Cruzan v. Director, Missouri Department of Health 1990

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Cruzan v. Director, Missouri Department of Health 1990

Petitioner: Nancy Beth Cruzan, by her parents and co-guardians

Respondent: Director, Missouri Department of Health

Petitioner's Claim: That the state of Missouri had no legal authority to interfere with parents' wish to remove a life-sustaining feeding tube from their daughter's comatose body.

Chief Lawyer for Petitioner: William H. Colby

Chief Lawyer for Respondent: Robert L. Presson, Attorney General of Missouri

Justices for the Court: Anthony Kennedy, Sandra Day O'Connor, Chief Justice William H. Rehnquist, Antonin Scalia, Byron R. White

Justices Dissenting: Harry A. Blackmun, William J. Brennan, Jr., Thurgood Marshall, John Paul Stevens

Date of Decision: June 25, 1990

Decision: Ruled in favor of Missouri by determining the state did not violate the Fourteenth Amendment guarantee of liberties of the comatose patient.

Significance: The case marked the first time the U.S. Supreme Court ruled in a right-to-die case. The Court ruled that rejection of life preserving medical treatment by a competent person is a liberty protected by the Constitution.

Right-to-die is a general term referring to a patient's right to die by natural causes when refusing life sustaining treatment. The refusal can be made by a competent (able to make decisions on their own) patient realizing that their decision may mean death.

Even before the birth of America, right-to-die had been considered a liberty in English common law (legal based on practices rather than laws). As under the U.S. Constitution, such liberties are fundamental freedoms in which a person may participate relatively free from government interference.

Right-to-die is quite different from assisted suicide which was prominent in news in the 1990s. Assisted suicide is when a doctor helps individuals to take their own lives. The patient dies not by natural causes, but by human action.

The first case involving right-to-die that come to the nation's attention was that of Karen Ann Quinlan in 1975. The case involved a young woman in a permanent vegetative state and her family's legal battle to remove life support from her. The case was decided in the New Jersey Supreme Court with a ruling to honor the family's wishes. Not until 1983 did a right-to-die case reach the U.S. Supreme Court.

An Accident on an Icy Missouri Road

Twenty-five year old Nancy Beth Cruzan, driving on an icy Missouri road in January of 1983, lost control of her car. The accident left Cruzan brain damaged and in what doctors described as a "permanent vegetative state." She could not move, speak, or communicate, and showed no indication of thinking abilities, but was able to breath on her own. About a month after the accident a feeding tube was inserted into her stomach through which she received all her nutrition and fluids (food and water). Doctors estimated with this life support she could be kept alive another thirty years.

Clear and Convincing Evidence

By 1988, Lester and Joyce Cruzan had lost all hope that their daughter could ever emerge from her vegetative state. They asked the Missouri state hospital to remove the feeding tube. Hospital officials refused, so the parents sought a court order to have the tube removed. The trial court ordered removal of the tube by finding that a person in Nancy's condition had a right to direct the removal of her life supporting feeding tube.

At issue with this decision was that Nancy could not actually relate her wishes. Before the accident as a healthy active, competent young woman, Nancy had neither made a living will nor appointed anyone to make health care decisions for her if she ever became incompetent (unable to make decisions on her own). However, she had apparently once remarked that she would not want to live in a "vegetative state." Similarly, she stated "that if she couldn't do things for herself 'even halfway, let alone not at all,' she wouldn't want to live that way." The trial court had decided these statements indicated Nancy would not desire to be kept in her vegetative condition and that her parent's wishes to remove the feeding tube should be honored.

The state of Missouri appealed to the Missouri Supreme Court which reversed (changed) the lower court's ruling. A majority of members of the Missouri Supreme Court believed Nancy's remarks about her future care were general and made in a casual way. For a parent or guardian to make a decision for an incompetent patient to remove life support, under Missouri law, the patient must have left "clear and convincing . . . reliable evidence" of her wishes. The court concluded that such evidence was not available from Nancy.

The Cruzans appealed to the U.S. Supreme Court which agreed to hear the case.

The Arguments

Lawyers for the Cruzan family argued before the Supreme Court that "forced . . . medical treatment, and even . . . artificially-delivered food and water [as in the case of Nancy's feeding tube]" would be a violation of a competent person's liberty. Likewise, "an incompetent person should possess the same right in this respect as is possessed by a competent person." A "substituted judgement" of close family members must be accepted, they argued, even if no proof existed that their views reflected the views of the patient. The lawyers contended that Missouri's refusal to allow the parents to direct the removal of their incompetent daughter's feeding tube was in violation of Nancy's constitutional liberty.

The state of Missouri argued that in the interest of protecting an individual's liberty to have their wishes carried out, the State requires that "clear and convincing evidence" be available and that this "rule of decision" is not prohibited by the U.S. Constitution.

U.S. Supreme Court's First Right-to-Die Ruling

In a 5-4 ruling, Chief Justice Rehnquist wrote the opinion for the majority. Rehnquist first affirmed (supported) that "the right of a competent individual to refuse medical treatment" (the right-to-die) is a "constitutionally protected liberty interest" under the Fourteenth Amendment. [The] Fourteenth Amendment provides that no State shall "deprive any person of life, liberty, or property, without due process of law." The Court clearly agreed that to deny a person the right to refuse medical treatment resulting in prolonged misery would deprive the person of their constitutional liberty.

Rehnquist described the problem before the Court, "In this Court, the question is simply and starkly whether the United States Constitution prohibits Missouri from choosing the rule of decision [using the clear evidence rule]" in such instances. Rehnquist recognized that Missouri honestly sought to safeguard against potential abuses in such situations where persons are incompetent. The state worries that family members would not always make the decision that the incompetent person might make if they were competent. Rehnquist asked, "Does Missouri have the right to put state interests to protect life above all else when the choice between life and death is a deeply personal decision of obvious and overwhelming finality [the final ending]?"

The Supreme Court, agreeing with the Missouri Supreme Court, ruled that Missouri's law requiring clear evidence of a person's wishes for the removal of life-saving treatment was, in fact, not prohibited by the Constitution's Fourteenth Amendment. Lacking such clear wishes, the state had an honest interest in preserving human life at all costs.

Four Justices Disagree with the Majority

Justice William J. Brennan, Jr., wrote for the dissenting justices,

Dying is personal . . . For many, the thought of an ignoble end [not noble] steeped in decay, is abhorrent [horrible] . . . , no state interests could outweigh the rights of an individual in Nancy Cruzan's position. Whatever a state's possible interest in mandating [requiring] life-support treatment under other circumstances, there is no good to be obtained here by Missouri's insistence that Nancy Cruzan remain on life-support systems if it is indeed her wish not to do so.

Further Explanation

Justice Sandra Day O'Connor, agreeing with the majority, expanded the meaning of the ruling. She pointed out that the Court considered both the advanced medical technology and simple food and water as the same. A person could refuse not only the complex treatment but the simple sustaining efforts. She wrote of the "difficult and sensitive" nature of right-to-die issues emphasizing that in this ruling the Court had only ruled that one state's, Missouri's, law did not violate the Constitution. However, O'Connor suggested the best place to develop "appropriate procedures for safeguarding incompetent's liberty interests is entrusted to the 'laboratory' of the states."


I n the 1990s the hottest topic involving death and dying was physician-assisted suicide. U.S. Supreme Court decisions of the 1980s and 1990s showed an inclination to give states broad decision-making power to develop laws to aid a person to die with dignity. Oregon became the first state in the United States to approve an assisted-suicide law. Oregon's Death With Dignity Act legalized physician-assisted suicide took effect October 27, 1997.

The law, carefully developed with many safeguards such as psychological evaluation and a fifteen-day waiting period, allowed terminally-ill state residents to receive from a doctor a prescription for lethal drugs which the patient would use to end his life. Opponents feared that terminally-ill patients, guilt-ridden over expensive medical care, would rush to use the option. After the first year, only twenty-three patients had received prescriptions for lethal drugs. Fifteen of those actually used the drugs and died. None of the fifteen had expressed concern about medical financial problems. Instead, patients were most concerned about loss of personal autonomy (self-control ) and control over the manner in which they died.

Ironically, the law has prompted improvements in health care. Hoping to avoid requests for assisted suicide, Oregon doctors showed increasing interest in relieving patient's suffering by offering seminars on improving care for the terminally ill. Also, although Oregon was already a leader in hospice care (care for the terminally ill), this type of care further expanded.


Although the Court's ruling went against the Cruzans' wishes because of Nancy's incompetency, it nevertheless did much to support patient's rights to influence medical decisions in their natural dying process. First, the Court affirmed as a constitutional right that a competent person may reject life-preserving medical treatment. Secondly, the Court ruled that a person could reject not only complex medical treatments but also food and water. Thirdly, the Court made it clear that the states are the most appropriate government bodies to best develop ways of protecting liberty interests of incompetent persons. The states could use either the "substituted judgement" of family or other means, such as clear evidence laws like Missouri.

Suggestions for further reading

Baird, Robert M., and Stuart E. Rosenbaum, eds. Euthanasia: The Moral Issues. Buffalo, NY: Prometheus Books, 1989.

Humphrey, Derek, and Mary Clement. Freedom to Die: People, Politics, and the Right-to-Die Movement. New York: St. Martin's Press, 1998.

McKhanna, Charles F. A Time to Die: The Place for Physician Assistance. New Haven: Yale University Press, 1999.