Five-minute digest
Cruzan v. Director, Missouri Department of Health
Summary
On the night of 11 January 1983 Nancy Beth Cruzan, a young Missouri woman, lost control of her car on a county road in Jasper County. Paramedics restored her breathing and heartbeat, but she never regained consciousness, and the trial court later found her to be in a persistent vegetative state, kept alive by a surgically implanted feeding tube in a state hospital. When it became clear she would not recover, her parents and coguardians, Lester and Joyce Cruzan, asked hospital staff to end the artificial nutrition and hydration. A state trial court authorized the withdrawal on the strength of remarks Nancy had made to a housemate. The Supreme Court of Missouri reversed by a divided vote, holding that the state's interest in life required clear and convincing evidence of the patient's own wishes, which it found lacking. The question for the Court was whether the Constitution required Missouri to permit the withdrawal. The Cruzans' counsel, William Colby, argued that every person has a liberty interest in refusing unwanted medical treatment, that the interest does not vanish when a person becomes incompetent, and that loving parents should be allowed to exercise it on her behalf. Missouri answered that it may protect human life, guard against mistakes and abuse in decisions no one can undo, and insist on reliable proof of what the patient herself wanted. On 25 June 1990 the Court affirmed, five to four. Chief Justice Rehnquist surveyed the state-court decisions since In re Quinlan (1976), assumed that a competent person would have a constitutionally protected right to refuse lifesaving nutrition and hydration, and held that Missouri could nonetheless require clear and convincing evidence before a surrogate acted for an incompetent patient. Because the decision was irreversible, he wrote, the state could place the risk of error on those seeking withdrawal, and the Due Process Clause did not oblige it to accept the substituted judgment of family members, however devoted. Justice O'Connor concurred, stressing that artificial feeding is medical treatment and that the Court had not decided whether states must honor a duly appointed surrogate. Justice Scalia also concurred separately, arguing that the Constitution leaves such questions to the states; his opinion is not part of the library text. Justice Brennan, joined by Justices Marshall and Blackmun, dissented on the ground that the right to refuse treatment is fundamental and that Missouri's rule unduly burdened it. Justice Stevens, dissenting alone, argued that the state's abstract interest in life should not override Nancy Cruzan's own best interests as found by the trial court. The library text gives the Chief Justice's opinion, O'Connor's concurrence and portions of both dissents, with the official notes removed. Later in 1990 the family presented new testimony from former co-workers about Nancy's wishes; the state withdrew from the case, a Jasper County judge authorized the withdrawal in December, and Nancy Cruzan died on 26 December 1990. Congress passed the Patient Self-Determination Act that year.
Top Lessons
The right to refuse treatment
The Chief Justice traced a line from the old rule against unconsented touching to the modern doctrine of informed consent, and from there to a right to decline treatment. The Court was willing to assume that a competent adult holds such a right under the Constitution, while leaving its exact scope undefined.
Who speaks for a person who cannot?
Nancy Cruzan could not tell anyone what she wanted. The majority held that Missouri could insist on clear proof of her own earlier wishes rather than accept her family's judgment; the dissenters answered that her best interests and the testimony of those who knew her should count.
The interest in life
Missouri claimed an interest in preserving life as such, apart from any judgment about its quality. The majority accepted that interest; Brennan and Stevens argued that a state has no interest in a person's life abstracted from the person. The opinions bring a long moral debate into the language of constitutional law.
Leaving questions to the states
O'Connor emphasized that the decision left states free to develop their own approaches, including recognizing appointed surrogates. In the years that followed, states and Congress expanded the use of written directives and health-care proxies, partly in response to the case.
Verified Quotes
Frequently cited
“The choice between life and death is a deeply personal decision of obvious and overwhelming finality.”
“But we do not think the Due Process Clause requires the State to repose judgment on these matters with anyone but the patient herself.”
“Because our notions of liberty are inextricably entwined with our idea of physical freedom and self-determination, the Court has often deemed state incursions into the body repugnant to the interests protected by the Due Process Clause.”
“But the State has no legitimate general interest in someone's life, completely abstracted from the interest of the person living that life, that could outweigh the person's choice to avoid medical treatment.”
“In my view, the Constitution requires the State to care for Nancy Cruzan's life in a way that gives appropriate respect to her own best interests.”
“Because death is so profoundly personal, public reflection upon it is unusual.”
Medical Lens
The first Supreme Court case on withdrawing life-sustaining treatment, Cruzan connects the history of informed consent to the modern clinical setting of the persistent vegetative state, records the medical profession's view that artificial feeding is a form of treatment, and helped bring advance directives and health-care proxies into ordinary practice.
- Opinion of the Court, paragraph beginning The logical corollary of the doctrine of informed consent
Traces how the right to refuse treatment grew out of informed consent and how Quinlan in 1976 began the line of state end-of-life decisions.
- Concurrence of Justice O'Connor, paragraph beginning The State's artificial provision of nutrition and hydration
Relies on statements of the American Medical Association and the Hastings Center to treat artificial feeding as medical treatment rather than ordinary care.
- Dissent of Justice Brennan, section A, paragraph opening with a quotation on the timing of death
Cites a federal technology-assessment report on how often deaths in hospitals and long-term care follow a decision to forgo treatment.