Cruzan v. Director, Missouri Department of Health (end-of-life, 1990)
Case Overview
Nancy Cruzan was injured in an automobile accident and suffered permanent brain damage, entering a persistent vegetative state with no realistic chance of recovery. Her parents requested that she be taken off artificial nutrition and hydration systems. When the hospital refused, they sued for court authorization to terminate treatment. A trial court granted relief, relying on testimony from Cruzan's former housemate that Nancy had expressed a wish not to be maintained artificially if injured too severely to live normally. The Missouri Supreme Court reversed, holding that the housemate's statements were unreliable for determining Nancy's intent and that Missouri's living will statute reflected a strong state policy favoring life preservation. The U.S. Supreme Court affirmed 5-4. Chief Justice William Rehnquist held that Missouri could require clear and convincing evidence of an incompetent's wishes regarding life-sustaining treatment. The state's legitimate interest in preserving life could only be overcome by substantial proof of the patient's own preferences, not family judgment alone. A formal living will would have provided the necessary proof.
Legal Issues
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The Facts
Nancy Cruzan suffered severe injuries in a car accident leaving her in a persistent vegetative state. Her parents sought court authorization to withdraw her feeding tube, but Missouri courts required clear and convincing evidence of her wishes. The case reached the Supreme Court to determine whether the Constitution protects the right to refuse life-sustaining treatment.
The Issue
• Does the Constitution protect a liberty interest in refusing unwanted medical treatment, including life-sustaining nutrition and hydration? • What standard of proof may a state require before allowing withdrawal of life support for an incompetent patient? • May a state impose procedural requirements such as clear and convincing evidence of the patient's wishes?
The Rules
No State shall deprive any person of life, liberty, or property, without due process of law.
A competent person has a constitutionally protected liberty interest under the Due Process Clause in refusing unwanted medical treatment, including artificially delivered food and water.
A state may require clear and convincing evidence of an incompetent patient's wishes before permitting withdrawal of life-sustaining treatment as a procedural safeguard.
The Application
Although the Court recognized that individuals possess a constitutionally protected liberty interest in refusing life-sustaining medical treatment, that right could not be exercised on Cruzan's behalf without reliable evidence of her own wishes, since she was incompetent and unable to communicate her preferences. Missouri's heightened evidentiary standard (requiring clear and convincing proof of her prior expressed wishes) served the state's legitimate interests in protecting vulnerable patients and preserving life by ensuring that surrogate decision-makers had substantial evidence of what the patient herself would have chosen. The Court found that this procedural safeguard did not violate the Constitution even though it made withdrawal of treatment more difficult, because states retain authority to set the standard of proof when incompetent patients' wishes must be inferred from past statements or conduct. Under this framework, Cruzan's parents could not authorize withdrawal based on their general sense of her values; they would need to demonstrate clear and convincing evidence that she had specifically expressed her wishes regarding artificial nutrition in a persistent vegetative state.
The Conclusion
**The Court held 5-4 that the Due Process Clause of the Fourteenth Amendment protects a liberty interest in refusing unwanted medical treatment.** However, the Court unanimously upheld Missouri's requirement of clear and convincing evidence of the patient's wishes before withdrawal of life support. The decision established that states may impose heightened procedural safeguards while recognizing the fundamental right to refuse treatment.
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