetent absence formalities required living statute clear convincing evidence patient wishes held constitution forbid missouri require evidence incompetent wishes withdrawal treatment proved clear convincing evidence pp state courts based right refuse treatment common law right informed consent see storar right constitutional privacy right see superintendent belchertown state school saikewicz mass addition relying state constitutions common law state courts also turned state statutes guidance see conservatorship drabick however sources available question simply whether federal constitution prohibits missouri choosing rule law pp competent person liberty interest due process clause refusing unwanted medical treatment jacobson massachusetts however question whether constitutional right violated must determined balancing liberty interest relevant state interests purposes case assumed competent person constitutionally protected right refuse lifesaving hydration nutrition mean incompetent person possess right since person unable make informed voluntary choice exercise hypothetical right right missouri effect recognized certain circumstances surrogate may act patient electing withdraw hydration nutrition thus cause death established procedural safeguard assure surrogate action conforms best may wishes expressed patient competent pp permissible missouri proceedings apply clear convincing evidence standard appropriate standard individual interests stake particularly important substantial mere loss money santosky kramer missouri general interest protection preservation human life well particular interests stake may legitimately seek safeguard personal element individual choice life death state also entitled guard potential abuses surrogates may act protect patient similarly entitled consider judicial proceeding regarding incompetent wishes may adversarial added guarantee accurate factfinding adversary process brings state may also properly decline make judgments quality particular individual life simply assert unqualified interest preservation human life weighed constitutionally protected interests individual interests substantial individual societal level involved common civil dispute clear convincing evidence standard also serves societal judgment risk error distributed litigants missouri may permissibly place increased risk erroneous decision seeking terminate treatment erroneous decision terminate results maintenance status quo least potential wrong decision eventually corrected impact mitigated event advancement medical science patient unexpected death however erroneous decision withdraw treatment susceptible correction although missouri proof requirement may frustrated effectuation cruzan desires constitution require general rules work flawlessly pp state commit constitutional error concluding evidence adduced trial amount clear convincing proof cruzan desire hydration nutrition withdrawn trial adopted clear convincing evidence standard cruzan observations want live life vegetable deal terms withdrawal medical treatment hydration nutrition due process clause require state accept substituted judgment close family members absence substantial proof views reflect patient decision upholding state favored treatment traditional family relationships michael gerald may turned constitutional requirement state must recognize primacy relationships situation like may decision upholding state right permit family decisionmaking parham turned constitutional requirement state recognize decisionmaking nancy cruzan parents surely qualified exercise right substituted judgment required constitution however reasons missouri may require clear convincing evidence patient wishes may also choose defer wishes rather confide decision close family members pp rehnquist delivered opinion white scalia kennedy joined post scalia post filed concurring opinions brennan filed dissenting opinion marshall blackmun joined post stevens filed dissenting opinion post william colby argued cause petitioners briefs david waxse walter williams edward kelly iii john powell steven shapiro robert presson assistant attorney general missouri argued cause respondent director missouri department health et al brief william webster attorney general robert northcutt thad mccanse pro se david mouton filed brief respondent guardian ad litem solicitor general starr argued cause amicus curiae urging affirmance brief acting assistant attorney general schiffer deputy solicitor general merrill brian martin briefs amici curiae urging reversal filed aids civil rights project walter allan american academy neurology john pickering american college physicians nancy bregstein american geriatrics society keith anderson american hospital association paul armstrong american medical association et al rex lee carter phillips elizabeth esty jack bierig russell pelton paul gebhard laurie rockett henry hart colorado medical society et al garth grissom concern dying henry putzel iii george annas evangelical lutheran church america susan reece martyn henry bourguignon general board church society methodist church thomas martin magda lopez missouri hospitals et al mark thornhill holland john shepherd national hospice organization barbara mishkin walter smith national academy elder law attorneys robert huffman society critical care medicine et al stephan lawton society right die fenella rouse wisconsin bioethicists et al robyn shapiro charles barr jay gold barbara burgoon et al vicki gottlich leslie blair fried stephanie edelstein john mcconnell et al stephen wise briefs amici curiae urging affirmance filed agudath israel america david zwiebel american academy medical ethics james bopp association american physicians surgeons et al edward grant kent masterson brown association retarded citizens et al james bopp thomas marzen stanley herr catholic lawyers guild archdiocese boston calum anderson leonard zandrow district attorney milwaukee county wisconsin michael mccann pro se john stoiber doctors life et al david danis gerard hempstead families life et al robert mauro focus family et al clarke forsythe paul benjamin linton robert showers free speech advocates et al thomas patrick monaghan jay alan sekulow international task force et al jordan lorence knights columbus james burnley iv robert cynkar carl anderson national right life committee james bopp new jersey right life committee et al donald campbell anne perone rutherford institute et al john whitehead james knicely david morris william hollberg amy dougherty thomas strahan william bonner john southworth charles bundren catholic conference mark chopko phillip harris value life committee walter weber elizabeth sadowski et al robert mauro briefs amici curiae filed american nurses association et al diane trace warlick ssm health care system et al jerome mansmann melanie dipietro chief justice rehnquist delivered opinion petitioner nancy beth cruzan rendered incompetent result severe injuries sustained automobile accident copetitioners lester joyce cruzan nancy parents coguardians sought order directing withdrawal daughter artificial feeding hydration equipment became apparent virtually chance recovering cognitive faculties missouri held clear convincing evidence nancy desire treatment withdrawn circumstances parents lacked authority effectuate request granted certiorari affirm night january nancy cruzan lost control car traveled elm road jasper county missouri vehicle overturned cruzan discovered lying face ditch without detectable respiratory cardiac function paramedics able restore breathing heartbeat accident site transported hospital unconscious state attending neurosurgeon diagnosed sustained probable cerebral contusions compounded significant anoxia lack oxygen missouri trial case found permanent brain damage generally results minutes anoxic state estimated cruzan deprived oxygen minutes remained coma approximately three weeks progressed unconscious state able orally ingest nutrition order ease feeding recovery surgeons implanted gastrostomy feeding hydration tube cruzan consent husband subsequent rehabilitative efforts proved unavailing lies missouri state hospital commonly referred persistent vegetative state generally condition person exhibits motor reflexes evinces indications significant cognitive function state missouri bearing cost care become apparent nancy cruzan virtually chance regaining mental faculties parents asked hospital employees terminate artificial nutrition hydration procedures agree removal cause death employees refused honor request without approval parents sought received authorization state trial termination found person nancy condition fundamental right state federal constitutions refuse direct withdrawal death prolonging procedures app pet cert also found nancy expressed thoughts age somewhat serious conversation housemate friend sick injured wish continue life unless live least halfway normally suggests given present condition wish continue nutrition hydration missouri reversed divided vote recognized right refuse treatment embodied common law doctrine informed consent expressed skepticism application doctrine circumstances case cruzan harmon en banc also declined read broad right privacy state constitution support right person refuse medical treatment every circumstance expressed doubt whether right existed constitution decided missouri living statute et seq embodied state policy strongly favoring preservation life found cruzan statements roommate regarding desire live die certain conditions unreliable purpose determining intent thus insufficient support coguardians claim exercise substituted judgment nancy behalf rejected argument cruzan parents entitled order termination medical treatment concluding person assume choice incompetent absence formalities required missouri living statutes clear convincing inherently reliable evidence absent also expressed view road policy questions bearing life death properly addressed representative assemblies judicial bodies granted certiorari consider question whether cruzan right constitution require hospital withdraw treatment circumstances common law even touching one person another without consent without legal justification battery see keeton dobbs keeton owen prosser keeton law torts pp ed turn century observed right held sacred carefully guarded common law right every individual possession control person free restraint interference others unless clear unquestionable authority law union pacific botsford notion bodily integrity embodied requirement informed consent generally required medical treatment justice cardozo appeals new york aptly described doctrine every human adult years sound mind right determine shall done body surgeon performs operation without patient consent commits assault liable damages schloendorff society new york hospital informed consent doctrine become firmly entrenched american tort law see dobbs keeton owen supra pp rozovsky consent treatment practical guide ed logical corollary doctrine informed consent patient generally possesses right consent refuse treatment years ago seminal decision quinlan cert denied sub nom garger new jersey number decisions relatively earlier cases involved patients refused medical treatment forbidden religious beliefs thus implicating first amendment rights well common law rights recently however advance medical technology capable sustaining life well past point natural forces brought certain death earlier times cases involving right refuse treatment burgeoned see collecting reported decisions quinlan case young karen quinlan suffered severe brain damage result anoxia entered persistent vegetative state karen father sought judicial approval disconnect daughter respirator new jersey granted relief holding karen right privacy grounded federal constitution terminate treatment quinlan recognizing right absolute however balanced asserted state interests noting state interest weakens individual right privacy grows degree bodily invasion increases prognosis dims concluded state interests give way case also concluded practical way prevent loss karen privacy right due incompetence allow guardian family decide whether exercise circumstances ibid quinlan however courts based right refuse treatment either solely common law right informed consent common law right constitutional privacy right see tribe american constitutional law ed superintendent belchertown state school saikewicz mass judicial massachusetts relied right privacy right informed consent permit withholding chemotherapy man suffering leukemia reasoning incompetent person retains rights competent individual value human dignity extends adopted substituted judgment standard whereby courts determine incompetent individual decision circumstances distilling certain state interests prior case law preservation life protection interests innocent third parties prevention suicide maintenance ethical integrity medical profession recognized first interest paramount noted greatest affliction curable opposed state interest issue whether long cost individual life may briefly extended storar cert denied new york appeals declined base right refuse treatment constitutional privacy right instead found right adequately supported informed consent doctrine eichner decided storar supra man suffered brain damage anoxia entered vegetative state thus incompetent consent removal respirator however found unnecessary reach question whether rights exercised others since found evidence clear convincing statements made patient competent want maintained vegetative coma use respirator companion storar case man suffering bladder cancer profoundly retarded life implicitly rejecting approach taken saikewicz supra reasoned due incompetency unrealistic attempt determine whether want continue potentially treatment competent evidence showed patient required blood transfusions involve excessive pain without mental physical abilities deteriorate concluded allow incompetent patient bleed death someone even someone close parent sibling feels best one incurable disease many later cases build principles established quinlan saikewicz instance conroy decided quinlan considered whether nasogastric feeding tube removed incompetent resident suffering irreversible mental physical ailments recognizing federal right privacy might apply case contrary approach quinlan decided base decision common law right informed consent balance right ordinarily outweighs countervailing state interests competent persons generally permitted refuse medical treatment even risk death cases held otherwise unless involved interest protecting innocent third parties concerned patient competency make rational considered choice reasoning right lost merely individual unable sense violation held incompetent individuals retain right refuse treatment also held right exercised surrogate decisionmaker using subjective standard clear evidence incompetent person exercised evidence lacking held individual right still invoked certain circumstances objective best interest standards thus trustworthy evidence existed individual wanted terminate treatment enough clearly establish person wishes purposes subjective standard burden prolonged life experience pain suffering markedly outweighed satisfactions treatment terminated standard trustworthy evidence existed person suffering make administration treatment inhumane standard used terminate treatment none conditions obtained held best err favor preserving life also rejected certain categorical distinctions drawn prior cases lacking substance decision purposes distinction actively hastening death terminating treatment passively allowing person die disease treating individuals initial matter versus withdrawing treatment afterwards ordinary versus extraordinary treatment treatment artificial feeding versus forms medical procedures last item acknowledged emotional significance food noted feeding implanted tubes medical procedur inherent risks possible side effects instituted skilled healthcare providers compensate impaired physical functioning analytically equivalent artificial breathing using respirator contrast conroy appeals new york recently refused accept less clearly expressed wishes patient permitting exercise right refuse treatment surrogate decisionmaker westchester county medical center behalf objection patient family members granted order insert feeding tube woman rendered incompetent result several strokes continuing recognize common law right refuse treatment rejected substituted judgment approach asserting inconsistent fundamental commitment notion person substitute judgment acceptable quality life another consequently adhere view despite pitfalls inevitable uncertainties inquiry must always narrowed patient expressed intent every effort made minimize opportunity error citation omitted held record lacked requisite clear convincing evidence patient expressed intent withhold treatment courts found state statutory law relevant resolution issues conservatorship drabick cert denied california appeal authorized removal nasogastric feeding tube man persistent vegetative state result auto accident noting right refuse treatment grounded common law constitutional right privacy held state probate statute authorized patient conservator order withdrawal treatment decision made good faith based medical advice conservatee best interests acknowledging claim patient right choose survives incompetence legal fiction best reasoned respect society accords persons individuals lost upon incompetence best preserved allowing others make decision reflects patient interests closely purely technological decision whatever possible see also conservatorship torres minnesota constitutional statutory authority authorize conservator order removal incompetent individual respirator since patient best interests estate longeway illinois considered whether woman rendered incompetent series strokes right discontinuance artificial nutrition hydration noting boundaries federal right privacy uncertain found right refuse treatment doctrine informed consent held state probate act impliedly authorized guardian exercise ward right refuse artificial sustenance event ward terminally ill irreversibly comatose declining adopt best interests standard deciding appropriate exercise ward right lets another make determination patient quality life opted instead substituted judgment standard finding expressed intent standard utilized supra rigid noted clear convincing evidence patient intent considered also adopted consensus opinion treats artificial nutrition hydration medical treatment cf mcconnell beverly right withdraw artificial nutrition hydration found connecticut removal life support systems act provid es functional guidelines exercise common law constitutional rights attending physician authorized remove treatment finding patient terminal condition obtaining consent family considering expressed wishes patient cases demonstrate common law doctrine informed consent viewed generally encompassing right competent individual refuse medical treatment beyond decisions demonstrate similarity diversity approach decision agree perplexing question unusually strong moral ethical overtones state courts available decision number sources state constitutions statutes common law available us question simply starkly whether constitution prohibits missouri choosing rule decision first case squarely presented issue whether constitution grants common parlance referred right die follow judicious counsel decision twin city bank nebeker said deciding question magnitude importance better part wisdom attempt general statement cover every possible phase subject fourteenth amendment provides state shall deprive person life liberty property without due process law principle competent person constitutionally protected liberty interest refusing unwanted medical treatment may inferred prior decisions jacobson massachusetts instance balanced individual liberty interest declining unwanted smallpox vaccine state interest preventing disease decisions prior incorporation fourth amendment fourteenth amendment analyzed searches seizures involving body due process clause thought implicate substantial liberty interests see breithaupt abram right individual person held inviolable must set interests society term course holding state procedures administering antipsychotic medication prisoners sufficient satisfy due process concerns recognized prisoners possess significant liberty interest avoiding unwanted administration antipsychotic drugs due process clause fourteenth amendment washington harper see also forcible injection medication nonconsenting person body represents substantial interference person liberty still cases support recognition general liberty interest refusing medical treatment vitek jones transfer mental hospital coupled mandatory behavior modification treatment implicated liberty interests parham child common adults substantial liberty interest confined unnecessarily medical treatment determining person liberty interest due process clause end inquiry whether respondent constitutional rights violated must determined balancing liberty interests relevant state interests youngberg romeo see also mills rogers petitioners insist general holdings cases forced administration medical treatment even food water essential life implicate competent person liberty interest although think logic cases discussed embrace liberty interest dramatic consequences involved refusal treatment inform inquiry whether deprivation interest constitutionally permissible purposes case assume constitution grant competent person constitutionally protected right refuse lifesaving hydration nutrition petitioners go assert incompetent person possess right respect possessed competent person rely primarily decisions parham supra youngberg romeo supra parham held mentally disturbed minor child liberty interest confined unnecessarily medical treatment certainly intimate minor child commitment liberty interest refusing treatment youngberg held seriously retarded adult liberty interest safety freedom bodily restraint youngberg however deal decisions administer withhold medical treatment difficulty petitioners claim sense begs question incompetent person able make informed voluntary choice exercise hypothetical right refuse treatment right right must exercised sort surrogate missouri effect recognized certain circumstances surrogate may act patient electing hydration nutrition withdrawn way cause death established procedural safeguard assure action surrogate conforms best may wishes expressed patient competent missouri requires evidence incompetent wishes withdrawal treatment proved clear convincing evidence question whether constitution forbids establishment procedural requirement state hold whether missouri clear convincing evidence requirement comports constitution depends part interests state may properly seek protect situation missouri relies interest protection preservation human life gainsaying interest general matter indeed civilized nations demonstrate commitment life treating homicide serious crime moreover majority country laws imposing criminal penalties one assists another commit suicide think state required remain neutral face informed voluntary decision physically able adult starve death context presented state particular interests stake choice life death deeply personal decision obvious overwhelming finality believe missouri may legitimately seek safeguard personal element choice imposition heightened evidentiary requirements disputed due process clause protects interest life well interest refusing medical treatment incompetent patients loved ones available serve surrogate decisionmakers even family members present course unfortunate situations family members act protect patient jobes state entitled guard potential abuses situations similarly state entitled consider judicial proceeding make determination regarding incompetent wishes may well adversarial one added guarantee accurate factfinding adversary process brings see ohio akron center reproductive health post finally think state may properly decline make judgments quality life particular individual may enjoy simply assert unqualified interest preservation human life weighed constitutionally protected interests individual view missouri permissibly sought advance interests adoption clear convincing standard proof govern proceedings function standard proof concept embodied due process clause realm factfinding instruct factfinder concerning degree confidence society thinks correctness factual conclusions particular type adjudication addington texas quoting winship harlan concurring mandated intermediate standard proof clear convincing evidence individual interests stake state proceeding particularly important substantial mere loss money santosky kramer quoting addington supra thus standard required deportation proceedings woodby ins denaturalization proceedings schneiderman civil commitment proceedings addington supra proceedings termination parental rights santosky supra level proof even higher one traditionally imposed cases involving allegations civil fraud variety kinds civil cases involving issues lost wills oral contracts make bequests like woodby supra think interests stake instant proceedings substantial individual societal level involved civil dispute standard proof reflect importance particular adjudication also serves societal judgment risk error distributed litigants santosky supra addington supra stringent burden proof party must bear party bears risk erroneous decision believe missouri may permissibly place increased risk erroneous decision seeking terminate incompetent individual treatment erroneous decision terminate results maintenance status quo possibility subsequent developments advancements medical science discovery new evidence regarding patient intent changes law simply unexpected death patient despite administration treatment least create potential wrong decision eventually corrected impact mitigated erroneous decision withdraw treatment however susceptible correction santosky one factors led require proof clear convincing evidence proceeding terminate parental rights decision case final irrevocable santosky supra must surely said decision discontinue hydration nutrition patient nancy cruzan agree result death also worth noting simply forbid oral testimony entirely determining wishes parties transactions important simply consequences decision terminate person life common law statute parol evidence rule prevents variations terms written contract oral testimony statute frauds makes unenforceable oral contracts leave property statutes regulating making wills universally require instruments writing see corbin contracts pp page law wills pp doubt statutes requiring wills writing statutes frauds require contract make writing occasion frustrate effectuation intent particular decedent missouri requirement proof case may frustrated effectuation desires nancy cruzan constitution require general rules work faultlessly general rule sum conclude state may apply clear convincing evidence standard proceedings guardian seeks discontinue nutrition hydration person diagnosed persistent vegetative state note many courts adopted sort substituted judgment procedure situations like whether limit consideration evidence prior expressed wishes incompetent individual whether allow general proof individual decision require clear convincing standard proof evidence see longeway mcconnell gardner jobes leach akron general medical center ohio misc missouri held case testimony adduced trial amount clear convincing proof patient desire hydration nutrition withdrawn reversed decision missouri trial found evidence suggest ed nancy cruzan desired continue measures app pet cert adopted standard clear convincing evidence enunciated testimony adduced trial consisted primarily nancy cruzan statements made housemate year accident want live face life vegetable observations effect observations deal terms withdrawal medical treatment hydration nutrition say missouri committed constitutional error reaching conclusion petitioners alternatively contend missouri must accept substituted judgment close family members even absence substantial proof views reflect views patient rely primarily upon decisions michael gerald parham think cases support claim michael upheld constitutionality california favored treatment traditional family relationships holding may turned around constitutional requirement state must recognize primacy relationships situation like parham patient minor also upheld constitutionality state scheme parents made certain decisions mentally ill minors petitioners seek turn decision allowed state rely family decisionmaking constitutional requirement state recognize decisionmaking constitutional law work way doubt engendered anything record nancy cruzan mother father loving caring parents state required constitution repose right substituted judgment anyone cruzans surely qualify think due process clause requires state repose judgment matters anyone patient close family members may strong feeling feeling ignoble unworthy entirely disinterested either wish witness continuation life loved one regard hopeless meaningless even degrading automatic assurance view close family members necessarily patient confronted prospect situation competent reasons previously discussed allowing missouri require clear convincing evidence patient wishes lead us conclude state may choose defer wishes rather confide decision close family members judgment missouri affirmed footnotes er respiration circulation artificially maintained within normal limits female oblivious environment except reflexive responses sound perhaps painful stimuli suffered anoxia brain resulting massive enlargement ventricles filling cerebrospinal fluid area brain degenerated cerebral cortical atrophy irreversible permanent progressive ongoing highest cognitive brain function exhibited grimacing perhaps recognition ordinarily painful stimuli indicating experience pain apparent response sound spastic quadriplegic four extremities contracted irreversible muscular tendon damage extremities cognitive reflexive ability swallow food water maintain daily essential needs never recover ability swallow sufficient sic satisfy needs sum nancy diagnosed persistent vegetative state dead terminally medical experts testified live another thirty years cruzan harmon mo en banc quotations omitted omitted legal purposes occurrence human death shall determined accordance usual customary standards medical practice provided death shall determined occurred unless following minimal conditions met respiration circulation artificially maintained irreversible cessation spontaneous respiration circulation respiration circulation artificially maintained total irreversible cessation brain function including brain stem determination made licensed physician fred plum creator term persistent vegetative state renowned expert subject described vegetative state following terms vegetative state describes body functioning entirely terms internal controls maintains temperature maintains heart beat pulmonary ventilation maintains digestive activity maintains reflex activity muscles nerves low level conditioned responses behavioral evidence either awareness surroundings learned manner jobes see generally karnezis patient right refuse treatment allegedly necessary sustain life collecting cases cantor patient decision decline medical treatment bodily integrity versus preservation life rutgers noting paucity cases see chapman uniform rights terminally ill act little late see also rozovsky consent treatment practical guide ed later trilogy cases new jersey stressed analytic framework adopted conroy limited elderly incompetent patients shortened life expectancies established alternative approaches deal different set situations see farrell competent mother terminal illness right removal respirator based common law constitutional principles overrode competing state interests peter woman persistent vegetative state right removal nasogastric feeding tube conroy subjective test power attorney hearsay testimony constituted clear convincing proof patient intent treatment withdrawn jobes woman persistent vegetative state entitled removal jejunostomy feeding tube even though hearsay testimony regarding patient intent insufficient meet clear convincing standard proof quinlan family close friends entitled make substituted judgment patient drabick drew support analysis earlier influential decisions rendered california courts appeal see bouvia superior cal rptr competent quadriplegic right removal nasogastric feeding tube inserted bartling superior cal rptr competent man right removal respirator barber superior physicians prosecuted homicide account removing respirator intravenous feeding tubes patient persistent vegetative state besides missouri cruzan courts mcconnell longeway drabick bouvia barber conroy jobes peter appellate courts least four one federal district specifically considered discussed issue withholding withdrawing artificial nutrition hydration incompetent individuals see gray romeo ri gardner grant brophy new england sinai hospital mass corbett courts permitted permit termination measures based rights grounded common law state federal constitution although many state courts held right refuse treatment encompassed generalized constitutional right privacy never held believe issue properly analyzed terms fourteenth amendment liberty interest see bowers hardwick see smith well ends well toward policy assisted rational suicide merely enlightened compiling statutes since cruzan patient state hospital litigation commenced state involved adversary beginning however expected many types disputes arise private institutions guardian ad litem similar party appointed sole representative incompetent individual litigation cases guardian may act entire good faith yet maintain position truly adversarial family indeed noted guardian ad litem case finds predicament believing nancy best interest tube feeding discontinued feeling appeal made responsibility attorneys guardians ad litem pursue matter highest state view fact case first impression state missouri cruzan guardian ad litem also filed brief urging reversal missouri decision none intended suggest guardian acted least bit improperly proceeding meant illustrate limits may obtain adversarial nature type litigation recognize cases involved instances government sought take action individual see price waterhouse hopkins plurality opinion contrast government seeks protect interests individual well institutional interests life see reason important individual interests afforded less protection simply government finds position defending find significant defendant rather plaintiff seeks clear convincing standard proof suggesting standard ordinarily serves shield rather sword government picked shield moment clear convincing standard proof variously defined context proof sufficient persuade trier fact patient held firm settled commitment termination life supports circumstances like presented westchester county medical center behalf evidence produces mind trier fact firm belief conviction truth allegations sought established evidence clear direct weighty convincing enable factfinder come clear conviction without hesitancy truth precise facts issue jobes quotation omitted cases evidence patient intent refuse medical treatment arguably stronger presented new york appeals new jersey respectively held proof failed meet clear convincing threshold see supra jobes supra faced case question whether state might required defer decision surrogate competent probative evidence established patient expressed desire decision terminate life sustaining treatment made individual petitioners also adumbrate brief claim based equal protection clause fourteenth amendment effect missouri impermissibly treated incompetent patients differently competent ones citing statement cleburne cleburne living center clause essentially direction persons similarly situated treated alike differences choice made competent person refuse medical treatment choice made incompetent person someone else refuse medical treatment obviously different state warranted establishing rigorous procedures latter class cases apply former class justice concurring agree protected liberty interest refusing unwanted medical treatment may inferred prior decisions see ante refusal artificially delivered food water encompassed within liberty interest see ante write separately clarify believe notes liberty interest refusing medical treatment flows decisions involving state invasions body see ante notions liberty inextricably entwined idea physical freedom often deemed state incursions body repugnant interests protected due process clause see rochin california illegally breaking privacy petitioner struggle open mouth remove forcible extraction stomach contents bound offend even hardened sensibilities union pacific botsford fourth amendment jurisprudence echoed concern see schmerber california integrity individual person cherished value society winston lee compelled surgical intrusion individual body evidence implicates expectations privacy security magnitude intrusion may unreasonable even likely produce evidence crime state imposition medical treatment unwilling competent adult necessarily involves form restraint intrusion seriously ill dying patient whose wishes honored may feel captive machinery required measures medical interventions forced treatment may burden individual liberty interests much state coercion see washington harper parham disputed child common adults substantial liberty interest confined unnecessarily medical treatment state artificial provision nutrition hydration implicates identical concerns artificial feeding readily distinguished forms medical treatment see council ethical judicial affairs american medical association ama ethical opinion withholding withdrawing medical treatment current opinions hastings center guidelines termination treatment care dying whether techniques used pass food water patient alimentary tract termed medical treatment clear involve degree intrusion restraint feeding patient means nasogastric tube requires physician pass long flexible tube patient nose throat esophagus stomach discomfort tube causes patients need restrained forcibly hands put large mittens prevent removing tube major medical procedures providing food water indications effects extraordinary means choice forgo food water lynn ed gastrostomy tube used provide food water nancy cruzan see ante jejunostomy tube must surgically implanted stomach small intestine office technology assessment task force technologies elderly requiring competent adult endure procedures burdens patient liberty dignity freedom determine course treatment accordingly liberty guaranteed due process clause must protect protects anything individual deeply personal decision reject medical treatment including artificial delivery food water also write separately emphasize today decide issue whether state must also give effect decisions surrogate decisionmaker see ante view duty may well constitutionally required protect patient liberty interest refusing medical treatment individuals provide explicit oral written instructions regarding intent refuse medical treatment become incompetent decline consider evidence instructions may frequently fail honor patient intent failures might avoided state considered equally probative source evidence patient appointment proxy make health care decisions behalf delegating authority make medical decisions family member friend becoming common method planning future see green legal status consent obtained families adult patients withhold withdraw treatment jama several recognized practical wisdom procedure enacting durable power attorney statutes specifically authorize individual appoint surrogate make medical treatment decisions state courts suggested agent appointed pursuant general durable power attorney statute also empowered make health care decisions behalf patient see peter see also atty interpreting md est trusts code ann authorizing delegatee make health care decisions allow individual designate proxy carry intent living procedures surrogate decisionmaking appear rapidly gaining acceptance may valuable additional safeguard patient interest directing medical care moreover patients likely select family member surrogate see president commission study ethical problems medicine biomedical behavioral research making health care decisions giving effect proxy decisions may also protect freedom personal choice matters family life cleveland board education lafleur today decision holding constitution permits state require clear convincing evidence nancy cruzan desire artificial hydration nutrition withdrawn preclude future determination constitution requires implement decisions patient duly appointed surrogate prevent developing approaches protecting incompetent individual liberty interest refusing medical treatment evident survey state decisions see ante national consensus yet emerged best solution difficult sensitive problem today decide one state practice violate constitution challenging task crafting appropriate procedures safeguarding incompetents liberty interests entrusted laboratory new state ice liebmann brandeis dissenting first instance see president commission study ethical problems medicine biomedical behavioral research making health care decisions surveyed gave instructions regarding like treated ever became sick make decisions put instructions writing lou harris poll september american medical association surveys physician public opinion health care issues surveyed told family members wishes concerning use treatment entered irreversible coma filled living specifying wishes least district columbia durable power attorney statutes expressly authorizing appointment proxies making health care decisions see alaska stat ann supp ann west supp idaho code supp ch supp supp tit supp supp ohio ann et seq supp tit purdon supp et seq vernon supp tit et seq district columbia general durable power attorney statutes see alaska supp ann ann west supp et seq supp tit et seq ann supp idaho code et seq supp ch iowa code supp baldwin la ann art west supp tit et seq supp trusts code ann interpreted attorney general see et seq ann supp supp ann et seq et seq supp west et seq mckinney stat et seq supp ohio ann supp okla tit supp tit et purdon supp codified laws ann et seq ann supp utah code ann et seq tit et seq et seq et seq supp stat interpreted attorney general see et seq thirteen living statutes authorizing appointment healthcare proxies see ann supp tit idaho code supp iowa code west supp et seq supp tex health safety code ann supp utah code ann supp ch justice scalia concurring agree analysis today therefore join opinion preferred announce clearly promptly federal courts business field american law always accorded state power prevent force necessary suicide including suicide refusing take appropriate measures necessary preserve one life point life becomes worthless point means necessary preserve become extraordinary inappropriate neither set forth constitution known nine justices better known nine people picked random kansas city telephone directory hence even demonstrated clear convincing evidence patient longer wishes certain measures taken preserve life citizens missouri decide elected representatives whether wish honored quite impossible constitution says nothing matter citizens decide upon line less lawful one choose unlikely know decide upon line less reasonable text due process clause protect individuals deprivations liberty simpliciter protects deprivations liberty without due process law determine deprivation occur nancy cruzan forced take nourishment unnecessary reopen historically recurrent debate whether due process includes substantive restrictions compare murray lessee hoboken land improvement scott sandford compare tyson bro banton olsen nebraska ex rel western reference bond compare ferguson skrupa moore east cleveland plurality opinion see easterbrook substance due process monaghan perfect constitution least true substantive due process claim maintained unless claimant demonstrates state deprived right historically traditionally protected state interference michael gerald plurality opinion bowers hardwick moore supra plurality opinion possibly established common law england suicide defined one deliberately puts end existence commits unlawful malicious act consequence death blackstone commentaries criminally liable ibid although abolished penalties imposed common law forfeiture ignominious burial spare innocent family legitimize act case law time fourteenth amendment generally held assisting suicide criminal offense see marzen crone balch suicide constitutional right duquesne short eighteen thirty ratifying prohibited assisting suicide eight seven ratifying definitely see also wharton criminal law rev ed system penal law presented house representatives representative livingston criminalized assisted suicide livingston system penal law penal code field penal code adopted dakota territory proscribed attempted suicide assisted suicide marzen crone balch supra explicitly prohibit assisted suicide recognized issue arose years following fourteenth amendment ratification assisted cases attempted suicide unlawful surveying development laws thus significant support claim right suicide rooted tradition may deemed fundamental implicit concept ordered liberty quoting palko connecticut petitioners rely three distinctions separate nancy cruzan case ordinary suicide permanently incapacitated pain bring death affirmative act merely declining treatment provides nourishment preventing effectuating presumed wish die requires violation bodily integrity none suffices suicide excused even committed avoid ills persons fortitude endure blackstone supra life life become burden hopelessly diseased fatally wounded nay even lives criminals condemned death protection law equally lives full tide life enjoyment anxious continue live blackburn state ohio thus man prepared poison placed within reach wife put end suffering terminal illness convicted murder people roberts incurable suffering suicide legal question hardly affect degree criminality note yale discussing roberts imminence patient death affected liability lives equally protection law protection last moment assisted suicide declared law murder irrespective wishes condition party poison administered blackburn supra see also commonwealth bowen mass second asserted distinction suggested recent cases canvassed concerning right refuse treatment ante relies dichotomy action inaction suicide said consists affirmative act end one life refusing treatment affirmative act causing death merely passive acceptance natural process dying readily acknowledge distinction action inaction bearing upon legislative judgment prevented suicide though even seem unreasonable draw line precisely action inaction rather various forms inaction make much sense say one may kill oneself walking sea may sit beach submerged incoming tide one may intentionally lock oneself cold storage locker may refrain coming indoors temperature drops freezing even legislative matter words intelligent line fall action inaction forms inaction consist abstaining ordinary care consist abstaining excessive heroic measures unlike action inaction line discerned logic legal analysis pretend return principal point present purposes irrelevance distinction starving oneself death different putting gun one temple far common law definition suicide concerned cause death cases suicide conscious decision pu end existence blackstone supra see caulk state ex rel white narick von holden chapman app course common law rejected distinction contexts involving taking human life well prosecution parent starvation death infant defense infant death caused action parent natural process starvation infant natural inability provide see lewis state people mcdonald hun app div commonwealth hall mass collecting cases wharton law homicide ed bishop commentaries criminal law ed hawley mcgregor criminal law ed physician moreover criminally liable failure provide care extended patient life even death immediately caused underlying disease physician failed treat barrow state people phillips surprising therefore early cases considering claimed right refuse medical treatment dismissed specious nice distinction passively submitting death actively seeking distinction may merely verbal adult sought death starvation instead drug state may interrupt one mode may equal authority interfere john kennedy memorial hosp heston see also application president directors georgetown college app wright chambers cert denied third asserted basis distinction frustrating nancy cruzan wish die present case requires interference bodily integrity likewise inadequate interference impermissible one begs question whether refusal undergo treatment suicide always lawful state even private citizens interfere bodily integrity prevent felony see phillips trull johns city council payne nott mccord vandeveer mattocks ind cooley law torts wilgus arrest without warrant restatement torts general rule course applied suicide common law even private person use force prevent suicide privileged colby jackson look choate mass commonwealth mink mass doyle porter ritch emmerich thorley state hembd addison law torts cooley supra even reasonable much less required constitution maintain although state right prevent person slashing wrists power apply physical force prevent power succeed apply coercively necessary medical measures stop flow blood hospital certain liable violation constitutional rights private hospital liable general tort law state suicide unlawful pumps stomach person intentionally taken overdose barbiturates despite person wishes contrary dissents justices brennan stevens make plausible case intervention embracing latter explicitly former implication political principle free adopt demonstrably imposed constitution state says justice brennan legitimate general interest someone life completely abstracted interest person living life outweigh person choice avoid medical treatment post emphasis added italicized phrase sounds moderate enough needed cover present case proposition logically limited one accepts must also accept think state legitimate interest outweigh person choice put end life similarly one agrees justice brennan state general interest life must accede nancy cruzan particularized intense interest choice medical treatment post emphasis added must also believe state must accede particularized intense interest choice whether continue living die insofar balancing relative interests state individual concerned nothing distinctive accepting death refusal medical treatment opposed accepting refusal food failure shut engine get car parking one garage work suppose nancy cruzan precisely condition today except fed digest food water without artificial assistance state interest keeping alive thereby increased interest deciding whether wants continue living reduced seems words justice brennan position ultimately rests upon proposition none state business person wants commit suicide justice stevens explicit point choices death touch core liberty ot much may said confidence death unless said faith alone reason enough protect freedom conform choices death individual conscience post view societies held free adopt wish view imposed constitutional traditions power state prohibit suicide unquestionable said meant suggest think desirable sure nancy cruzan wanted die keep alive means issue assert constitution nothing say subject raise constitutional right create nothing exists neither text tradition constitutional principle whereby although state may insist individual come cold eat food may insist take medicine although may pump stomach empty poison ingested may fill stomach food failed ingest reasonable humane limits exceeded requiring individual preserve life obviously set forth due process clause assures us limits exceeded constitutional guarantee source protection protects us example assessed tax income subsistence level forbidden drive cars required send children school hours day none horribles categorically prohibited constitution salvation equal protection clause requires democratic majority accept loved ones impose need authority inject every field human activity irrationality oppression may theoretically occur tries destroy justice brennan justice marshall justice blackmun join dissenting medical technology effectively created twilight zone suspended animation death commences life form continues patients however want part life sustained medical technology instead prefer plan medical treatment allows nature take course permits die dignity grown woman time accident nancy previously expressed wish forgo continuing medical care circumstances family friends convinced want see infra guardian ad litem appointed trial also convinced nancy want see higgins dissenting denial rehearing yet missouri alone among state courts deciding question determined irreversibly vegetative patient remain passive prisoner medical technology nancy perhaps next years see today tentatively accepting degree constitutionally protected liberty interest avoiding unwanted medical treatment including medical treatment artificial nutrition hydration affirms decision missouri majority opinion read affirm decision ground state may require clear convincing evidence nancy cruzan prior decision forgo treatment circumstances order ensure actual wishes honored see ante believe nancy cruzan fundamental right free unwanted artificial nutrition hydration right outweighed interests state find improperly biased procedural obstacles imposed missouri impermissibly burden right respectfully dissent nancy cruzan entitled choose die dignity timing death matter fate matter human choice office technology assessment task force life sustaining technologies elderly approximately two million people die year die hospitals care institutions perhaps decision forgo treatment made nearly every death involves decision whether undertake medical procedure prolong process dying decisions difficult personal must made basis individual values informed medical realities yet within framework governed law role courts confined defining framework delineating ways government may may participate decisions starting point legal analysis must whether competent person constitutional right avoid unwanted medical care earlier term held due process clause fourteenth amendment confers significant liberty interest avoiding unwanted medical treatment washington harper today concedes prior decisions support recognition general liberty interest refusing medical treatment see ante however avoids discussing either measure liberty interest application assuming purposes case competent person constitutionally protected liberty interest free unwanted artificial nutrition hydration see ante justice opinion less parsimonious openly affirms often deemed state incursions body repugnant interests protected due process clause liberty interest avoiding unwanted medical treatment encompasses right free artificially delivered food water see ante competent person liberty interest free unwanted medical treatment majority justice concede must fundamental dealing decision involves one basic civil rights man skinner oklahoma ex rel williamson invalidating statute authorizing sterilization certain felons whatever liberties protected due process clause fundamental liberties deeply rooted nation history tradition among bowers hardwick quoting moore east cleveland supra plurality opinion tradition commands respect part constitution carries gloss history richmond newspapers virginia brennan concurring judgment right free medical attention without consent determine shall done one body deeply rooted nation traditions majority acknowledges see ante right long firmly entrenched american tort law securely grounded earliest common law ante see also mills rogers right refuse medical treatment emerged doctrines trespass battery applied unauthorized touchings physician law starts premise follows man considered master body may sound mind expressly prohibit performance lifesaving surgery medical treatment natanson kline inviolability person held sacred carefully guarded common law right union pacific botsford thus freedom unwanted medical attention unquestionably among principles rooted traditions conscience people ranked fundamental snyder massachusetts may serious consequences involved refusal medical treatment issue vitiate right common law tradition medical rule general law patient physician ultimately decides treatment treatment given rule never qualified application either nature purpose treatment gravity consequences acceding foregoing tune walter reed army medical hospital dc see also downer veilleux rationale rule lies fact every competent adult right forego treatment even cure entails intolerable consequences risks however unwise sense values may others material distinction drawn treatment nancy cruzan continues subject artificial nutrition hydration medical treatment see ante concurring artificial delivery nutrition hydration undoubtedly medical treatment technique nancy cruzan subject artificial feeding gastrostomy tube involves tube implanted surgically stomach incisions abdominal wall may obstruct intestinal tract erode pierce stomach wall cause leakage stomach contents abdominal cavity see page andrassy sandler techniques delivery liquid diets nutrition clinical surgery deitel ed tube cause pneumonia reflux stomach contents lung see bernard forlaw complications prevention enteral tube feeding rombeau caldwell eds typically case see tr commercially prepared formulas used rather fresh food see matarese enteral alimentation surgical nutrition fischer ed type formula method administration must experimented avoid gastrointestinal problems patient must monitored daily medical personnel weight fluid intake fluid output blood tests must done weekly artificial delivery food water regarded medical treatment medical profession federal government according american academy neurology artificial provision nutrition hydration form medical treatment analogous forms treatment use respirator patient unconscious respirator artificial feeding device serve support replace normal bodily functions compromised result patient illness position american academy neurology certain aspects care management persistent vegetative state patient neurology see also council ethical judicial affairs american medical association current opinions opinion medical treatment includes medication artificially technologically supplied respiration nutrition hydration president commission treatment includes respirators kidney dialysis machines special feeding procedures federal government permits cost medical devices formulas used enteral feeding reimbursed medicare see note following supp formulas regulated federal drug administration medical foods see feeding tubes regulated medical devices cfr ii right free unwanted medical attention right evaluate potential benefit treatment possible consequences according one values make personal decision whether subject oneself intrusion patient like nancy cruzan sole benefit medical treatment kept metabolically alive neither artificial nutrition form medical treatment available today cure way ameliorate condition irreversibly vegetative patients devoid thought emotion sensation permanently completely unconscious see supra president commission concluded approving withdrawal life support equipment irreversibly vegetative patients reatment ordinarily aims benefit patient preserving life relieving pain suffering protecting disability returning maximally effective functioning prognosis permanent unconsciousness correct however continued treatment confer benefits pain suffering absent joy satisfaction pleasure disability total return even minimal level social human functioning possible president commission apparent testimony patient mind invasiveness systems nasogastric tube upon integrity body also utter helplessness permanently comatose person wasting strong body submission private bodily functions attention others gardner although right free unwanted medical intervention like constitutionally protected interests may absolute state interest outweigh rights individual nancy cruzan position whatever state possible interests mandating treatment circumstances good obtained missouri insistence nancy cruzan remain systems indeed wish missouri claim society whole benefited nancy receiving medical treatment third party situation improved harm others averted cf nn supra state interest asserted general interest preservation life state legitimate general interest someone life completely abstracted interest person living life outweigh person choice avoid medical treatment regulation constitutionally protected decisions must predicated legitimate state concerns disagreement choice individual made otherwise interest liberty protected due process clause nullity hodgson minnesota post opinion stevens emphasis added thus state general interest life must accede nancy cruzan particularized intense interest choice medical treatment simply nothing legitimately within state purview gained superseding decision moreover may considerable danger missouri rule decision impair rather serve interest state sustaining life current medical practice recommends use heroic measures scintilla chance patient recover assumption measures discontinued patient improve president commission approved withdrawal life support equipment irreversibly vegetative patients explained even troubling wrong occurs treatment might save life improve health started health care personnel afraid find difficult stop treatment fairly likely proves little benefit greatly burdens patient president commission new jersey recognized families well doctors might discouraged inability stop measures even attempting certain types care thereby force hasty premature decisions allow patient die conroy see also brief american academy neurology amicus curiae expressing concern iii say state legitimate interests assert majority recognizes ante missouri parens patriae interest providing nancy cruzan incompetent accurate possible determination exercise rights circumstances second determined nancy cruzan want continue treatment state may legitimately assert interest providing treatment nancy wishes determined state interest may asserted interest accuracy determination accuracy therefore must touchstone missouri may constitutionally impose procedural requirements serve enhance accuracy determination nancy cruzan wishes least consistent accurate determination missouri safeguard upholds today meet standard determination needed context whether incompetent person choose live persistent vegetative state avoid medical treatment missouri rule decision imposes markedly asymmetrical evidentiary burden evidence specific statements treatment choice made patient competent admissible support finding patient persistent vegetative state wish avoid medical treatment moreover evidence must clear convincing proof required support finding incompetent person wish continue treatment majority offers several justifications missouri heightened evidentiary standard first majority explains state may constitutionally adopt rule govern determinations incompetent wishes order advance state substantive interests including unqualified interest preservation human life see ante missouri evidentiary standard however rest state interest particular substantive result sure courts long erected clear convincing evidence standards place greater risk erroneous decisions bringing disfavored claims cases however choice discourage certain claims legitimate constitutional policy choice contrast missouri power disfavor choice nancy cruzan avoid medical treatment missouri legitimate interest providing nancy treatment established represents choice see supra state may override nancy choice directly may indirectly imposition procedural rule second majority offers two explanations missouri clear convincing evidence standard means enhancing accuracy neither persuasive majority initially argues clear convincing evidence standard necessary compensate possibility proceedings lack guarantee accurate factfinding adversary process brings citing ohio akron center reproductive health post upholding clear convincing evidence standard ex parte proceeding ante without supporting decision case note proceeding determine incompetent wishes quite different proceeding determine whether minor may bypass notifying parents undergoing abortion ground mature enough make decision abortion best interest adversarial proceeding particular importance one side strong personal interest needs counterbalanced assure questions fully explored minor strong interest obtaining permission abortion without notifying parents may come forward whether society satisfied made decision seasoned judgment adult proceeding different nature barring venal motives trial means ferreting decision come forward request judicial order stop treatment represents slowly carefully considered resolution least one adult frequently several adults discontinuation treatment patient wish addition bypass procedure issue akron supra ex parte secret may notify minor parents siblings friends one may present submit evidence unless brought forward minor contrast proceeding determine nancy cruzan wishes neither ex parte secret hearing determine treatment preferences incompetent person limited adjusting burdens proof means protecting possible imbalance indeed concern come forward present view better addressed appointing guardian ad litem use state powers discovery gather present evidence regarding patient wishes guardian ad litem task uncover conflicts interest ensure party likely relevant evidence consulted brought forward example members family friends clergy doctors see colyer missouri heightened evidentiary standard attempts achieve balance discounting evidence guardian ad litem technique achieves balance probing additional evidence family members friends doctors guardian ad litem agree process failed majority suggests see ante genuine dispute nancy preference majority next argues important individual rights stake clear convincing evidence standard long held appropriate means enhancing accuracy citing decisions concerning process individual due deprived liberty interest see ante cases however imposed clear convincing standard constitutional minimum basis evaluation one side interests clearly outweighed second side interests therefore second side bear risk error see santosky kramer requiring clear convincing evidence standard termination parental rights parent interest fundamental state legitimate interest termination unless parent unfit finding state interest finding best home child arise parent found unfit addington texas requiring clear convincing evidence involuntary commitment hearing interest individual far outweighs state legitimate interest confining individuals mentally ill pose danger others moreover always recognized shifting risk error reduces likelihood errors one direction cost increasing likelihood errors see addington supra contrasting heightened standards proof preponderance standard two sides share risk error roughly equal fashion society favor one outcome cases cited majority imbalance imposed heightened evidentiary standard acceptable required standard deployed protect individual exercise fundamental right majority admits ante contrast missouri imposed clear convincing standard obstacle exercise fundamental right majority claims allocation risk error justified important terminate someone wish continued honor wishes someone erroneous decision terminate irrevocable says majority erroneous decision terminate results maintenance status quo see ante point view patient erroneous decision either direction irrevocable erroneous decision terminate artificial nutrition hydration sure lead failure last remnant physiological life brain stem result complete brain death erroneous decision terminate however robs patient qualities protected right avoid unwanted medical treatment degraded existence perpetuated family suffering protracted memory leaves behind becomes distorted even later decision grant wish undo intervening harm later decision unlikely event discovery new evidence majority refers hypothetical plausible majority also misconceives relevance possibility advancements medical science treating reason force someone continue medical treatment possibility medical miracle indeed part calculus part patient calculus current research suggests hope cure even moderate improvement possible within projected factor accorded significant weight assessing patient choose even heightened evidentiary standard missouri categorical exclusion relevant evidence dispenses semblance accurate factfinding adverted evidence supporting decision held clear convincing inherently reliable evidence presented show nancy want avoid treatment failed consider statements nancy made family members close friend also failed consider testimony nancy mother sister certain nancy want discontinue artificial nutrition hydration even found nancy family loving without malignant motive see also failed consider conclusions guardian ad litem appointed trial clear convincing evidence nancy want discontinue medical treatment best interests higgins dissenting denial rehearing brief respondent guardian ad litem specifically define kind evidence consider clear convincing general discussion suggests living equivalently formal directive patient competent meet standard see people execute living wills equivalently formal directives evidentiary rule ensure adequately wishes incompetent persons honored might wise social policy encourage people furnish instructions general conclusion patient choice drawn absence formalities probability becoming irreversibly vegetative low many people may feel urgency marshal formal evidence preferences may wish dwell physical deterioration mortality even someone resolute determination avoid circumstances nancy still need know things living wills exist execute one often legal help necessary especially given majority apparent willingness permit insist person wishes truly known unless particular medical treatment specified see ante california appellate observed lack generalized public awareness statutory scheme typically human characteristics procrastination reluctance contemplate need arrangements however makes tool often go unused might desire barber superior person tells family close friends want life sustained artificially express ing wishes terms familiar clearly lay person asked express require unrealistic practical purposes precludes rights patients forego treatment simons dissenting missouri enacted living statute specifically provided absence living warrant presumption patient wishes continued medical treatment see supra thus apparently even missouri legislature believes person execute living fails wishes continuous medical treatment circumstances testimony close friends family members hand may often best evidence available patient choice patient likely discussed questions know patient best family members unique knowledge patient vital decision behalf newman treatment refusals critically terminally ill proposed rules family physician state human rights annual missouri decision ignore whole category testimony also odds practices see peter brophy new england sinai hospital mass severns missouri disdain nancy statements serious conversations long accident opinions nancy family friends values beliefs certain choice even opinion outside objective factfinder appointed state evinces disdain nancy cruzan right choose rules incompetent person wishes determined must represent every effort determine wishes rule missouri adopted upholds however skews result away determination accurately possible reflects individual preferences beliefs rule transforms human beings passive subjects medical technology edical care decisions must guided individual patient interests values allowing persons determine medical treatment important way society respects persons individuals moreover respect due persons individuals diminish simply become incapable participating treatment decisions still possible others make decision reflects patient interests closely purely technological decision whatever possible lacking ability decide patient right decision takes interests account conservatorship drabick cert denied suggest must sit helplessly choices incompetent patients danger ignored see ante even ruled missouri rule decision unconstitutional believe nevertheless remain free fashion procedural protections safeguard interests incompetents circumstances constitution provides merely framework protections must genuinely aimed ensuring decisions commensurate patient must reliable instruments end many instituted protections missouri virtually one fashioned rule lessens likelihood accurate determinations contrast nothing constitution prevents reviewing advisability family decision requiring proceeding appointing impartial guardian ad litem various approaches determining incompetent patient treatment choice use several today may advantages disadvantages approaches yet envisioned choice largest part left long state seeking reliable manner discover patient want momentous interests balance must avoid procedures prejudice decision err either way keep person alive circumstances rather allowed die allow person die chosen cling life deeply unfortunate conroy finally agree majority possible determine choice incompetent patient make state role parens patriae permits state automatically make choice see ante explaining due process clause require state confide decision anyone patient fair rules evidence improbable determine patient choice rule decision adopted missouri upheld today occasions might numerous neither case follow constitutionally acceptable state invariably assume role deciding patient state legitimate interest safeguarding patient choice furthered simply appropriating majority justifies position arguing close family members may strong feeling question automatic assurance view close family members necessarily patient confronted prospect situation competent ibid quarrel observation leads another question reason suppose state likely make choice patient made someone knew patient intimately ask answer new jersey observed family members best qualified make substituted judgments incompetent patients peculiar grasp patient approach life also special bonds treat patient person rather symbol cause jobes state contrast stranger patient state inability discern incompetent patient choice still need mean state rendered powerless protect choice find due process clause prohibits state state may ensure person makes decision patient behalf one patient selected make choice state may exclude consideration anyone improper motives state generally must either repose choice person patient likely chosen proxy leave decision patient family iv many patients maintained persistent vegetative number expected increase significantly near future see cranford supra medical technology developed past years often capable resuscitating people stopped breathing hearts stopped beating people brought fully back life two decades ago swallow digest food died intravenous solutions provide sufficient calories maintain people short time today various forms artificial feeding developed able keep people metabolically alive years even decades see spencer palmisano specialized nutritional support patients hospital legal duty quality addition century chronic degenerative ailments replaced communicable diseases primary causes death see weir abating treatment critically ill patients president commission americans die hospitals likely meet end sedated comatose state betubed nasally abdominally intravenously far like manipulated objects like moral subjects fifth adults surviving age suffer progressive dementing disorder prior death see cohen eisdorfer dementing disorders practice geriatrics calkins davis ford eds aw equity justice must quail helpless face modern technological marvels presenting questions hitherto unthought quinlan cert denied new medical technology reclaim irretrievably lost decades ago restore active lives nancy cruzan failed others wasting incurable disease may doomed failure unfortunate situations bodies preferences memories victims escheat state constitution permit state government commandeer singularity feeling exists upon government might confidently rely parens patriae president commission years research concluded areas health care people evaluations experiences varied uniquely personal assessments nature value processes associated dying every moment life inestimable value others life without desired level mental physical ability worthless burdensome moderate degree suffering may important means personal growth religious experience one person frightening despicable another president commission respectfully dissent rasmussen fleming en banc vegetative state patients may react reflexively sounds movements normally painful stimuli feel pain sense anybody anything vegetative state patients may appear awake completely unaware see cranford persistent vegetative state medical reality hastings see president commission study ethical problems medicine biomedical behavioral research deciding forego life sustaining treatment hereafter president commission see lipton decisions community hospital incidence implications outcomes jama see canterbury spence app cert denied root premise informed consent concept fundamental american jurisprudence human adult years sound mind right determine shall done body quoting schloendorff society new york hospital cardozo see generally washington harper stevens dissenting doubt competent individual right refuse psychotropic medication fundamental liberty interest deserving highest order protection traditional tort law exceptions found protect dependent children see cruzan harmon mo citing cases missouri courts ordered blood transfusions children religious objection parents see also winthrop university hospital hess nassau ordered blood transfusion religious objector mother infant explained objection signing consent transfusion application president directors georgetown college app cert denied blood transfusion ordered mother infant cf estate brooks finding lower erred ordering blood transfusion woman whose children grown concluding even though may consider appellant beliefs unwise foolish ridiculous absence overriding danger society may permit interference therewith form conservatorship established waning hours life sole purpose compelling accept medical treatment forbidden religious principles previously refused full knowledge probable consequences missouri appears alone among state courts suggest otherwise although rely distinction artificial feeding forms medical treatment see delio westchester county medical center app review decisions jurisdictions failed uncover single case confronted application discontinue feeding artificial means evaluated medical procedures provide nutrition hydration differently types procedures brain stem cells survive minutes without oxygen cells cerebral hemispheres destroyed deprived oxygen minutes see cranford smith critical distinctions brain death persistent vegetative state ethics sci med estimated nancy brain deprived oxygen minutes see ante patients like nancy fallen persistent vegetative past years due loss oxygen brain three even partial recoveries documented medical literature brief american medical association et al amici curiae longest person ever persistent vegetative state recovered months see snyder cranford rubens bundlic rockswold delayed recovery postanoxic persistent vegetative state annals neurol nancy state seven years american academy neurology offers three independent bases medical profession rests neurological conclusions first direct clinical experience patients demonstrates behavioral indication awareness pain suffering second persistent vegetative state patients studied date examination reveals overwhelming bilateral damage cerebral hemispheres degree incompatible consciousness third recent data utilizing positron emission tomography indicates metabolic rate glucose cerebral cortex greatly reduced persistent vegetative state patients degree incompatible consciousness position american academy neurology certain aspects care management persistent vegetative state patient neurology nancy cruzan instance totally permanently disabled four limbs severely contracted fingernails cut wrists app pet cert incontinent bowel bladder intimate aspects existence exposed controlled strangers brief respondent guardian ad litem family convinced nancy find state degrading see infra general information exists people choose prefer chosen circumstances also indicates importance ensuring means patients exercise right avoid unwanted medical treatment poll conducted american medical association found surveyed favored withdrawal life support systems hopelessly ill irreversibly comatose patients families requested new york times june citing american medical news june another poll conducted colorado university graduate school public affairs showed questioned want lives maintained artificial nutrition hydration became permanently unconscious coloradoan attitudes translated considerable political action since district columbia enacted natural death acts expressly providing situations see brief society right die amicus curiae weiner privacy family medical decision making persistent vegetative patients cardozo thirteen district columbia enacted statutes authorizing appointment proxies making health care decisions see ante concurring see jacobson massachusetts upholding massachusetts law imposing fines imprisonment refusing vaccinated paramount necessity state fight smallpox epidemic interests stake however find due process clause places limits invasive medical procedures forced unwilling comatose patient pursuit interests third party missouri correct interests outweigh nancy interest avoiding medical procedures long free pain physical discomfort see apparent state choose remove one kidneys without consent ground society better recipient kidney saved renal poisoning nancy feel surgical pain see supra removal one kidney expected shorten life expectancy see american medical association family medical guide kunz ed patches skin also removed provide grafts burn victims scrapings bone marrow provide grafts someone leukemia perhaps state lawfully remove vital organs transplanting others cured ailments provided state placed nancy equipment replace lost function indeed state perform medical experiments body experiments might save countless lives cause greater burden already bears fed gastrostomy tube brave new world submit constitution missouri reviewed state interests identified courts potentially relevant prevention homicide suicide protection interests innocent third parties maintenance ethical integrity medical profession preservation life concluded case state interest preservation life implicated event state interest identified missouri comprehensive unqualified interest preserving life even well supported state enactments first place missouri law requiring every person procure needed medical care state health insurance program underwrite care blackmar dissenting second state admitted missouri living statute specifically allows encourages termination life ibid see fact missouri actively provides citizens choose natural death certain circumstances suggests state interest life unqualified suggests true particular statute apply nonterminal patients include artificial nutrition hydration one measures may declined nonetheless missouri also chosen require review every decision withhold withdraw made behalf incompetent patient decisions made every day without state participation see blackmar dissenting addition precisely implication drawn statute limitations unclear given inclusion series interpretive provisions act first provision explains act interpreted consistently following person primary right request refuse medical treatment subject state interest protecting innocent third parties preventing homicide suicide preserving good ethical standards medical profession second subsections explains act provisions cumulative intended increase decrease right patient make decisions lawfully effect withholding withdrawal medical care third subsection provides presumption concerning intention individual executed declaration consent use withholding medical procedures shall created thus even conceivable state assert interest sufficiently compelling overcome nancy cruzan constitutional right missouri law demonstrates modest interest best see generally capital cities cable crisp finding state regulations narrow scope indicated state moderate interest professed goal see colorado new mexico requiring clear convincing evidence one state permitted divert water another accommodate society interests stable property rights efficient use resources new york new jersey promoting federalism requiring clear convincing evidence using power control conduct one state behest another maxwell case requiring clear unequivocal convincing evidence set aside annul correct patent title property issued government order secure settled expectations concerning property rights marcum zaring promoting stability marriage requiring clear convincing evidence prove invalidity stevenson stein promoting settled expectations concerning property rights requiring clear convincing evidence prove adverse possession majority definition status quo course begs question artificial delivery nutrition hydration represents status quo state chosen permit doctors hospitals keep patient systems protests family guardian status quo absent state interference natural result accident illness family decision majority definition status quo however large extent predictable yet accidental confluence technology psyche inertia general citizenry never said favored creation coma wards permanently unconscious patients tended years years populace whole authorize preeminence doctors families making treatment decisions incompetent patients rhoden litigating life death nancy cruzan cure improvement view much brain deteriorated replaced fluid see app pet cert apparently medical advance restore consciousness body brain transplant cf infra trial relied testimony athena comer friend coworker housemate several months sufficient show nancy cruzan wish free medical treatment present circumstances app pet cert comer described conversation nancy living together concerning comer sister become ill suddenly died night comer family told lived night vegetative state nancy lost grandmother months comer testified nancy said never want live vegetative state normal even know like half way things nancy always want live talked lot tr said several times want live way going live wanted able live lay bed able move ca anything said hoped people family knew want live vegetative state knew usually family whether lived way conversation took place approximately year nancy accident described comer serious conversation continued approximately half hour without interruption missouri dismissed nancy statement unreliable ground informally expressed reaction people medical conditions missouri refer evidence nancy wishes explain rejected nancy sister christy close testified nancy two serious conversations year half accident day two niece stillborn badly damaged lived nancy said maybe part greater plan baby stillborn face possible life mere existence tr month later grandmother died long battle heart problems nancy said better grandmother kind brought back forth medical treatment brought back critical near point death nancy sister christy nancy mother another nancy friends testified nancy want discontinue hydration nutrition christy said nancy horrified state also want take burden away family based lifetime experience know nancy wishes discontinue hydration nutrition nancy mother testified nancy want like christy us us trying know mother surveys show overwhelming majority americans executed written instructions see emmanuel emmanuel medical directive new comprehensive advance care document jama americans execute advance directives wish treatment decisions handled became incompetent american medical association surveys physician public opinion health care issues surveyed executed living wills president commission study ethical problems medicine biomedical behavioral research making health care decisions surveyed said put treatment instructions writing new york state besides missouri deny request terminate life support ground clear convincing evidence prior expressed intent absent although new york context different situations subject several times expressed desire placed going able care however daughters testified know whether mother want decline artificial nutrition hydration present circumstances cf supra moreover despite damage several strokes conscious capable responding simple questions requests medical testimony suggested might improve extent cf supra new york appeals also denied permission terminate blood transfusions severely retarded man terminal cancer evidence treatment choice made man competent never competent see storar cert denied relied evidence man conscious functioning way always transfusions cause substantial pain although clear like exceedingly rare case state find family member friend trusted endeavor genuinely make treatment choice patient made state become legitimate surrogate decisionmaker fadiman liberation lolly gronky life magazine quoting medical ethicist joseph fletcher justice stevens dissenting make exception permits state abstract undifferentiated interest preservation life overwhelm best interests nancy beth cruzan interests according undisputed finding served allowing guardians exercise constitutional right discontinue medical treatment ironically reaches conclusion despite endorsing three significant propositions save dilemma first competent individual decision refuse medical procedures aspect liberty protected due process clause fourteenth amendment see ante second upon proper evidentiary showing qualified guardian may make decision behalf incompetent ward see ante third answering important question presented tragic case wise attempt general statement cover every possible phase subject see ante citation omitted together considerations suggest nancy cruzan liberty free medical treatment must understood light facts circumstances particular hold view constitution requires state care nancy cruzan life way gives appropriate respect best interests case first consider whether constitution protects liberty seriously ill patients free medical treatment put question general profound need however resolve question abstract responsibility judges enables compels us treat problem illuminated facts controversy us important facts clear convincing evidence established nancy cruzan oblivious environment except reflexive responses sound perhaps painful stimuli cognitive reflexive ability swallow food water never recover abilities cerebral cortical atrophy irreversible permanent progressive ongoing app pet cert recovery consciousness impossible highest cognitive brain function hoped grimace recognition ordinarily painful stimuli apparent response sound thus evaluating nancy cruzan medical condition trial judge next examined interests third parties affected nancy parents allowed withdraw gastrostomy tube implanted daughter findings make clear parents request economic motivation granting request neither adversely affect innocent third parties breach ethical standards medical profession considered rejected religious objection decision explained concluded ward constitutional right liberty outweighed general public policy state relied fundamental natural right expressed constitution right liberty permits individual refuse direct withholding withdrawal artificial death prolonging procedures person cognitive brain function ward physicians agree hope recovery deterioration brain continues overall worsening physical contractures extent statute public policy prohibits withholding withdrawal nutrition hydration euthanasia mercy killing definition circumstances arbitrarily exceptions violation ward constitutional rights depriving liberty without due process law decide otherwise medical treatment undertaken must continued irrespective lack success benefit patient effect gives one body medical science without sic consent required exercise legal authority act best interests ward discharge duty free act authority may determine footnotes omitted ii believed duty independent guardian ad litem appealed trial order missouri appeal however guardian advised disagree trial decision specifically endorsed critical finding nancy cruzan best interests tube feeding discontinued important conclusion thus disputed litigants one might reasonably suppose dispositive nancy cruzan interest continued treatment liberty interest free unwanted treatment cessation treatment adverse impact third parties reason exists doubt good faith nancy parents possible basis state insisting upon continued medical treatment yet instead questioning endorsing trial conclusions nancy cruzan interests state largely ignored opinion referred four different state interests identified somewhat similar cases acknowledged state general interest preservation life implicated case defined interest follows state interest life embraces two separate concerns interest prolongation life individual patient interest sanctity life cruzan harmon three dissenting judges found nancy cruzan interests compelling agreed trial evaluation state policy persuasive dissent judge blackmar explained decisions care chronically ill patients traditionally private disagreement principal opinion lies fundamentally emphasis interest role state represented attorney general decisions prolongation life recent origin world history presently parts world decisions never arise technology available decisions medical treatment customarily made patient closest patient patient youth infirmity unable make decisions nothing new substituted decisionmaking state seldom called upon decisionmaker accept assumption inherent principal opinion advanced technology state must necessarily become involved decision using extraordinary measures prolong life decisions kind made daily patient relatives basis medical advice conclusion best cases reach doubt whether case us fact nancy lies state hospital place primary emphasis patient expressions except possibly unusual case find example books patient expresses view available life supports made use closest patient best positioned make judgments patient best interest unrealistic say preservation life absolute without regard quality life make statement context case trial judge found chance amelioration nancy condition principal opinion accepts conclusion appropriate consider quality life making decisions extraordinary medical treatment made decisions matters without resort courts certainly consider quality life balance unpleasant consequences patient evidence nancy may react pain stimuli awareness surroundings life must living hell unable express anything alter situation parents closest relatives best able feel decide best state substitute decisions impressed cited principal opinion declaim sanctity life without regard quality dwell ivory towers cruzan family appropriately came seeking relief circuit judge properly found facts applied law factual findings supported record legal conclusions overwhelming weight authority principal opinion attempts establish absolutes expense human factors unnecessarily subjects nancy close continuous torture family forced endure portion opinion considers merits case similarly unsatisfactory fails respect best interests patient relies tantamount waiver rationale dying patient best interests put one side entire inquiry focused prior expressions intent innocent person constitutional right free unwanted medical treatment thereby categorically limited patients foresight make unambiguous statement wishes competent decision affords protection children young people victims unexpected accidents illnesses countless thousands elderly persons either fail decide fail explain want treated experience similar fate nancy beth cruzan foresight preserve constitutional right living comparable clear convincing alternative right gone forever fate hands state legislature instead family independent neutral guardian ad litem impartial judge agree course action best interests willingness find waiver constitutional right reveals distressing misunderstanding importance individual liberty iii perhaps predictable courts might undervalue liberty stake death profoundly personal public reflection upon unusual sad case shows however reflection must become common deal responsibly modern circumstances death medical advances altered physiological conditions death ways may alarming highly invasive treatment may perpetuate human existence merger body machine might reasonably regard insult life rather continuation advances reorganization medical care accompanying new science technology also transformed political social conditions death people less likely die home likely die relatively public places hospitals nursing homes ultimate questions might dealt intimacy family physician become concern institutions institution state hospital case government becomes involved dying nonetheless remains part life characteristically place home poe ullman harlan dissenting integrity life something fundamental found draw protection principles one explicitly granted constitutional right decisions demarcated private realm family life state enter prince massachusetts physical boundaries home course remain crucial guarantors life within see payton new york stanley georgia nevertheless long recognized liberty make decisions choices constitutive private life fundamental concept ordered liberty palko connecticut choices must occasionally afforded direct protection see meyer nebraska griswold connecticut roe wade thornburgh american college obstetricians gynecologists stevens concurring respect choices guided recognition rights pertaining bodily integrity constitutional decisions identifying rights like common law tradition upon built mindful makers constitution recognized significance man spiritual nature olmstead brandeis dissenting may truly said notions liberty inextricably entwined idea physical freedom ante concurring thus construed due process clause preclude physically invasive recoveries evidence procedures brutal also offensive human dignity rochin california interpreted constitution interpose barriers state efforts sterilize criminals proposed punishment irreparable injury bodily integrity arriage procreation concern basic civil rights man skinner oklahoma ex rel williamson sanctity individual privacy human body obviously fundamental liberty every violation person bodily integrity invasion liberty washington harper stevens concurring part dissenting part yet constitutional protection physical curtilage home surely result solicitude protect privacies life within poe ullman harlan dissenting constitutional protection human body surely inseparable concern mind spirit dwell therein background decisional law constitutional tradition illuminates right free unwanted medical treatment must understood right presupposes abandonment desire life reducible protection batteries undertaken name treatment guarantee infliction bodily discomfort choices death touch core liberty duty concomitant freedom come terms conditions mortality undoubtedly rooted traditions conscience people ranked fundamental snyder massachusetts indeed essential incidents unalienable rights life liberty endowed us creator see meachum fano stevens dissenting precise constitutional significance death difficult describe much may said confidence death unless said faith alone reason enough protect freedom conform choices death individual conscience may also however justly assume death life simple opposite necessary terminus rather completion ethical tradition long regarded appreciation mortality essential understanding life significance may fact impossible live anything without prepared die something certainly disdain life nathan hale famous declaration patrick henry words instead bespeak passion life forever preserves lives memories countrymen honored dead take increased devotion cause gave last full measure devotion considerations cast stark relief injustice unconstitutionality missouri treatment nancy beth cruzan nancy cruzan death comes historic act heroism inevitably consequence tragic accident nancy cruzan interest life less person includes interest thought death whose opinions mattered doubt life made dear family others dies affect life remembered trial order authorizing nancy parents cease daughter treatment permitted family cares nancy bring close tragedy death missouri objection order subordinates nancy body family lasting significance life state interests decision review thereby interferes constitutional interests highest order constitutionally permissible missouri intrusion upon fundamental liberties must minimum bear reasonable relationship legitimate state end see meyer nebraska doe bolton missouri asserts policy related state interest protection life view however effort define life rather protect heart missouri policy missouri insists without regard nancy cruzan interests upon equating life biological persistence bodily functions nancy cruzan must remembered simply incompetent persistent vegetative state seven years trial found party contested nancy possibility recovery consciousness seems errs insofar characterizes case involving judgments quality life particular individual may enjoy ante nancy cruzan obviously alive physiological sense patients like nancy cruzan consciousness chance recovery serious question whether mere persistence bodies life word commonly understood used constitution declaration independence state unflagging determination perpetuate nancy cruzan physical existence comprehensible effort define life meaning attempt preserve sanctity much clear oddity missouri definition alone life particularly human life commonly thought merely physiological condition function sanctity often thought derive impossibility reduction people speak life often mean describe experiences comprise person history said somebody led good life may also mean refer practical manifestation human spirit meaning captured familiar observation somebody added life assembly shared thread among various opinions subject may life activity matrix integration person interests event absent theological abstraction idea life conceived separately idea living person yet precisely separation missouri asserts interest nancy cruzan life opposition nancy cruzan interests resulting definition uncommon indeed laws punishing homicide upon relies ante support contrary inference obviously laws protect life interests otherwise victims even laws suicide presuppose inclined take lives interest living indeed depressed people whose lives preserved may later thankful state intervention likewise decisions address quality life incompetent conscious patients rest upon recognition patients interest continuing lives even interest pales eyes measured interests dignity comfort contrary suggestion missouri protection life form abstracted living commonplace aberrant missouri treatment nancy cruzan find precedent various state law cases surveyed majority despite assertion state courts demonstrated similarity diversity approach issue us none decisions surveyed interposed absolute bar termination treatment patient persistent vegetative state example westchester county medical center behalf pertained incompetent patient coma vegetative state conscious capable responding simple questions requests sometimes squeezing questioner hand sometimes verbally likewise storar involved conscious patient incompetent profoundly retarded mental age months decided conroy new jersey noted conroy brain dead comatose chronic vegetative state distinguished quinlan ground karen quinlan persistent vegetative comatose state contrast unbroken stream cases authorized procedures cessation treatment patients persistent vegetative considered background cases involving patients persistent vegetative instead broader inapt category cases involving chronically ill incompetent patients missouri decision anomalous short reasonable ground believing nancy beth cruzan personal interest perpetuation state decided life already suggested possible hypothesize interest basis theological philosophical conjecture even posit basis state action condemn within province secular government circumscribe liberties people regulations designed wholly purpose establishing sectarian definition life see webster reproductive health services stevens dissenting disagreement thus unrelated endorsement clear convincing standard proof cases kind indeed agree controlling facts must established unmistakable clarity critical question however prove controlling facts rather proven facts controlling view constitutional answer clear best interests individual especially buttressed interests related third parties must prevail general state policy simply ignores interests indeed apparent secular basis state interest life policy persuasive impact upon people nancy family yet lthough state may properly perform teaching function although teaching may foster respect sanctity life state may pursue project infringing constitutionally protected interests symbolic effect carey population services international stevens concurring part concurring judgment failure missouri policy heed interests dying individual respect matters private ample evidence policy illegitimacy missouri arrogated power define life permits usurpation nancy cruzan life liberty put disquieting conflict nancy cruzan life defined reference interests life expired biological existence ceased serving interests constitutionally protected interest freedom unwanted treatment come conflict constitutionally protected interest life conversely evidence nancy cruzan defined life encompass every form biological persistence human continuation treatment serve nancy liberty conflict life liberty opposition life liberty case thus result nancy cruzan tragic accident instead artificial consequence missouri effort willingness abstract nancy cruzan life nancy cruzan person iv majority state majority express great deference policy choice made state legislature deference view based upon severe error constitutional logic believes liberty interest claimed behalf nancy cruzan peculiarly problematic incompetent person able make informed voluntary choice exercise hypothetical right refuse treatment right ante impossibility exercise affords state according discretion interpose procedural requirement effectively compels continuation nancy cruzan treatment however nothing hypothetical nancy cruzan constitutionally protected interest freedom unwanted treatment difficulties involved ascertaining interests way justify state decision oppose interests case comes us crucial question question addressed nancy cruzan interests whether state must give effect certainly nothing novel practice permitting next friend assert constitutional rights behalf incompetent patient unable see youngberg romeo whitmore arkansas thus nancy cruzan incapacity exercise rights alter balance interests state must explanation offers two possibilities neither satisfactory first possibility state policy favoring life nature less intrusive upon patient interest alternative suggests missouri policy results maintenance status quo subject reversal decision terminate treatment susceptible correction death irreversible ante yet explanation begs question assumes either state policy consistent nancy cruzan interests damage done ignoring interests first assumption without basis record case obviate need state rely upon interests rather upon patient second assumption unconscionable insofar nancy cruzan interest remembered lived rather died damage done memories prolongation death irreversible insofar nancy cruzan interest cessation pain continuation pain irreversible insofar nancy cruzan interest closure life consistent beliefs rather missouri legislature state imposition contrary view irreversible deny importance consequences effect deny nancy cruzan interests thereby deny personhood name preserving sanctity life second possibility state must allowed define interests incompetent patients respect treatment procedure capable determining interests particular case points various possible abuses inaccuracies may affect procedures authorizing termination treatment see ante correctly notes cases may conflict interests incompetent patient interests members family state procedures must guard risk survivors interests mistaken patient yet appointment neutral guardian ad litem coupled searching inquiry conducted trial judge imposition clear convincing standard proof effectively avoided risk case procedural safeguards adequate avoid similar risk cases question simply ignores indeed argue mere possibility error case suffices allow state interests override particular interests incompetent individuals every case argue interests individuals unknowable therefore may subordinated state concerns deny nancy cruzan personhood meaning respect personhood others gravely ill incapacitated admittedly easily defined choices life death profound ones susceptible resolution recourse medical legal rules may best ensure choices made care enough patient investigate interests particularity caution seems recognize much cautions formulating general inflexible rule govern cases might arise area law ante deference legislature however inflexible rule one willing apply case even though principal grounds deferring missouri legislature hypothetical circumstances relevant nancy cruzan interests either explanation deference seems ultimately derive premise chronically incompetent persons constitutionally cognizable interests persons within meaning constitution deference sort patently unconstitutional also dangerous ways may immediately apparent today state missouri announced intent spend several hundred thousand dollars preserving life nancy beth cruzan order vindicate general policy favoring preservation human life tomorrow another state equally eager champion interest quality life might favor policy designed ensure quick comfortable deaths denying treatment categories marginally hopeless cases state fact interest defining life state policy respect termination treatment commands deference judiciary unclear resulting conflict best interests individual general policy state resolved believe constitution requires individual vital interest liberty prevail general policy case contrary result readily imaginable majority theory makes manifest defer state policy drives theoretical wedge person life one hand person liberty happiness consequence theory deny personhood whose lives defined state interests rather consequence may acceptable theology speculative philosophy see meyer radically inconsistent foundation legitimate government constitution presupposes respect personhood every individual nowhere strict adherence principle essential judicial branch see thornburgh american college obstetricians gynecologists stevens concurring case doubt true many others predicament confronted healthy members cruzan family merely adds emphasis best interests finding made trial judge us interest kind memories survive death end individual decisions often motivated impact others member kind family identified trial findings case likely normal interest minimizing burden illness imposes others also interest memories filled predominantly thoughts past vitality rather current condition meaning completion life controlled persons best interests heart state legislature concerned preservation human life cruzan family continuing concern provides concrete reminder nancy cruzan interests disappear vitality consciousness however commendable may state interest human life pursue interest appropriating nancy cruzan life symbol purposes lives exist abstraction persons pretend otherwise honor desecrate state responsibility protecting life state seeks demonstrate commitment life may aiding actively struggling life health endeavor unfortunately state lack opportunities need make example tragic cases like nancy cruzan respectfully dissent stated declaration independence hold truths men created equal endowed creator certain unalienable rights among life liberty pursuit happiness secure rights governments instituted among men deriving powers consent governed whenever form government becomes destructive ends right people alter abolish institute new government laying foundation principles organizing powers form shall seem likely effect safety happiness trial found follows basis clear convincing evidence respiration circulation artificially maintained within essentially normal limits female vital signs recently reported bp pulse regular respiration spontaneous per minute oblivious environment except reflexive responses sound perhaps painful stimuli suffered anoxia brain resulting massive enlargement ventricles filling cerebrospinal fluid area brain degenerated cerebral cortical atrophy irreversible permanent progressive ongoing highest cognitive brain function exhibited grimacing perhaps recognition ordinarily painful stimuli indicating experience pain apparent response sound spastic quadriplegic contractures four extremities slowly progressive irreversible muscular tendon damage extremities cognitive reflexive ability swallow food water maintain daily essential needs never recover ability swallow sufficient satisfy needs app pet economic considerations case rest respondent employer state missouri bearing entire cost care ward adult without financial resources social security whose inconsiderable medical insurance exhausted since january case innocent third parties requiring state protection neither homicide suicide committed consensus medical witnesses indicated concerns personal legal consequences actions rather objections good ethical standards profession breached nutrition hydration withdrawn artificial death prolonging procedures statute specifically authorizes nancy present unresponsive hopeless existence ruler man forcefully feed swallow thus fueling respiratory circulatory pumps cognitive purpose except sound perhaps pain appellant guardian ad litem advised informed trial felt nancy cruzan best interests tube feeding discontinued find position appealing judgment basically agree cruzan harmon mo higgins dissenting four state interests identified preservation life prevention homicide suicide protection interests innocent third parties maintenance ethical integrity medical profession see section rsmo brophy case state interest preservation life implicated state concern sanctity life rests principle life precious worthy preservation without regard quality ibid tempting equate state interest preservation life measure quality life discussion follows shows courts find quality life convenient focus justifying termination treatment state interest quality life broad policy statements legislature make distinction shall quality life issue persons manner handicaps might find state seeking terminate lives instead state interest life interest unqualified previously stated however state interest quality life state interest unqualified interest life argument made nancy recover thinly veiled statement life present form worth living yet diminished quality life support decision cause death ibid given fact nancy alive burdens treatment excessive believe right refuse treatment whether right proceeds constitutional right privacy common law right refuse treatment outweighs immense clear fact life state maintains vital interest see especially ante think state may properly decline make judgments quality life particular individual may enjoy simply assert unqualified interest preservation human life weighed constitutionally protected interests individual ante stating government seeking protect institutional interests life see ante latter part century medicine relatively little treatment offer dying vast majority persons died home rather hospital brief american medical association et al amici curiae deaths americans age occurred hospital nursing home sager easterling et changes location death passage medicare prospective payment system national study new according president commission study ethical problems medicine biomedical behavioral research recent years seen alterations underlying causes death places people die also changed recorded history deaths natural causes usually occurred home everyone knew death first hand nothing unfamiliar even queer phenomenon people seem known lot process case today deathbed real place dying person usually knew time assemble family call priest even people get admitted medical care institution whose conditions proved incurable discharged care families health care system longer helpful also alcohol opiates drugs available ease pain suffering available without prescription institutional care reserved poor without family support hospitals often aimed saving patients souls providing medical care medicine able dying patients care increasingly delivered institutional settings institutions sites deaths figure perhaps deaths occur hospitals care institutions nursing homes change ill patients treated permits health care professionals marshall instruments scientific medicine effectively people dying may well find setting alienating unsupportive deciding forego life sustaining treatment footnotes omitted quoting thomas dying failure annals recognized special relationship patient physician often encompassed within domain private life protected due process clause see griswold connecticut roe wade thornburgh american college obstetricians gynecologists recognizes state involved adversary beginning case nancy cruzan patient state hospital litigation commenced ante seems however draws precisely wrong conclusion insight apparently believes absence state litigation created problem agreement among family independent guardian ad litem nancy cruzan best interests might prevented treatment becoming focus truly adversarial proceeding ibid may reasonably debated whether judicial process required treatment discontinued issue divided state courts compare estate longeway requiring judicial approval guardian decision hamlin discussing circumstances judicial approval unnecessary cf conservatorship torres oral argument disclosed average life support systems disconnected weekly minnesota tend however agree judge blackmar intervention state proceedings adversary much cure part disease see ante ante right held sacred carefully guarded common law right every individual possession control person free restraint interference others unless clear unquestionable authority law union pacific botsford many philosophies religions example long venerated idea life death human soul endures even human body perished surely missouri wish define interest life way antithetical tradition see johnston nathan hale biography memorials axelrad patrick henry voice freedom lincoln gettysburg address documents american history commager ed ed judicial massachusetts observed connection balance state interest prolonging patient life rights patient reject prolongation must recognize state interest life encompasses broader interest mere corporeal existence certain thankfully rare circumstances burden maintaining corporeal existence degrades humanity meant serve brophy new england sinai hospital mass brophy stressed reflection upon nature state interest life distinguishable considerations related quality particular patient life considerations regarded irrelevant inquiry see also eichner app patient persistent vegetative state health true sense life state protect modified storar one learned observer suggests course discussing persistent vegetative us accept preservation reduced level function proper goal medicine even though sadly accept unfortunate unforeseen result treatment higher aspirations even refuse actively cause vegetative life cease kass toward natural science assessment may controversial nevertheless tend agree judge blackmar dissent missouri decision contended unreasonable state assume people fact hold view contrary one described kass view buttressed comments president commission study ethical problems medicine biomedical behavioral research primary basis medical treatment patients prospect individual interests specifically interest wellbeing promoted thus treatment ordinarily aims benefit patient preserving life relieving pain suffering protecting disability returning maximally effective functioning prognosis permanent unconsciousness correct however continued treatment confer benefits pain suffering absent joy satisfaction pleasure disability total return even minimal level social human functioning possible deciding forego treatment sense word explains use describe biography example boswell life johnson beveridge life john marshall reader book titled surprised find contained compilation biological data see estate longeway authorizing removal gastronomy tube permanently unconscious patient judicial approval obtained mcconnell beverly authorizing pursuant statute removal gastronomy tube patient persistent vegetative state patient previously expressed wish treatment sustained gray romeo ri authorizing removal feeding tube patient persistent vegetative state rasmussen fleming en banc authorizing procedures removal feeding tube patient persistent vegetative state gardner allowing discontinuation procedures patient persistent vegetative state peter authorizing procedures cessation treatment elderly nursing home patient persistent vegetative state jobes authorizing procedures cessation treatment nonelderly patient determined clear convincing evidence persistent vegetative state brophy new england sinai hospital mass permitting removal feeding tube patient persistent vegetative state john kennedy memorial hospital bludworth holding approval needed authorize cessation patient persistent vegetative state executed living conservatorship torres authorizing removal permanently unconscious patient systems allowing parents terminate life support infant chronic vegetative state hamlin allowing termination without judicial intervention life support patient vegetative state doctors guardian concur conflicts among doctors guardian respect cessation treatment resolved trial colyer modified grounds hamlin allowing guardian authorize cessation treatment patient persistent vegetative state eichner decided storar authorizing removal patient persistent vegetative state respirator cert denied quinlan authorizing constitutional grounds removal patient persistent vegetative state respirator cert denied corbett authorizing removal nasogastric feeding tube patient persistent vegetative state conservatorship drabick life sustaining treatment necessary probate code section offers reasonable possibility returning conservatee cognitive life otherwise conservatee best interests determined conservator good faith delio westchester county medical center app authorizing discontinuation artificial feeding patient persistent vegetative state leach akron general medical center ohio misc authorizing removal patient persistent vegetative state respirator severns authorizing discontinuation medical support measures patient virtual vegetative state cases ones allowed cessation treatment incompetent patients see superintendent belchertown state school saikewicz mass holding treatment withheld profoundly mentally retarded patient bouvia superior los angeles allowing removal nasogastric tube competent highly intelligent patient extreme pain although reasoning entails conclusion best interests incompetent patient must respected even patient conscious rather vegetative state considerations pertaining quality life addition considerations definition life might relevant state interest protecting life thereby interests incompetent patient accordingly forceful constitutional questions correspondingly complicated thus state wrote state expressed strong policy favoring life believe policy dictates err side preserving life change policy must come people elected representatives broad policy questions bearing life death issues properly addressed representative assemblies vast fact opinion gathering synthesizing powers unavailable courts exercise powers particularly appropriate issues invoke concerns medicine ethics morality philosophy theology law assuming change appropriate issue demands comprehensive resolution courts provide judicial massachusetts anticipated possibility brophy decision observed duty state preserve life must encompass recognition individual right avoid circumstances individual feel efforts sustain life demean degrade humanity otherwise state defense life tantamount effort state make decisions regarding individual quality life mass accord gray romeo judge campbell said behalf florida district appeal second district want acknowledge began deliberations matter drafted declaration independence solemnity gratefulness knowledge men endowed creator life without considerable searching hearts souls minds well jurisprudence great land reached conclusions forcefully affirm life endowed creator lightly taken relinquished recognize however also endowed certain amount dignity right pursuit happiness therefore may determined reason advanced scientific medical technologies day life causes beyond control reached unconscious vegetative state remains forced function body vital functions including artificial sustenance body recognize right allow natural consequence removal artificial life sustaining measures corbett