Cruzan v. Director, MDH, 497 US 261 (1990)

Answer

In a 5-4 decision, the US Supreme Court held that the State of Missouri had a right to establish its own statutes and policies regarding end-of-life decisions, and that its requirement of "clear and convincing" evidence of an incompetent person's wishes was not unconstitutional. The US Supreme Court affirmed the Missouri Supreme Court's decision denying Cruzan's parents permission to terminate her life.

Explanation

On January 11, 1983, Nancy Cruzan lost control of her car and rolled it on her way home from work. Cruzan was thrown from the wreck and landed face down in a ditch, where the highway patrol found her sometime later. When paramedics arrived, Cruzan was without respiration or pulse, but they decided to attempt resuscitation anyway. Although able to restart Cruzan's vital functions, her brain had been starved of oxygen for an estimated 12-14 minutes, leaving her in a persistent vegetative state. She was unable to communicate, unaware of her surroundings, and lacked executive cognitive function.

For the next two-and-a-half years, Cruzan moved from hospitals to rehabilitation facilities, but showed no improvement. She was eventually admitted to a state hospital in Mt. Vernon, MO, for long-term care. Cruzan's parents, acting as legal guardians, asked the hospital to remove her feeding tube, which provided nutrition and hydration, and allow her to die. But the hospital director and many nurses responsible for their daughter's care believed the family's choice was morally wrong and refused to withdraw support without a court order.

Cruzan's parents brought suit a Carthage, Missouri, probate court where Judge Charles Teel authorized the hospital to end treatment on the basis of a statement from a former roommate who claimed Nancy Cruzan said she wouldn't want to live if she were unable to function.

The State appealed Judge Teel's decision directly to the Missouri Supreme Court, where a divided panel of seven judges reversed the lower court order on the grounds that Cruzan's parent's lacked standing to make a life-ending decision for their comatose daughter. They also held that the roommate's testimony was insufficient evidence of Nancy Cruzan's wishes.

Under Missouri state law, a competent person could refuse treatment, but an incompetent person couldn't be deniedtreatment unless he or she had issued a medical directive under the State Living Will statute prior to becoming incompetent. The Missouri Supreme Court concluded the state had a strong interest in the preservation of life that couldn't be superseded by the family's substitute judgment, except in the face of "clear and convincing evidence" that they were acting according to the incompetent person's instructions.

The Cruzans appealed to the US Supreme Court, asking whether Missouri had a constitutional right to impose the "clear and convincing evidence" test and deny legal guardians the right to make life-ending medical decisions.

In a 5-4 decision divided along ideological lines, the Court held that nothing in the Constitution prevented Missouri from establishing statutes or policies using a "clear and convincing evidence" standard for end-of-life decisions. While the justices acknowledged a liberty interest to refuse treatment protected under the Fourteenth Amendment Due Process Clause, the right doesn't extend to an incompetent person. Further, the state was within its rights to "properly decline to make judgments about the "quality" of a particular individual's life, and simply assert an unqualified interest in the preservation of human life...."

Chief Justice Rehnquist stated, in the opinion of the Court:

"An erroneous decision not to terminate [life] results in a maintenance of the status quo, with at least the potential that a wrong decision will eventually be corrected or its impact mitigated by an event such as an advancement in medical science or the patient's unexpected death. However, an erroneous decision to withdraw such treatment is not susceptible of correction. Although Missouri's proof requirement may have frustrated the effectuation of Cruzan's not-fully-expressed desires, the Constitution does not require general rules to work flawlessly."

The Supreme Court affirmed the Missouri Supreme Court decision, allowing right-to-life laws to be determined by the states.

Epilogue

Two months after the Supreme Court decision was released, the Cruzans petitioned Probate Judge Teel for a rehearing to present new evidence. The State of Missouri was dropped from the suit, and declined to interfere with the lower court proceedings.

Three of Nancy Cruzan's former co-workers testified that she had expressed the same desire to them that she had to the roommate; the doctors in charge of Cruzan's medical treatment described her life as a "living hell"; and her court-appointed guardian agreed that allowing Cruzan to die was in the patient's best interest. Judge Teel ordered life support withdrawn.

Nancy Cruzan had become the center of a battle between right-to-life and pro-choice factions (as in abortion issues), and a crowd of them held vigil outside the hospital when Cruzan's feeding tube was removed on December 14, 1990. Cruzan died peacefully with her family at her side on December 26, 1990.

The Cruzan case successfully raised awareness for Living Wills and advance medical directives, which remain the most reliable means of ensuring a person's medical decisions are acted upon if he or she becomes unable to communicate.

For more information, see Related Questions, below.

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