Cruzan Ex Rel. Cruzan v. Director, Missouri Department of Health
111 L. Ed. 2d 224, 1990 U.S. LEXIS 3301, 497 U.S. 261 (1990)
Premium Feature
Subscribe to Lexplug to listen to the Case Podcast.
Rule of Law:
A state may, consistent with the Due Process Clause of the Fourteenth Amendment, require a heightened evidentiary standard of clear and convincing evidence of an incompetent person's wishes as to the withdrawal of life-sustaining treatment.
Facts:
- In 1983, Nancy Beth Cruzan was in a car accident which left her in a persistent vegetative state.
- Cruzan's brain was deprived of oxygen for an estimated 12 to 14 minutes, causing irreversible brain damage.
- She was unable to swallow, and surgeons implanted a gastrostomy tube to provide her with nutrition and hydration.
- Medical experts testified that Cruzan had no chance of regaining her cognitive functions but could live for up to thirty more years.
- After it became clear she would not recover, Cruzan's parents, Lester and Joyce Cruzan, asked hospital employees to terminate the artificial nutrition and hydration.
- Hospital employees refused to terminate the treatment without a court order.
- Before her accident, Cruzan had told a housemate that she would not want to live as a 'vegetable' or if she could not live at least 'halfway normally'.
Procedural Posture:
- Lester and Joyce Cruzan, as co-guardians for their daughter Nancy, sought authorization from a Missouri state trial court to terminate her artificial nutrition and hydration.
- The trial court found that Nancy Cruzan had a fundamental right to refuse 'death prolonging procedures' and granted the authorization.
- The state-appointed guardian ad litem and the State of Missouri appealed the trial court's decision to the Supreme Court of Missouri.
- The Supreme Court of Missouri reversed the trial court's decision in a divided vote, holding that there was not clear and convincing evidence of Nancy's intent to have life-sustaining treatment withdrawn.
- The Cruzans petitioned the United States Supreme Court for a writ of certiorari, which was granted.
Premium Content
Subscribe to Lexplug to view the complete brief
You're viewing a preview with Rule of Law, Facts, and Procedural Posture
Issue:
Does the Due Process Clause of the Fourteenth Amendment permit a state to require clear and convincing evidence of an incompetent person's wishes before allowing the termination of life-sustaining nutrition and hydration?
Opinions:
Majority - Chief Justice Rehnquist
Yes. A state may constitutionally require that evidence of an incompetent person's wishes as to the withdrawal of life-sustaining treatment be proven by clear and convincing evidence. While a competent person has a constitutionally protected liberty interest in refusing unwanted medical treatment, an incompetent person is unable to make such a choice. A state has a legitimate interest in the protection and preservation of human life and may safeguard an individual's personal choice between life and death by imposing heightened evidentiary requirements. Missouri's 'clear and convincing' standard is a permissible procedural safeguard that serves the state's interest in protecting against potential abuses and ensuring that any decision to terminate life reflects the patient's true wishes. An erroneous decision to terminate life support is irreversible, so a state may permissibly place the risk of an erroneous decision on those seeking to withdraw treatment.
Concurring - Justice O'Connor
Yes. The constitutionally protected liberty interest in refusing unwanted medical treatment encompasses the refusal of artificially delivered food and water, as these procedures involve bodily intrusion and restraint. However, the Court's decision correctly holds that a state may require a clear and convincing evidence standard. This decision does not decide whether a state must also give effect to the decisions of a surrogate decisionmaker, which may well be a constitutionally required means of protecting a patient's liberty interest, especially since few people provide explicit instructions.
Concurring - Justice Scalia
Yes. The federal courts have no business in this field, as the Constitution is silent on the matter of a 'right to die.' The power to prevent suicide has always been within the authority of the states. It is up to the citizens of each state, through their elected representatives, to decide whether a patient's wish to have life-sustaining treatment withdrawn will be honored, not federal judges.
Dissenting - Justice Brennan
No. Nancy Cruzan has a fundamental right to be free of unwanted artificial nutrition and hydration, which is not outweighed by any state interest. Missouri's procedural rule, which requires clear and convincing evidence and excludes relevant testimony from family and friends, impermissibly burdens that fundamental right. The state's only legitimate interest is in accurately determining the patient's wishes, but Missouri's rule is improperly biased toward continuing treatment and skews the accuracy of the fact-finding process. An erroneous decision to continue treatment is just as irreversible from the patient's perspective, as it robs them of their dignity and perpetuates a degraded existence.
Dissenting - Justice Stevens
No. The Constitution requires the State to care for Nancy Cruzan's life in a way that respects her own best interests, which are not served by continuing treatment. Missouri's policy improperly defines life as mere biological persistence, abstracted from the interests of the living person. The state’s abstract interest in preserving life cannot be used to subordinate Nancy Cruzan’s body, her family, and the lasting significance of her life. The decision should be controlled by those with her best interests at heart, not a state legislature imposing a uniform policy.
Analysis:
This was the first 'right to die' case decided by the Supreme Court, and it established a critical precedent regarding state authority over end-of-life decisions. The Court recognized a liberty interest in refusing medical treatment but held that this right is not absolute and can be regulated by the states. By upholding Missouri's 'clear and convincing' evidence standard, the decision granted states significant leeway to create high procedural barriers to the withdrawal of life-sustaining treatment for incompetent patients. This ruling spurred widespread public debate and led to federal legislation like the Patient Self-Determination Act of 1990, which encouraged the use of advance directives such as living wills and durable powers of attorney for health care.
Unlock the full brief for Cruzan Ex Rel. Cruzan v. Director, Missouri Department of Health