1. CRUZAN v. DIRECTOR, MISSOURI DEPARTMENT OF HEALTH U.S. SUPREME COURT 1990

2. CRUZAN QUESTION AND DECISION QUESTION –WHETHER THE U.S. CONSTITUTION PROHIBITS MISSOURI FROM CHOOSING THE RULE OF DECISION THAT IT DID [I.E., CLEAR AND CONVINCING EVIDENCE MUST BE PRESENT BEFORE THE TERMINATION OF LIFE-SUSTAINING TREATMENT FOR AN INCOMPETENT]. DECISION –THE U.S. CONSTITUTION DOES NOT FORBID MISSOURI FROM REQUIRING THAT EVIDENCE OF AN INCOMPETENT’S WISHES AS TO THE WITHDRAWAL OF LIFE-SUSTAINING TREATMENT BE PROVIDED BY THE CLEAR AND CONVINCING EVIDENCE STANDARD.

3. CRUZAN GROUNDS AND ASSUMPTIONS INFORMED CONSENT DOCTRINE 14TH AMENDMENT LIBERTY INTEREST –“... NOR SHALL ANY STATE DEPRIVE ANY PERSON OF LIFE, LIBERTY, OR PROPERTY, WITHOUT DUE PROCESS OF LAW.” PATIENT HAS A LIBERTY INTEREST IN REFUSING LIFE-SUSTAINING TREATMENT WHICH CAN BE OUTWEIGHED BY THE STATE’S INTEREST IN PRESERVING LIFE MEDICALLY ADMINISTERED NUTRITION AND HYDRATION ARE MEDICAL TREATMENT

4. CRUZAN POWERS OF THE PATIENT, I COMPETENT PATIENTS CAN REFUSE ANY AND ALL TREATMENT. PATIENTS ARE ENCOURAGED TO EXPRESS THEIR WISHES ABOUT LIFE-SUSTAINING TREATMENT IN ADVANCE OF DECISIONAL INCAPACITY. SUBSTITUTED JUDGMENT STANDARD IS STRENGTHENED.

5. STANDARDS FOR SURROGATE DECISION MAKING SUBSTITUTED JUDGMENT SURROGATE ATTEMPTS TO REPLICATE FAITHFULLY THE DECISION THAT THE INCAPACITATED PERSON WOULD MAKE IF HE/SHE WERE ABLE TO MAKE A CHOICE SURROGATE LOOKS AT THE DECISION THROUGH THE “VALUE EYES” OF THE INCAPACITATED PERSON GROUNDED IN THE PRINCIPLE OF AUTONOMY BASED UPON –DIRECT STATEMENTS BY PATIENT –INFERENCES FROM VALUE CHOICES OF PATIENT SUBSTITUTED JUDGMENT STANDARD IS PREFERABLE BUT BEST INTEREST STANDARD IS PERMITTED AND OFTEN NECESSARY

6. STANDARDS FOR SURROGATE DECISION MAKING BEST INTERESTS SURROGATE MAKES THE DECISION, FROM AN OBJECTIVE STANDPOINT, WHICH APPEARS TO PROMOTE A PATIENT’S GOOD WITHOUT REFERENCE TO THE INCAPACITATED PATIENT’S ACTUAL OR SUPPOSED PREFERENCES WEIGHING BENEFITS AND BURDENS FROM THE STANDPOINT OF A “REASONABLE” PERSON LOOKING AT THE CLINICAL OUTCOMES –“REASONABLE” = SELF-REFLECTIVE, RELATIVELY UNBIASED, ATTEMPTING FACT-BASED OBJECTIVITY, SETTING ASIDE SELF-INTEREST GROUNDED IN THE PRINCIPLE OF BENEFICENCE

7. CRUZAN POWERS OF THE PATIENT, II IMPORTANCE OF INFORMED CONSENT IS UNDERSCORED AND BROADENED TO INCLUDE DISCUSSION RELEVANT FOR ADVANCE DIRECTIVES. EXPRESSED WISHES OF THE INCOMPETENT PATIENT MUST BE HONORED BARRING AN OUTWEIGHING STATE INTEREST. ADVANCE DIRECTIVES, WHEN SPECIFIC WITH REGARD TO CONDITION AND TREATMENT, ACT AS CLEAR AND CONVINCING EVIDENCE.

8. CRUZAN LIMITATIONS ON DECISION MAKING BEST INTEREST TEST DOES NOT QUALIFY AS CLEAR AND CONVINCING EVIDENCE. FAMILY MEMBERS DO NOT HAVE AN AUTOMATIC RIGHT TO BE DECISION MAKERS IN A CONTEXT OF CLEAR AND CONVINCING EVIDENCE STANDARD. CLEAR AND CONVINCING EVIDENCE MAY REQUIRE EXPLICIT STATEMENTS FROM THE PATIENT, EXCLUDING MERE INFERENCES. STATE MAY IGNORE “QUALITY OF LIFE CONSIDERATIONS” AND MAY ASSERT AN UNQUALIFIED INTEREST IN PRESERVING LIFE BALANCED AGAINST THE CONSTITUTIONAL PROTECTIONS OF INDIVIDUALS.