Cruzan v. Director, Missouri Department of Health

Cruzan v. Director, Missouri Department of Health, 497 U.S. 261 (1990), argued 6 Dec. 1989, decided 25 June 1990 by vote of 5 to 4; Rehnquist for the Court, Brennan, joined by Marshall, Blackmun, and Stevens, in dissent. In June 1990, the U.S. Supreme Court issued its first pronouncement concerning the constitutional interests of dying medical patients. The case dealt with the fate of Nancy Cruzan, a woman mired in a permanently unconscious state in the wake of an automobile accident in which she sustained severe brain injuries. Her parents sought judicial authorization to act on their daughter's behalf to end the artificial nutrition maintaining Nancy's existence. Nancy had previously made informal oral declarations indicating she would not have wished to be maintained in a permanently vegetative state. The Missouri Supreme Court had ruled, however, that there was inadequate evidence to establish the now‐incompetent patient's preferences. In the absence of “clear and convincing” evidence of the patient's will, the Missouri court refused to permit a guardian's determination to withdraw life‐preserving medical treatment. The parents appealed to the U.S. Supreme Court, contending that Nancy's constitutional right to reject unwanted medical treatment had been violated.

By a 5‐to‐4 margin, the Supreme Court rejected this challenge. Chief Justice William Rehnquist's majority opinion ruled both that a state may confine terminal decisions on behalf of incompetent patients to instances when the patient has previously expressed such a preference and that the state may demand clear evidence of the patient's wishes. These precautions were reasonable, the majority declared, in order to safeguard against potential abuses. Missouri could legitimately be concerned about subjective, “quality of life” decisions being made on behalf of incompetent patients. The Court was dubious that family members—in the absence of clear prior expressions—would make precisely the decision the patient would want.

Although the Supreme Court rejected the constitutional challenge, the Cruzan decision contained some encouragement for the advancement of patient rights to shape medical intervention in natural dying processes. The majority was willing to assume that a competent patient has a constitutionally based liberty or right to reject life‐preserving medical treatment. Moreover, the Court did not draw any distinction between artificial nutrition and other forms of medical technology. Likewise, no distinction was drawn between a patient facing unavoidable, imminent death and one whose life might be preserved for years. Finally, the Court appears to have endorsed giving full recognition to a patient's prior expressions even after the patient has lost competence. This increases the incentive for people to make advance directives governing their medical care in the event of later incompetence.

In 1997, the Supreme Court gave further consideration to the relevance of the Constitution to end‐of‐life decision making. In Washington v. Glucksberg (1997), Chief Justice Rehnquist acknowledged what had been implied in Cruzan—that competent persons have a constitutional right to reject life‐sustaining medical intervention. At the same time, the Court rejected a constitutional claim that a suffering, dying person has a broader right to control the manner and timing of death (by securing assistance in committing suicide).

The Cruzan decision did nothing to disrupt the policies regarding incompetent medical patients that prevail in most states. Most states allow guardians to make medical decisions—including rejection of life‐preserving intervention—on behalf of incompetent patients even without clear prior expressions. Some states authorize a “substituted judgment” standard, which allows consideration of informal patient declarations as well as other indices of the patient's preferences. Some states allow guardians to secure withdrawal of life‐preserving care when such a decision promotes the “best interests” of the patient. A best interests determination includes consideration of a patient's previous informal declarations. Cruzan makes clear that nothing in the Constitution prevents states from continuing to use such standards.

Even though the Constitution permits surrogate decision makers to use a best interests formula to shape end‐of‐life care, several state courts (including those in New York, Wisconsin, and California) have confined surrogate removal of life support to instances where the incapacitated patient has previously indicated a wish to be allowed to die in the medical circumstances now at hand.

Bibliography

Norman L. Cantor , Twenty‐Five Years after Quinlan: A Review of the Jurisprudence of Death and Dying, Journal of Law, Medicine & Ethics 29 (2001): 182–196.

Norman L. Cantor