Legal Document

497 U.S. 261 110 S.Ct. 2841 111 L.Ed.2d 224 Nancy Beth CRUZAN, by her Parents and Co-Guardians, Lester L. et ux., Petitionersv.DIRECTOR, MISSOURI DEPARTMENT OF HEALTH, al. No. 88-1503. Argued Dec. 6, 1989. Decided June 25, 1990. Syllabus Petitioner Cruzan is incompetent, having sustained severe injuries in an automobile accident, now lies a Missouri state hospital what referred to as persistent vegetative state: generally, condition which person exhibits motor reflexes but evinces no indications of significant cognitive function. The State bearing the cost care. Hospital employees refused, without court approval, honor request Cruzan's parents, co-petitioners here, terminate artificial nutrition hydration, since that would result death. A trial authorized termination, finding has fundamental right under Federal Constitutions direct or refuse withdrawal death-prolonging procedures, expression former housemate she not wish continue life if sick injured unless could live at least halfway normally suggested on with hydration. Supreme Court reversed. While recognizing treatment embodied common-law doctrine informed consent, questioned its applicability this case. It also declined read into Constitution broad privacy support unrestricted expressed doubt such right. then decided Living Will statute policy strongly favoring preservation life, statements were unreliable for purpose determining intent. rejected argument parents entitled order termination medical treatment, concluding can assume choice incompetent absence formalities required clear convincing evidence patient's wishes. Held: 1. United States does forbid require incompetent's wishes life-sustaining be proved evidence. Pp. 269-285. (a) Most courts have based see, e.g., In re Storar, 52 N.Y.2d 363, 438 N.Y.S.2d 266, 420 N.E.2d 64, both constitutional right, Superintendent Belchertown School v. Saikewicz, 373 Mass. 728, 370 417. addition relying constitutions common law, turned statutes guidance, Conservatorship Drabick, 200 Cal.App.3d 185, 245 Cal.Rptr. 840. However, these sources are available Court, where question simply whether prohibits from choosing rule law it did. 269-278. (b) competent liberty interest Due Process Clause refusing unwanted treatment. Cf., Jacobson Massachusetts, 197 11, 24-30, 25 358, 360-363, 49 L.Ed. 643. been violated must determined balancing against relevant interests. For purposes case, assumed constitutionally protected lifesaving hydration nutrition. This mean should possess same unable make voluntary exercise hypothetical any other effect recognized certain circumstances surrogate may act patient electing withdraw thus cause death, established procedural safeguard assure surrogate's action conforms best while competent. 278-280. (c) permissible Missouri, proceedings, apply standard, appropriate standard when individual interests stake particularly important more substantial than mere loss money, Santosky Kramer, 455 745, 756, 102 1388, 1396, 71 599. Here, general protection human well other, particular interests, stake. legitimately seek personal element individual's between guard potential abuses surrogates who protect patient. Similarly, consider judicial proceeding regarding adversarial, added guarantee accurate factfinding adversary process brings it. properly decline judgments about "quality" assert unqualified weighed individual. self-evident substantial, societal level, those involved civil dispute. serves judgment how risk error distributed litigants. permissibly place increased erroneous decision seeking An results maintenance status quo, wrong will eventually corrected impact mitigated event advancement science unexpected susceptible correction. Although Missouri's proof requirement frustrated effectuation not-fully-expressed desires, rules work flawlessly. 280-285. 2. did commit adduced amount desire withdrawn. had adopted observations want "vegetable" deal terms P. 285. 3. accept "substituted judgment" close family members their views reflect patient's. Court's upholding State's favored traditional relationships, Michael H. Gerald D., 491 110, 109 2333, 105 91, recognize primacy relationships situation like this. Nor permit decisionmaking, Parham J.R., 442 584, 99 2493, 61 101, decisionmaking. surely qualified Constitution. reasons wishes, choose defer only rather confide members. 285-287. 760 S.W.2d 408, affirmed. REHNQUIST, C.J., delivered opinion WHITE, O'CONNOR, SCALIA, KENNEDY, JJ., joined. J., post, p. 287, 292, filed concurring opinions. BRENNAN, dissenting opinion, MARSHALL BLACKMUN, joined, 301. STEVENS, 330. William Colby, Kansas City, Mo., petitioners. Robert Presson, Jefferson respondents. Sol. Gen. Kenneth W. Starr, Washington, D.C., U.S., amicus curiae, supporting respondents, special leave Court. Chief Justice REHNQUIST 1 was rendered during accident. Copetitioners Joyce Cruzan, Nancy's coguardians, sought directing daughter's feeding equipment after became apparent virtually chance recovering faculties. held because there withdrawn circumstances, lacked authority effectuate request. We granted certiorari, 492 917, 3240, 106 587 (1989), affirm. 2 On night January 1983, lost control car traveled down Elm Road Jasper County, Missouri. vehicle overturned, discovered lying face ditch detectable respiratory cardiac Paramedics able restore breathing heartbeat accident site, transported unconscious state. attending neurosurgeon diagnosed probable cerebral contusions compounded anoxia (lack oxygen). case found permanent brain damage generally 6 minutes anoxic state; estimated deprived oxygen 12 14 minutes. She remained coma approximately three weeks progressed orally ingest some ease further recovery, surgeons implanted gastrostomy tube consent husband. Subsequent rehabilitative efforts unavailing. commonly function.1 After become regaining mental faculties, asked procedures. All agree removal refused approval. received authorization termination. "death prolonging procedures." App. Pet. Cert. A99. "expressed thoughts age twenty-five somewhat serious conversation friend suggests given present hydration." Id., A97-A98. 3 reversed divided vote. skepticism application Harmon, 416-417 (1988) (en banc). "support every circumstance," existed 417-418. statute, Mo.Rev.Stat. § 459.010 seq. (1986), life. S.W.2d, 419-420. roommate die conditions "unreliable intent," id., 424, "and insufficient co-guardians['] claim substituted behalf." 426. "no convincing, inherently reliable absent here." 425. view "[b]road questions death addressed representative assemblies" bodies. 4 certiorari circumstances. 5 At even touching one another legal justification battery. See Keeton, D. Dobbs, R. & Owen, Prosser Keeton Law Torts 9, pp. 39-42 (5th ed. 1984). Before turn century, observed "[n]o sacred, carefully guarded, possession his own person, free all restraint interference others, unquestionable law." Union Pacific Co. Botsford, 141 250, 251, 11 1000, 1001, 35 734 (1891). notion bodily integrity Cardozo, Appeals New York, aptly described doctrine: "Every being adult years sound mind determine shall done body; surgeon performs operation commits assault, he liable damages." Schloendorff Society York Hospital, 211 N.Y. 125, 129-130, N.E. 92, 93 (1914). firmly entrenched American tort law. supra, 32, 189-192; F. Rozovsky, Consent Treatment, Practical Guide 1-98 (2d 1990). logical corollary possesses is, Until 15 ago seminal Quinlan, 70 N.J. 10, 355 A.2d 647, cert. denied sub nom. Garger Jersey, 429 922, 97 319, 50 289 (1976), number right-to-refuse-treatment decisions relatively few.2 earlier cases patients forbidden religious beliefs, implicating First Amendment rights self-determination.3 More recently, however, advance technology capable sustaining past point natural forces brought times, involving burgeoned. 412, n. (collecting 54 reported 1976 through 1988). 7 Quinlan young Karen suffered entered Karen's father approval disconnect respirator. Jersey relief, holding grounded N.J., 38-42, A.2d, 662-664. Recognizing absolute, balanced asserted Noting "weakens grows degree invasion increases prognosis dims," concluded give way 41, 664. "only practical way" prevent due incompetence allow guardian decide "whether circumstances." Ibid. 8 most either solely Tribe, Constitutional 15-11, 1365 417 (1977), Judicial Massachusetts relied withholding chemotherapy profoundly retarded 67-year-old man suffering leukemia. 737-738, N.E.2d, 424. Reasoning retains "because value dignity extends both," whereby 752-753, 757-758, 427, 431, 434. Distilling prior law—the innocent third parties, prevention suicide, ethical profession—the first paramount noted greatest affliction curable, "as opposed where, issue whether, when, long, [a] briefly extended." 742, 9 denied, 454 858, 309, 153 (1981), base Instead, right"ade quately supported" doctrine. 376-377, N.Y.S.2d, 272, 70. Eichner (decided supra ), 83-year-old court, unnecessary reach exercised others made "did maintained use respirator." 380, 274, 72. companion Storar 52-year-old bladder cancer Implicitly rejecting approach taken reasoned life-long incompetency, "it unrealistic attempt potentially competent." N.Y.2d, 275, As showed blood transfusions involve excessive pain them physical abilities deteriorate, "allow bleed someone, someone parent sibling, feels incurable disease." 382, 73. 10 Many later build principles Storar/Eichner. instance, Conroy, 98 321, 486 1209 (1985), considered nasogastric removed 84-year-old nursing-home resident irreversible ailments. federal might contrary self-determination informedcon sent. 348, 1223. "On balance, ordinarily outweighs countervailing persons permitted otherwise, they protecting concerned competency rational choice." 353-354, 1225. merely sense violation it, individuals retain decisionmaker using "subjective" Where lacking, still invoked objective "best interest" standards. 361-368, 1229-1233. Thus, trustworthy wanted enough clearly establish person's subjective burden prolonged experience markedly outweighed satisfactions, terminated "limited-objective" standard. existed, administration inhumane, "pure-objective" used If none obtained, err favor preserving 364-368, 1231-1233. categorical distinctions drawn refusal-of-treatment lacking substance purposes: distinction actively hastening terminating passively allowing disease; treating initial matter versus withdrawing afterwards; ordinary extraordinary treatment; forms 369-374, 1233-1237. last item, acknowledged "emotional significance" food, tubes "medical procedur[e] inherent risks possible side effects, instituted skilled health-care providers compensate impaired functioning" analytically equivalent 373, 1236.4 13 contrast recently less before permitting decisionmaker. Westchester County Medical Center behalf O'Connor, 72 517, 534 886, 531 607 (O'Connor ). There, over objection members, insert 77-year-old woman several strokes. continuing asserting inconsistent our commitment substitute acceptable quality another. Consequently, we adhere that, despite pitfalls inevitable uncertainties, inquiry always narrowed intent, effort minimize opportunity error." 530, 892, 613 (citation omitted). record requisite intent withhold 531-534, 892-894, 613-615. Other statutory resolution issues. 840, 488 958, 399, 387 (1988), California Appeal 44-year-old auto privacy, probate conservator good faith advice conservatee's acknowledging "to [a patient's] 'right choose' survives fiction best," respect society accords upon preserved reflects closely purely technological do whatever possible."5 Cal.App.3d, 208, Cal.Rptr., 854-855. Torres, 357 N.W.2d 332 (Minn.1984) (Minnesota authorize respirator interests). Estate Longeway, 133 Ill.2d 33, 139 Ill.Dec. 780, 549 292 Illinois 76-year-old series strokes discontinuance boundaries uncertain, consent. 43-45, 784-785, 296-297. Probate Act impliedly ward's sustenance ward terminally ill irreversibly comatose. 45-47, Ill.Dec., 786, 298. Declining adopt deciding "lets determination life," opted instead 49, 787, 299. Finding intent" utilized too rigid, considered. Ill.2d, 50-51, 300. "consensus [that] treats treatment." 42, 784, 296. Cf. McConnell Beverly Enterprises-Connecticut, Inc., 209 Conn. 692, 705, 553 596, 603 (1989) (right Connecticut Removal Life Support Systems Act, "provid[es] functional guidelines self-determination"; physician remove terminal condition, obtaining family, considering patient).6 16 demonstrate, viewed encompassing Beyond demonstrate similarity diversity approaches perplexing unusually strong moral overtones. sources—state constitutions, statutes, law—which us. starkly squarely presented grants parlance "right die." follow judicious counsel Twin City Bank Nebeker, 167 196, 202, 17 766, 769, 42 134 (1897), said "a magnitude importance . [better] part wisdom attempt, statement, cover phase subject." Fourteenth provides "deprive liberty, property, principle inferred decisions. 360-361, 643 (1905), declining smallpox vaccine preventing disease. Decisions incorporation Fourth analyzed searches seizures body thought implicate See, Breithaupt Abram, 352 432, 439, 77 448 (1957) ("As inviolable set ."). 18 Just Term, course procedures administering antipsychotic medication prisoners sufficient satisfy concerns, avoiding drugs Amendment." Washington Harper, 494 210, 221-222, 1028, 1036, 108 178 (1990); see 229, S.Ct., 1041 ("The forcible injection nonconsenting represents liberty"). Still recognition Vitek Jones, 445 480, 494, 100 1254, 1264, 63 552 (1980) (transfer coupled mandatory behavior modification implicated interests); 600, 2503, 101 (1979) ("[A] child, adults, confined unnecessarily treatment"). 19 But "liberty end inquiry;7 respondent's interests." Youngberg Romeo, 457 307, 2452, 2461, 73 28 (1982). Mills Rogers, 291, 299, 2442, 2448, 20 Petitioners insist holdings cases, forced artificially food water essential interest. think logic discussed above embrace interest, dramatic consequences refusal inform deprivation permissible. grant 21 go possessed person. They rely primarily Parham, mentally disturbed minor child "not treatment," certainly intimate commitment, Youngberg, seriously safety freedom restraint, 320, 2460. administer 22 difficulty petitioners' begs question: Such "right" her, all, sort surrogate. requires question, then, forbids establishment State. hold not. 23 Whether comports depends situation. relies gainsaying matter, States—indeed, civilized nations—demonstrate homicide crime. Moreover, majority country laws imposing criminal penalties assists suicide.8 remain neutral physically starve 24 context deeply obvious overwhelming finality. believe imposition heightened evidentiary requirements. cannot disputed protects Not loved ones serve decisionmakers. And present, "[t]here will, course, unfortunate situations patient." Jobes, 394, 419, 529 434, 447 (1987). situations. very adversarial one, it.9 Ohio Akron Reproductive Health, 502, 515-516, 2972, 2981-2982, 405 (1990). Finally, enjoy, view, adoption "clear convincing" govern proceedings. "The function proof, concept realm factfinding, 'instruct factfinder concerning confidence thinks correctness factual conclusions type adjudication.' " Addington Texas, 441 418, 423, 1804, 1808, 60 323 (quoting Winship, 397 370, 90 1068, 1076, 368 (1970) (Harlan, concurring)). "This mandated intermediate proof—'clear evidence' 'particularly important' 'more money.' 1397, 599 (1982) Addington, 1808). deportation Woodby INS, 385 276, 87 483, 362 (1966), denaturalization Schneiderman States, 320 118, 1333, 1796 (1943), proceedings parental rights, Santosky, supra.10 Further, level "or higher traditionally imposed allegations fraud, variety kinds issues wills, oral contracts bequests, like." Woodby, 285, 18, 488, 18. 26 instant run-of-the-mine adjudication, litigants." 755, 1395; 1807-1808. stringent party bear, bears decision. quo; possibility subsequent developments advancements science, discovery new changes create mitigated. factors led final irrevocable. 759, 1397-1398. discontinue 27 worth noting most, testimony entirely parties transactions which, important, does. parol prevents variations written contract testimony. frauds makes unenforceable property regulating making wills universally instruments writing. A. Corbin, Contracts 398, 360-361 (1950); Page, Wills §§ 19.3-19.5, 61-71 (1960). There requiring writing, occasion frustrate decedent, just desires Cruzan. faultlessly; can. sum, conclude seeks note many procedure this, limit consideration individual, been, 300; McConnell, Conn., 707-710, 604-605; 529-530, 613; Gardner, 947, 952-953 (Me.1987); 412-413, 443; Leach General Center, 68 Misc. 1, 426 809, 815 (1980). 29 so doing, "suggest[ed]" desired measures, A98, evidence" enunciated consisted year "vegetable," effect. say committed reaching conclusion did.11 30 alternatively contend 91 (1979). claim. H., upheld constitutionality California's relationships; around minor, scheme minors. Here again petitioners allowed decisionmaking way. 31 No engendered anything mother loving caring parents. repose anyone, Cruzans qualify. matters anyone herself. Close feeling—a feeling ignoble unworthy, disinterested, either—that witness continuation regard hopeless, meaningless, degrading. automatic assurance necessarily confronted prospect previously lead us members.12 32 33 Affirmed. 34 concurring. I decisions, ante, 278-279, encompassed within 279. write separately clarify why so. 36 notes, flows invasions body. 278-279. Because notions inextricably entwined idea self-determination, often deemed incursions repugnant Clause. Rochin California, 342 165, 172, 205, 209-210, 96 183 (1952) ("Illegally breaking petitioner, struggle open mouth there, extraction stomach's contents bound offend hardened sensibilities"); Our jurisprudence echoed concern. Schmerber 384 757, 772, 86 1826, 1836-1837, 908 (1966) cherished society"); Winston Lee, 470 753, 1611, 1616, 84 662 (1985) ("A compelled surgical intrusion implicates expectations security 'unreasonable' likely produce crime"). unwilling involves form intrusion. dying whose honored feel captive machinery measures interventions. much coercion. 221, ("It 37 provision identical concerns. Artificial readily distinguished Council Ethical Affairs, Association, AMA Opinion 2.20, Withholding Withdrawing Life-Prolonging Current Opinions (1989); Hastings Guidelines Termination Life-Sustaining Treatment Care Dying 59 techniques pass alimentary tract termed restraint. Feeding means long flexible nose, throat, esophagus stomach. discomfort causes, "[m]any need restrained forcibly hands put large mittens removing tube." Major, Procedures Providing Food Water: Indications Effects, By Extraordinary Means: Choice Forgo Water (J. Lynn 1986). (as provide 266) jejunostomy surgically stomach small intestine. Office Technology Assessment Task Force, Technologies Elderly 282 (1988). Requiring endure burdens dignity, Accordingly, guaranteed protect, anything, reject including delivery water. 38 emphasize today 12. my duty Few explicit instructions incompetent.1 frequently fail failures avoided equally probative source evidence: appointment proxy health care behalf. Delegating member becoming method planning future. Areen, Legal Status Obtained Families Adult Patients Withhold Withdraw 258 JAMA 230 Several enacting durable power attorney specifically appoint decisions.2 Some agent appointed pursuant empowered patient.3 Peter, 365, 378-379, (1987); Op.Md.Atty.Gen. 88-046 (interpreting Md.Est. Trusts Code Ann. 13-601 13-602 (1974), authorizing delegatee decisions). designate carry out living will.4 These appear rapidly gaining acceptance, valuable additional select surrogate, President's Commission Study Problems Medicine Biomedical Behavioral Research, Making Health 240 (1982), giving proxy's "freedom life." Cleveland Board Education LaFleur, 414 632, 639, 94 791, 796, 39 (1974). Today's decision, permits withdrawn, preclude future implement duly developing evident survey ante 271-277 national consensus yet emerged solution difficult sensitive problem. Today practice violate Constitution; challenging task crafting safeguarding incompetents' entrusted "laboratory" Ice Liebmann, 285 262, 311, 371, 386-87, 76 747 (1932) (Brandeis, dissenting), instance. 40 41 various opinions portray quite difficult, indeed agonizing, constantly increasing keep alive longer reasonable inhabit begun grapple problems legislation. am concerned, tenor today's opinions, poised confuse enterprise successfully confused legislating abortion—requiring conducted background imperatives unknown newly crafted Term Term. That great misfortune. analysis today, therefore join preferred announce, promptly, business field; accorded prevent, force necessary, suicide—including suicide take necessary preserve one's life; becomes "worthless," "extraordinary" "inappropriate," neither forth nor known nine Justices better people picked random telephone directory; hence, demonstrated up citizens decide, elected representatives, honored. impossible (because says nothing matter) line lawful choose; unlikely know "life death" do) reasonable. 43 text deprivations simpliciter. "without To occur nourishment reopen historically recurrent debate "due process" includes substantive restrictions. Compare Murray's Lessee Hoboken Land Improvement Co., How. 372 (1856), Scott Sandford, 393, 450, 691 (1857); compare Tyson Brother Banton, 273 47 426, 718 (1927), Olsen Nebraska ex rel. Western Reference Bond Assn., 313 236, 246-247, 862, 865-866, 85 1305 (1941); Ferguson Skrupa, 726, 730, 83 1031, (1963), Moore East Cleveland, 431 1932, (1977) (plurality opinion); Easterbrook, Substance Process, 1982 S.Ct.Rev. 85; Monaghan, Perfect Constitution, 56 N.Y.U.L.Rev. 353 (1981). true "substantive claimant demonstrates him interference. 122, 2341, Bowers Hardwick, 478 186, 192, 2841, 2844-2845, 92 140 (1986); Moore, 502-503, 1937-1938 opinion). possibly here. 44 England, suicide—defined "deliberately puts existence, unlawful malicious act, consequence death," Blackstone, Commentaries *189—was criminally liable. abolished (i.e., forfeiture ignominious burial), spare legitimize act. Case time assisting offense. Marzen, O'Dowd, Crone, Balch, Suicide: Right?, Duquesne L.Rev. ("In short, twenty-one thirty-seven states, eighteen thirty ratifying states prohibited suicide. Only eight seven definitely not"); Wharton, Criminal 122 (6th rev. 1868). System Penal House Representatives Representative Livingston 1828 criminalized assisted E. Livingston, Law, (1828). Field Code, Dakota Territory 1877, proscribed attempted 76-77. explicitly prohibit 1868 recognized, arose following Amendment's ratification, (in cases) unlawful. 77-100; 148-242 (surveying development States' laws). "there rooted tradition 'fundamental' 'implicit ordered liberty.' Palko Connecticut, 302 325, 58 149, 152, 82 288 (1937)). 45 separate suicide: (1) permanently incapacitated pain; (2) bring affirmative nourishment; (3) effectuating presumed integrity. None suffices. Suicide excused avoid ills [persons] fortitude endure." *189. whom burden—of hopelessly diseased fatally wounded—nay, lives criminals condemned full tide life's enjoyment, anxious live." Blackburn State, St. 146, 163 (1873). prepared poison, placed wife, suffering" illness convicted murder, People Roberts, Mich. 187, 198, N.W. 690, 693 (1920); "incurable hardly affect criminality. ." Note, Yale L.J. 412 (1921) (discussing Roberts imminence affected liability. moment. [Assisted suicide] declared irrespective poison administered. Blackburn, 163; Commonwealth Bowen, 356, 360 (1816). 46 second distinction—suggested recent canvassed 270-277—relies dichotomy inaction. Suicide, said, consists "causing" passive acceptance dying. acknowledge inaction legislative ought prevented suicide—though seem me unreasonable draw precisely inaction, kill oneself walking sea, sit beach until submerged incoming tide; intentionally lock cold storage locker, refrain coming indoors temperature drops below freezing. Even words, intelligent fall consist abstaining "ordinary" "excessive" "heroic" measures. Unlike discerned analysis, pretend is. return principal irrelevance action-inaction distinction. Starving different putting gun temple far definition concerned; suicide's conscious "pu[t] existence." Caulk, 125 N.H. 226, 232, 480 93, (1984); White Narick, 170 W.Va. 195, S.E.2d (1982); Von Holden Chapman, App.Div.2d 66, 450 623 Of contexts taking well. prosecution starvation infant, defense infant's "caused" starvation, inability itself. Lewis Ga. 164 (1883); McDonald, Hun 67, N.Y.S. 703 Dept., App.Div.1888); Hall, 322 523, 528, 78 644, 647 (1948) cases); Homicide 134-135, 304 1875); J. Bishop, 686 1872); Hawley M. McGregor, 152 (3d 1899). physician, moreover, failure extended immediately caused underlying disease failed treat. Barrow Okl.Cr. 340, 188 351 Phillips, 64 Cal.2d 574, P.2d (1966). 48 surprising, therefore, early claimed dismissed specious nice "passively submitting verbal, drug. interrupt mode self-destruction, equal interfere other." John Kennedy Memorial Hosp. Heston, 576, 581-582, 279 670, 672-673 (1971); Application President Directors Georgetown College, 118 U.S.App.D.C. 80, 88-89, 331 F.2d 1008-1009 (Wright, chambers), 377 978, 1883, 746 (1964). basis distinction—that frustrating integrity—is likewise inadequate, impermissible undergo private citizens, felony. Phillips Trull, Johns. (N.Y.1814); Payne, Nott McCord 475 (S.C.1821); Vandeveer Mattocks, Ind. 479 (1852); T. Cooley, 174-175 (1879); Wilgus, Arrest Without Warrant, Mich.L.Rev. 673 (1924); Restatement 119 (1934). applied privileged. Colby Jackson, 526, 530-531 (1842); Look Choate, 116, 120 (1871); Mink, 123 422, (1877); Doyle, R.I. 537, 539, 159, 159-160 (1889); Porter Ritch, 235, 255, 169, 175 (1898); Emmerich Thorley, App.Div. 452, 456, 793-794 Hembd, 305 Minn. 120, 130, 232 872, 878 (1975); C. Addison, 819 (1876); 179-180. reasonable, maintain although slashing wrists, doing so, power, succeed, apply, coercively stop flow blood. state-run hospital, certain, U.S.C. 1983 if, unlawful, pumps hasinten tionally overdose barbiturates, contrary. dissents BRENNAN STEVENS plausible intervention here embracing—the latter implication—a political adopt, demonstrably "[T]he State," "has legitimate someone's completely abstracted outweigh Post, (emphasis added). italicized phrase sounds moderate needed case—but proposition logically limited. One accepts accept, think, "the agrees accede particularized intense ibid. added), "particularized insofar relative distinctive accepting shut off engine get parking garage work. Suppose except fed digest assistance. How "interest" keeping thereby increased, wants reduced? seems me, BRENNAN's position ultimately rests point: "Choices touch core liberty. [N]ot faith, alone reason conform choices conscience." 343. societies held, wish. traditions, unquestionable. 51 What meant suggest desirable, sure die, subject. raise (for exists tradition) whereby, come eat medicine; pump empty ingested, fill ingest. Are humane limits exceeded life? obviously are, assures protection—what us, example, assessed tax 100% income subsistence drive cars, send children school hours day, horribles categorically salvation Equal Protection Clause, democratic themselves impose you me. not, to, inject itself field activity irrationality oppression theoretically occur, tries destroy BLACKMUN join, dissenting. 53 "Medical effectively created twilight zone suspended animation commences form, continues. patients, technology. prefer plan allows nature dignity."1 dwelt six years. oblivious surroundings 411 (Mo.1988). Her twitches reflexively, consciousness. areas once thought, felt, experienced sensations degenerated badly cavities remaining filling cerebro-spinal fluid. 'cerebral cortical atrophy irreversible, permanent, progressive ongoing.' "Nancy never interact meaningfully environment again. death." 422.2 swallow, 55 grown forgo these. friends convinced want. 20, infra. ad litem 444 (Higgins, denial rehearing). Yet among prisoner technology—for Nancy, perhaps next 427. tentatively affirms affirm ground hers ensure actual 282-283, 286-287. find improperly biased obstacles impermissibly respectfully dissent. dignity. 57 * timing death—once fate—is Sustaining million each year, 80% hospitals long-term institutions,3 70% made.4 Nearly undertake prolong personal. values, realities, framework governed role defining framework, delineating ways government participate narrow one: now-incompetent rigorously prior, express choice. 277-278. issue, scrutinized standards Zablocki Redhail, 434 374, 388, 673, 682, 618 (1978), "significantly interferes supported sufficiently tailored imposes obligation "examine extent [the advanced] served challenged regulation." 499, 1936, (1977). Carey Population Services International, 678, 2010, 2018-2019, 675 (invalidating bore relation interest"). rule, prohibition, meet significantly Fundamental "are heavy-handed frontal attack, stifled subtle governmental interference." Bates Little Rock, 361 516, 80 416, B starting Earlier confers 1036-1037, Today, concedes 278. avoids discussing measure assuming, only, O'CONNOR's parsimonious. openly Clause," encompasses "artificially water." 287. O'CONNOR concede, fundamental. "We dealing decision] basic man." Skinner Oklahoma Williamson, 316 535, 541, 62 1110, 1113, 1655 (1942) sterilization felons). Whatever liberties fundamental, "those 'deeply Nation's history tradition' them. 2844, (1986) 503, 1938 "Such commands carries gloss history." Richmond Newspapers, Inc. Virginia, 555, 589, 2814, 2834, 65 973 (BRENNAN, judgment). attention body, acknowledges. 270. "firmly law" securely earliest 294, 4, 2446, ("[T]he doctrines trespass battery, unauthorized touchings physician"). "Anglo-American starts premise thorough-going self determination. follows master may, mind, expressly performance surgery, Natanson Kline, 186 Kan. 406-407, 350 1093, 1104 inviolability person" "sacred" "carefully guarded" 251-252, unquestionably "so traditions conscience ranked fundamental." Snyder 291 97, 105, 330, 332, 674 (1934).5 vitiate self-determination. well-established patient, decides treatment—any treatment—is all. gravity acceding foregoing it." Tune Walter Reed Army 602 F.Supp. 1452, 1455 (DC 1985). Downer Veilleux, 82, (Me.1974) rationale fact forego cure, entails intolerable risks, however unwise values others").6 material continues subject—artificial hydration—and 288-289 (O'CONNOR, concurring). undoubtedly technique tube—involves incisions abdominal wall. obstruct intestinal tract, erode pierce wall, leakage cavity. Andrassy, Sandler, Techniques Delivery Liquid Diets, Nutrition Clinical Surgery 66-67 (M. Deitel 2d pneumonia reflux lung. Bernard Forlaw, Complications Their Prevention, Enteral Tube Rombeau Caldwell eds. Typically, (see Tr. 377), commercially formulas used, fresh food. Matarese, Alimentation, Surgical 726 Fischer 1983). formula experimented gastrointestinal problems. 748. monitored daily personnel weight, fluid intake, output; tests weekly. 749, 751. regarded profession Government.7 According Academy Neurology: analogous When unconscious, device replace normal functions compromised illness." Position Neurology Certain Aspects Management Persistent Vegetative Patient, (Jan.1989). Affairs Opinions, 2.20 ("Life-prolonging artifically technologically supplied respiration, hydration"); 88 (life-sustaining respirators, kidney dialysis machines, procedures). Government devices enteral reimbursed Medicare. Pub.L. 99-509, 9340, 1395u, 592 (1982 ed., Supp. V). regulated Drug Administration foods," 360ee, devices, CFR 876.5980 (1989). deprive rights. 315-316, 2459-2460, (holding severely man's safety, training survive involuntary commitment); (recognizing child's treatment); Jackson Indiana, 406 715, 738, 1845, 1858, 435 (1972) Indiana deaf mute committing indefinite stand charges him). recognizes, 280, exercised. explained Thompson Oklahoma, 487 815, 2687, 702 (1988): adjust manner affords renders freely rationally. Children, insane, function, 'rights,' sure, meaningful agents acting principals mind." 825, 23, 2693, "To deny [its] right." Foody Manchester Conn.Supp. 127, 133, 482 713, (1984). II 66 evaluate benefit according subject sole kept metabolically alive. Neither cure ameliorate condition.8 Irreversibly devoid emotion, sensation; unconscious. 2, supra.9 approving patients: 67 "[T]reatment aims relieving suffering, disability, returning maximally effective functioning. unconsciousness correct, continued confer benefits. Pain absent, joy, satisfaction, pleasure. Disability total minimal social functioning possible." 181-182. profound. many, end, steeped decay, abhorrent. quiet, proud bodilyinteg rity intact, extreme consequence. "In thankfully rare, maintaining corporeal existence degrades humanity serve." Brophy England Sinai 398 417, 626, 635-636 (finding "in [he] indicated degrading dignity" "[t]he encompass himself sustain demean degrade humanity"). Another hearing similar noted: 69 "It invasiveness systems, [nasogastric] tube, utter helplessness comatose wasting submission others." 953 (Me.1987). humiliating contemplate,10 visiting anguished vigil spouse, children. drawn-out debilitating Carnwath Johnson, Psychiatric Morbidity Among Spouses With Stroke, 294 Brit.Med.J. 409 Who Care, 919 (1985). some, remembered disturbing.11 intervention, absolute,12 position. mandating life-support obtained insistence systems claim, whole benefited receiving party's improved harm averted. nn. 8, supra.13 life.14 regulation predicated concerns disagreement made. Otherwise, nullity." Hodgson Minnesota, 435, 2926, 2937, 344 (1990) (opinion J.) purview gained superseding considerable danger impair recommends heroic scintilla recover, assumption discontinued improve. approved "[a]n troubling occurs save improve started afraid fairly likely, proves little greatly 75. families doctors discouraged "even attempting types [which] hasty premature 1209, 1234 Brief Amicus Curiae (expressing concern).15 III 74 282, parens patriae providing Second, beendeter mined, safe-guarding accuracy 75 Accuracy, touchstone. requirements enhance consistent "safeguard" upholds asymmetrical burden. specific admissible state, convincing. offers justifications First, explains determinations 10. rest result. erected greater bringing disfavored claims.16 discourage claims legitimate, contrast, disfavor 312-314. override directly, indirectly rule. two explanations enhancing accuracy, persuasive. initially argues lack "guarantee it," citing (upholding parte proceeding). Ante, 281-282. bypass notifying undergoing abortion mature needs counterbalanced fully explored. permission forward satisfied seasoned adult. nature. Barring venal motives, ferreting out, slowly adults discontinuation 79 addition, Akron, secret. notify minor's siblings, friends. submit preferences limited adjusting imbalance. Indeed, concern one-sided appointing litem, powers gather litem's uncover conflicts consulted friends, clergy, doctors. Colyer, Wash.2d 114, 660 748-749 (1983). attempts achieve balance discounting evidence; achieves probing Where, doctors, agree, failed, suggests. 281, 9. genuine dispute preference. stake, 283. minimum evaluation side's bear error. 766-767, 1401-1402, (requiring parent's unfit, home arise unfit); 426-427, 1809-1810, confining pose others). shifting reduces likelihood errors direction other. 1807-1808 (contrasting preponderance sides "share roughly fashion" outcome other). cited majority, imbalance deployed admits, obstacle 81 allocation justified irrevocable, "results quo." 283.17 But, remnant physiological stem, complete support, robs qualities His degraded perpetuated; family's protracted; memory leaves behind distorted. undo intervening harm. event. evidence," refers, ibid., plausible. misconceives relevance "advancements science," will. miracle calculus, calculus. current research hope improvement span projected, factor weight assessing choose.18 court's exclusion dispenses semblance factfinding. adverted show friend.19 sister hydration,20 malignant motive. 412. rehearing); Respondent Guardian Ad Litem 2-3. define kind discussion equivalently formal directive 424-425. Too few execute directives adequately honored.21 wise encourage furnish instructions, formalities. probability low urgency marshal preferences. dwell deterioration mortality. resolute things exist one. Often help especially majority's willingness truly specified. appellate observed: generalized public awareness typically characteristics procrastination reluctance contemplate arrangements tool unused Barber Superior 147 1006, 1015, 195 484, 489 tells artificially, "express[ing] familiar lay unrealistic, purposes, precludes 551, 905, 607, 626 (Simons, dissenting).22 enacted provided warrant presumption 15, supra. apparently legislature believes fails continuous hand, be. best. "Family unique knowledge vital Newman, Refusals Critically Terminally Ill: Proposed Rules Family, Physician, N.Y.L.S. Human Rights Annual 35, ignore category odds practices States. 419 Severns, 425 156 (Del.Ch.1980). disdain conversations beliefs choice, outside choose. represent upholds, skews away accurately beliefs. transforms beings subjects "[M]edical guided values. Allowing respects individuals. 89 diminish incapable participating [I]t possible. Lacking ability patient] takes account." 854-855, C helplessly ignored. 281. ruled unconstitutional, have, nevertheless fashion protections incompetents here: Protections genuinely aimed ensuring commensurate end. protections, fashioned lessens determinations. reviewing advisability impartial litem. advantages disadvantages envisioned. largest part, left seeking, manner, discover momentous prejudice way—to chosen cling life—would unfortunate." 343, 1220. D make, automatically 286 (explaining "anyone herself"). Under fair evidence, improbable occasions numerous. invariably furthered appropriating justifies arguing quarrel observation. leads Is suppose knew intimately? ask answer peculiar grasp bonds her. treat symbol cause." stranger discern powerless that. selected him. exclude improper motives. family.23 IV 95 10,000 expected increase near Cranford, 27, 31. technology, developed years, resuscitating stopped hearts beating. back Two decades ago, swallow died. Intravenous solutions calories short time. decades. Spencer Palmisano, Specialized Nutritional Patients—A Hospital's Duty?, Quality Rev.Bull. 160, 160-161 chronic degenerative ailments replaced communicable diseases primary causes Weir, Abating Ill 12-13 15-16. Americans "likely 'in sedated betubed nasally, abdominally intravenously; manipulated objects subjects.' "24 fifth surviving suffer dementing disorder Cohen Eisdorfer, Dementing Disorders, Practice Geriatrics 194 (E. Calkins, Davis, A, Ford "[L]aw, equity justice quail helpless modern marvels presenting hitherto unthought of." 44, 665, (1976). reclaim irretrievably active lives. disease, doomed failure. situations, bodies memories victims escheat State; commandeer singularity confidently patriae. Commission, research, concluded: people's evaluations experiences varied uniquely assessments processes associated moment inestimable value; worthless burdensome. growth frightening despicable another." 276. displaced assessment discarded ignored approximating humanly disingenuously name own. motivated matter. prominent jurists warned ago: "Experience teach government's beneficent. dangers lurk insidious encroachment men zeal, meaning understanding." Olmstead 277 438, 479, 564, 572-573, 944 (1928) dissenting). born governments secure "Life, Liberty, pursuit Happiness."1 naturally ends compatible, mutually enhancing, coincident. exception abstract, undifferentiated overwhelm would, undisputed finding, guardians Ironically, reaches endorsing propositions dilemma. aspect Amendment. proper showing, ward. 284-285. Third, answering tragic 'not subject.' 278 Together, considerations understood light facts 103 hold: gives 104 how, So put, resolve abstract. responsibility judges enables compels problem illuminated controversy these: "Clear "oblivious reflexive responses painful stimuli"; "she water"; recover" abilities; "cerebral ongoing." A94-A95. Recovery consciousness impossible; highest hoped grimace "recognition stimuli" "apparent response sound." A95.2 evaluating judge examined daughter. findings parents' economic motivation,3 granting adversely breach profession.4 He considered, rejected, decision,5 liberty" relied: otherwise undertaken success [sic] 107 Co-guardians Ward discharge determine." A98-A99 (footnotes believed independent appealed appeal, advised disagree Specifically, endorsed critical discontinued."6 reasonably dispositive: cessation adverse insisting treatment? Yet, questioning largely four identified life" case.7 defined follows: 112 state's embraces concerns: prolongation sanctity itself." 113 characterize repeatedly "quality patient.8 state-court foreclose evidenced, terms, issue—or birth—are irrelevant unprotected reasoning four-judge majority. 114 compelling. agreed policy. persuasive dissent, Judge Blackmar chronically private: 115 "My fundamentally emphasis represented Attorney General. origin. world's history, presently parts world, available. customarily closest youth infirmity, seldom called 116 "I assumption, advanced relatives, Very hospital. expressions, unusual example books, expresses supports of. Those positioned interest." 428. 117 argued controversial objectionable meaning: statement amelioration condition. conclusion. resort unpleasant react stimuli. surroundings, hell. herself alter theirs. impressed crypto-philosophers declaim quality. ivory towers." 429. illegitimate theoretical abstraction, severed from, appropriately came relief. circuit authority. absolutes, expense factors. torture 429-430. 121 frame such, propounds reasoning: portion considers merits similarly unsatisfactory. It, too, patient.9 tantamount waiver rationale: side, entire focused expressions intent.10 foresight unambiguous children, accidents illnesses, countless thousands elderly explain, treated fate. comparable alternative, gone forever fate judge—all reveals distressing misunderstanding predictable undervalue personal, reflection unusual. sad shows, responsibly advances altered alarming: Highly invasive perpetuate merger machine insult continuation. advances, reorganization accompanying transformed death: home, places, nursing homes.11 124 Ultimate dealt intimacy physician12 institutions. institution involved.13 nonetheless remains characteristically home," Poe Ullman, 367 497, 1752, 1781, 989 (1961) "integrity something right," 551-552, demarcated "private enter." Prince 321 158, 166-167, 442, 645 (1944). crucial guarantors Payton 573, 1371, 1381, 639 (1980); Stanley Georgia, 394 557, 565, 1243, 1248, 542 (1969). Nevertheless, constitutive "concept liberty," (1937), occasionally afforded protection. Meyer Nebraska, 262 390, 625, 1042 (1923); Griswold 381 1678, 510 (1965); Roe Wade, 410 113, (1973); Thornburgh College Obstetricians Gynecologists, 476 747, 772-782, 2169, 2184-2190, 779 (STEVENS, Respect pertaining identifying built,14 mindful "makers significance spiritual nature." 478, 572, "our self-determination." 287 Thus construed recoveries "brutal" "offensive dignity." 174, (1952). interpreted interpose barriers sterilize proposed punishment "irreparable injury" integrity, "[m]arriage procreation" (1942). sanctity, liberty." 237, 1045, part). "physical curtilage solicitude privacies within," 1781 inseparable spirit therein. 126 decisional illuminates, understood. presupposes abandonment reducible batteries infliction discomfort. Choices duty, concomitant freedom, mortality fundamental," (1934), incidents unalienable endowed Creator. Meachum Fano, 427 215, 230, 2532, 2541, 451 (1976) 127 precise describe; conscience. also, justly simple opposite, terminus,15 completion. appreciation understanding significance. fact, something. Certainly Nathan Hale's famous declaration Patrick Henry's; words bespeak passion preserves countrymen.16 From "honored dead devotion gave devotion."17 128 cast stark relief injustice, unconstitutionality, comes, historic heroism; inevitably mattered dear others. dies remembered. cease cares tragedy subordinates lasting review order. 129 permissible, must, minimum, relationship 400, 627; Doe Bolton, 179, 194-195, 199, 739, 748-749, 751, 201 (1973). asserts related heart insists, equating biological persistence functions. remembered, incompetent. found, contested, recovery 130 errs characterizes "judgments 'quality' enjoy," 282. "alive sense. word understood, Declaration Independence.18 unflagging comprehensible meaning, sanctity. 131 oddity alone. Life, function.19 Its derive impossibility reduction. speak describe comprise somebody "led life."20 refer manifestation spirit, captured observation "added assembly. shared thread subject, matrix for, integration of, event, theological conceived separation opposition resulting uncommon indeed. 132 punishing homicide, relies, inference. Obviously, victims. pre-suppose inclined living, and, indeed, depressed thankful intervention. Likewise, address conscious, lives, pales eyes measured comfort. Contrary suggestion, commonplace; aberrant. precedent state-law surveyed Despite assertion "both approaches" interposed absolute bar pertained "was responding requests sometimes squeezing questioner's hand verbally." 524-525, 888-889, 609-610. "profoundly months." 270, 68. "Ms. Conroy dead, comatose, state," 337, 1217, "persistent state." 358-359, 1228. unbroken stream states.21 Considered broader inapt—category anomolous. believing perpetuation already suggested, hypothesize philosophical conjecture. posit condemn province secular circumscribe regulations designed wholly establishing sectarian Webster Services, 490, 566-572, 3040, 3082-3085, 135 My unrelated endorsement kind. controlling unmistakable clarity. prove proven controlling. clear: buttressed prevail ignores interests.22 policy's family. "[a]lthough perform teaching function," foster pursue project infringing "symbolic effect." 2031, heed ample illegitimacy. 136 arrogated usurpation, disquieting conflict. reference expired ceased serving conflict Conversely, being, effort, willingness, abstract 137 Both deference legislature.23 logic. peculiarly problematic 280. discretion requirement" 138 "hypothetical" difficulties ascertaining justify oppose comes question—and Court—is novel 310, 2455, Whitmore Arkansas, 495 161-164, 1717, 1734-1735, incapacity "exercise" State's, explanation possibilities, satisfactory. intrusive alternative. quo," reversal, "is correction" irreversible. assumes ignoring obviate rely, does, unconscionable. Insofar lived died, pain, closure Legislature, personhood points "abuses" inaccuracies correctly notes survivors' mistaken searching Why safeguards adequate ignores. argue suffices unknowable subordinated personhood. personhood, gravely incapacitated, admittedly, easily defined: profound ones, recourse rules. investigate particularity caution. cautions formulating inflexible area willing though grounds deferring Legislature 142 explanation, cognizable Deference patently unconstitutional. dangerous apparent. announced spend hundred thousand dollars vindicate Tomorrow, eager champion quick comfortable deaths denying categories marginally hopeless cases. judiciary, unclear resolved.24 143 imaginable theory manifest drives wedge happiness, other.25 theology speculative philosophy, Meyer, 401-402, 627-628, radically foundation government. nowhere strict adherence branch. 781-782, 2189-2190 V 144 predicament healthy adds judge. Each minimizing filled predominantly vitality completion controlled heart—not "preservation 145 concrete reminder disappear However commendable purposes. Lives abstraction persons, desecrate aiding struggling health. endeavor, unfortunately, opportunities: 146 adopting findings, ". [H]er respiration circulation thirty-year-old female; stimuli; massive enlargement ventricles cerebrospinal [her] ongoing; (4) exhibited grimacing stimuli, indicating sound; (5) spastic quadriplegic; (6) extremities contracted muscular tendon extremities; (7) recover needs. dead. ill. experts testified years." (Mo.1988) banc) (quotations omitted; footnote observing statute: "For occurrence accordance usual customary practice, occurred met: "(1) maintained, spontaneous circulation; "(2) stem licensed physician." 194.005 (1986). Since fit proviso statute. Dr. Fred Plum, creator term state" renowned expert "vegetative terms: 'Vegetative describes internal controls. maintains temperature. beat pulmonary ventilation. digestive activity. reflex muscles nerves conditioned responses. behavioral self-awareness learned manner.' 403, Association Amici consciousness"). Karnezis, Patient's Right Refuse Allegedly Necessary Sustain A.L.R.3d Cantor, Decision Decline Life-Saving Treatment: Bodily Integrity Versus Preservation Rutgers 228, (1973) (noting paucity cases). Uniform Act: Little, Late?, Ark.L.Rev. 324, 415-423 trilogy stressed analytic elderly, shortened expectancies, alternative Farrell, 335, 404 (1987) (37-year-old overrode competing (65-year-old tube—under test, hearsay constituted withdrawn); (31-year-old tube—even patient). Drabick drew earlier, influential Courts Appeal. Bouvia 179 1127, 225 297 (competent 28-year-old quadriplegic inserted will); Bartling 220 (1984) 70-year-old, respirator); 484 (1983) (physicians prosecuted account intravenous state). Besides Bouvia, Barber, District Gray 697 580 (RI 1988); 947 Grant, 545, Corbett D'Alessandro, So.2d (Fla.App.1986). held. 2846, Smith, All's Well Ends Well: Toward Policy Assisted Rational Merely Enlightened Self-Determination?, U.C.D.L.Rev. 290-291, (compiling statutes). litigation commenced, beginning. disputes institutions, litigation. below, [in case] finds 'best discontinued,' 'feeling appeal attorneys impression Missouri.' 410, brief urging reversal intended acted bit proceeding. illustrate obtain instances Price Waterhouse Hopkins, 490 253, 1775, 1792, 268 institutional defending "[W]e defendant plaintiff" proof—"suggesting shield sword." 1792. variously "proof persuade trier firm settled presented," 531, (O'Connor), "produces belief conviction truth established, clear, weighty enable factfinder] conviction, hesitancy, issue." 407-408, (quotation arguably stronger respectively, threshold. 526-534, 889-894, 610-615; 442-443, faced adumbrate differently Cleburne 473 3249, 3254, "essentially situated alike." differences else warranted rigorous class class. 241-242 (36% ever decisions; 23% writing) (Lou Harris Poll, September 1982); Surveys Physician Public Issues 29-30 (56% told coma; 15% specifying wishes). Columbia proxies Alaska Stat.Ann. 13.26.335, 13.26.344(l ) (Supp.1989); Cal.Civ.Code 2500 (West Supp.1990); D.C.Code 21-2205 Idaho 39-4505 Ill.Rev.Stat., ch. 1101/2, &Par; 804-1 804-12 (Supp.1988); Kan.Stat.Ann. 58-625 Me.Rev.Stat.Ann., Tit. 18-A, 5-501 Nev.Rev.Stat. 449.800 Rev.Code 1337.11 Ore.Rev.Stat. 127.510 Pa.Con.Stat.Ann., 5603(h) (Purdon Supp.1989); R.I.Gen.Laws 23-4.10-1 Tex.Rev.Civ.Stat.Ann., Art. 4590h-1 (Vernon Vt.Stat.Ann., 14, 3451 statutes. Ala.Code 26-1-2 13.26.350 13.26.356 Ariz.Rev.Stat.Ann. 14-5501 Ark.Code 28-68-201 28-68-203 2400 Colo.Rev.Stat. 15-14-501 Conn.Gen.Stat. 45-69o Del.Code Ann., 12, 4901-4905 21-2081 Fla.Stat. 709.08 Ga.Code 10-6-36 Haw.Rev.Stat. 551D-1 551D-7 15-5-501 ¶ 802-6 Ind.Code 30-2-11-1 30-2-11-7 (1988); Iowa 633.705 58-610 (1983); Ky.Rev.Stat.Ann. 386.093 (Baldwin 1983); La.Civ.Code 3027 (1974) General, (Oct. 17, 1988)); Mass.Gen.Laws 201B, Mich.Comp.Laws 700.495, 700.497 (1979); Minn.Stat. 523.01 Miss.Code 87-3-13 404.700 (Supp.1990); Mont.Code 72-5-501 72-5-502 Neb.Rev.Stat. 30-2664 30-2672, 30-2667 (1985); 111.460 N.H.Rev.Stat.Ann. 506:6 N.J.Stat.Ann. 46:2B-8 1989); N.M.Stat.Ann. 45-5-501 N.Y.Gen.Oblig.Law 5-1602 (McKinney N.C.Gen.Stat. 32A-1 N.D.Cent.Code 30.1-30-01 30.1-30-05 1337.09 Okla.Stat., 58, 1071-1077 127.005 5601 seq., 5602(a)(9) 34-22-6.1 S.C.Code 62-5-501 62-5-502 S.D.Codified Laws 59-7-2.1 (1978); Tenn.Code 34-6-101 Tex.Prob.Code 36A Utah 75-5-501 3051 Va.Code 11-9.1 Wash.Rev.Code 11.94.020 W.Va.Code 39-4-1 Wis.Stat. 243.07 (1987-1988) Wis.Op.Atty.Gen. 35-88 (1988)); Wyo.Stat. 3-5-101 Thirteen proxies. 20-17-202 16, 2502 765.05(2) 39-4504 16-8-11-14(g)(2) 144A.7(1)(a) La.R.S.Ann., 40:1299.58.1, 40:1299.58.3(C) 145B.01 Tex.Health Safety 672.003(d) 75-2-1105, 75-2-1106 54.1-2986(2) 1987 Wash.Laws, 162, Sec. (1)(b); 35-22-102 Rasmussen Fleming, 154 Ariz. 207, 211, 741 674, 678 reflexively sounds, movements, anybody anything. awake unaware. State: Reality, Ctr.Rep. 28, Deciding Forego 17-18 (hereafter Commission). Lipton, Do-Not-Resuscitate Community Hospital: Incidence, Implications Outcomes, 256 1164, 1168 Canterbury Spence, 150 263, 271, 464 1064 root premise" concept, jurisprudence, '[e]very body' ") (1914) (Cardozo, J.)). 241, 1047, dissenting) ("There [psychotropic] deserving protection"). exceptions dependent (citing parents); Winthrop University Hess, Misc.2d 804, 996 (Sup.Ct. Nassau Cty. 1985) (court transfusion objector infant signing itself); 88, 1008 (blood infant); Brooks, 361, 205 441-442 (1965) lower erred ordering woman—whose grown—and concluding: "Even appellant's unwise, foolish ridiculous, overriding therewith conservatorship waning compelling principles, consequences"). appears 423. Delio 19, 516 677, 689 ("[R]eview jurisdictions single evaluated procedures"). cells oxygen, hemispheres destroyed Cranford Critical Distinctions Between Brain Death Ethics Sci. Med. 203 266. Out 100,000 who, fallen persistive brain, partial documented literature. 11-12. longest recovered months. Snyder, Rubens, Bundlie, Rockswold, Delayed Postanoxic Annals Neurol. bases neurological conclusions: "First, clinical indication suffering. "Second, studied date, post-mortem examination bilateral incompatible "Third, data utilizing positron emission tomography indicates metabolic rate glucose cortex reduced consciousness." totally disabled. limbs contracted; fingernails cut wrists. A93. incontinent bowel bladder. aspects exposed strangers. information 1988 poll requested Times, 5, 1988, col. News, 3, 1). Colorado Graduate 85% Coloradoan, Sept. 29, attitudes translated action. 1976, Acts, Die, 8; Weiner, Privacy, Patients, Cardozo 720 290, 26-27, 361-362, (1905) fines imprisonment vaccinated "of necessity" fight epidemic). Were places party. correct discomfort, kidneys recipient saved renal poisoning. pain. shorten expectancy. Family 506 Kunz 1982). Patches skin grafts burn victims, scrapings bone marrow Perhaps lawfully organs transplanting cured ailments, experiments tube? brave world submit, reviewed profession, life—and that: implicated." 419. Court—a comprehensive "unqualified" 420, 424—is enactments. place, procure insurance program underwrite (Blackmar, admitted, "allows encourages pre-planned Ibid.; 459.015.1 nonterminal include declined. Nonetheless, participation. 428 implication statute's limitations inclusion "interpretive" provisions Act. consistently following: "Each profession." 459.055(1) subsections Act's cumulative decrease 459.055(2). subsection intention executed procedures" created. 459.055(3). conceivable overcome modest Capital Cities Cable, Crisp, 467 691, 2694, 2708-2709, scope professed goal). Mexico, 2433, 247 divert accommodate society's stabile efficient resources); 296, 492, 937 (promoting federalism conduct behest another); Maxwell Land-Grant Case, 949 (1887) unequivocal, aside, annul, patent title issued rights); Marcum Zaring, 970 (Okla.1965) stability marriage invalidity); Stevenson Stein, Pa. (1963) possession). "status question. quo" protests guardian. (and decision). predictable, accidental confluence psyche, inertia. citizenry creation wards tended populace preeminence patients." Rhoden, Litigating Death, Harv.L.Rev. 375, 433-434 view. deteriorated fluid, A94, transplant. 22, Athena Comer, long-time friend, co-worker, months, A94. Ms. Comer together, Comer's suddenly died night. night, grandmother months before. testified: state] couldn't even, know, half way, yourself, did, didn't talked lot." 388-389. "several times" wouldn't going live, bed move can't yourself." 396. "[S]he [all the] usually not." 399. took "very serious" hour interruption. 390. "unreliable" informally reaction conditions. explain rejected. Christy, close, day niece stillborn (but damaged lived), maybe "greater plan" baby 537. month later, battle problems, [by] [treatment], 541. mother, Christy horrified in." 535. "want [her family]." 544. Based lifetime [I wishes] nutrition." 542. now. [I]f trying mother." 526. instructions. Emmanuel Emmanuel, Directive: Comprehensive Advance Document, 3288 (only 9% handled incompetent); wills); (23% writing). besides Mrs. times daughters 13, strokes, O'Connor extent. competent, Again, had, (although them). exceedingly rare trusted endeavor Fadiman, Liberation Lolly Gronky, Magazine, 1986, ethicist Joseph Fletcher). stated Independence truths self-evident, equal, Creator Rights, Liberty Happiness. Governments Men, deriving governed,—That whenever Form destructive ends, abolish institute Government, laying organizing Happiness." evidence": "1. essentially old female signs BP 130/80; pulse regular; per minute. "2. "3. degenerated. ongoing. "4. sound. "5. quadriplegic. "6. contractures extremities. "7. needs." Respondent's employer, financial resources Social Security inconsiderable exhausted 1986." A96. protection, witnesses actions objections breached authorizes." A98. "Nancy's unresponsive Ruler forcefully feed fueling circulatory pain." A97. "There liberty,' physicians overall worsening contractures. euthanasia mercy killing, definition, arbitrarily exceptions, Ward's depriving "Appellant advises court: 'we [trial] felt discontinued. ourselves appealing basically with.' "Four identified: profession. Section 459.055(1), RSMo 1986; Brophy, 634. precious worthy quality." tempting equate convenient focus justifying distinction; we. handicaps unqualified." 420. "As stated, 422. thinly veiled living. diminished "Given proceeds immense, ("[W]e individual"); (stating "its interests" life). 284. "Until medicine offer vast hospital." et. 6. 1985, 83% [of] home. Sager, Easterling, al., Changes Location Passage Medicare's Prospective Payment System: National Study, Eng.J.Med. 433, (1989)." Research: "Just seen alterations changed. recorded (of causes) 'Everyone hand; unfamiliar queer phenomenon. lot today. "deathbed" real assemble call priest.' admitted institution, discharged families. system helpful, alcohol opiates (the suffering) prescription. Institutional reserved poor support; saving patients' souls increasingly settings. 1949, institutions sites 50% deaths; 1958, figure 61%; 1977, 70%. homes. change professionals marshall scientific effectively. setting alienating unsupportive." omitted), quoting Thomas, Failure, Am.Acad.Pol. Soc.Sci. domain 481, 1679, 152-153, 726-727, 2178, recognizes beginning" commenced," draws insight. problem, agreement "truly adversarial" debated discontinued; courts. 51, 788, 300 guardian's decision), Hamlin, 810, 818-819, 1372, 1377-1378 unnecessary). 341, ("At disclosed average disconnected weekly Minnesota"). tend, 269, "No philosophies religions venerated soul endures perished. Surely antithetical tradition. Johnston, Hale 1776: Biography Memorials 128-129 (1914); Axelrad, Henry: Voice Freedom 110-111 (1947). Lincoln, Gettysburg Address, Documents History (H. Commager ed.) (9th 1973). connection: "When prolongation, existence. 433-434, 635 distinguishable inquiry. Eichner, 465, 543 (A health, sense, protect"), modified observer suggests, "few goal medicine, sadly unforeseen aspirations, cease." Kass, Natural Science controversial. tend Blackmar, dissent contended Kass. comments (specifically, well-being) promoted. 181-182 biography: Boswell's Johnson Beveridge's Marshall. reader book titled surprised contained compilation data. (authorizing obtained); (authorizing, sustained); 1988) state); (Me.1987) (allowing nonelderly (permitting Bludworth, 452 921 (Fla.1984) systems); L.H.R., 253 716 1372 concur; resolved court); 738 (1983), grounds, court-appointed respirator), (1981); (1976); (Fla.App.1986) 218, 861 ("Life 'necessary' section 2355 conservatee faith") (footnote omitted); 677 33-year-old 809 (Del.Ch.1980) "virtual state"). patients. withheld patient); Los Angeles highly pain). respected relevant. accordingly forceful, correspondingly complicated. wrote: dictates policy, representatives. Broad assemblies. gathering synthesizing unavailable courts; invoke ethics, morality, Assuming appropriate, demands provide." anticipated "duty humanity," Mass., 635. Accord, F.Supp., 588. Campbell Florida Second District: began deliberations drafted Independence, solemnity gratefulness 'that Life.' hearts, souls, minds, reached conclusions. lightly relinquished. recognize, 'Pursuit Happiness.' When, technologies has, beyond control, body's functions, itself, measures." So.2d, 371.

Classification Label: 4