Cruzan v. Director, Missouri Dept. of Health (1990)

At the time of the Cruzan case, about 10,000 Americans were living in a persistent, comatose state. No one was sure who, if anyone, had the authority to end these people's lives. Healthy older people became depressed by the possibility of living in such a condition during the last years of their lives. Under such circumstances, does a person have a personal, private right to choose when to end his or her life? Does this right override any compelling State interest in the prevention of suicide?

Twenty-five year-old Nancy Cruzan was in an automobile accident in 1983. Massive injuries resulted in her falling into an unconscious state, unresponsive to outside stimulation. She was placed on life-support equipment and was fed intravenously. After emerging from a three-week long coma, Nancy remained in a “persistent vegetative state,“ a condition in which an unconscious person displays motor reflexes but exhibits no indications of significant cognitive function. Although doctors felt that she could endure many more years in her present condition-that is, with her life functions carried out by machine support-her own doctor said she had no chance of recovery.

Five years after the accident and facing a hopeless prognosis, Nancy's parents asked that their daughter's feeding tubes be disconnected. By then, most of the annual cost for her hospitalization was being paid by the State of Missouri. The catastrophic cost of Nancy's care had exhausted the family's resources.

A Missouri district court granted the request of the Cruzan family, but the director of the Missouri Department of Health took the case on appeal to the Missouri Supreme Court. Missouri insisted on a high standard of proof of Cruzan's wish to die. The State argued that Cruzan's casual statement before the accident that she would not want to live as a “vegetable“ was not “clear and convincing evidence“ that she would want to be taken off the life-support equipment. The Missouri Supreme Court refused to authorize the termination of artificial feeding for Nancy. Life support was continued and the Cruzans appealed to the Supreme Court.

Is there a “family right of sovereignty“ that overrides the State's interest in preserving life? Would Nancy Cruzan, presently unable to make decisions for herself, choose to live in this condition? Nancy did not leave specific instructions to terminate life support if she were ever in a persistent, comatose state. Who, then, should decide to withhold medical treatment? The family? A doctor? A court?

For the Cruzan Family: The decision of the Missouri Supreme Court was not wise. It considered the general ramifications of the decision on matters such as suicide and abortion, rather than deciding the Cruzan case on its own merits. It neglected to consider the pain and suffering of Nancy Cruzan and her family. Moreover, the enormous cost to the State for Nancy Cruzan's care could be better spent on medical procedures for children facing death. Family and friends of severely injured people should be able to consult with medical-care providers and make a decision about the patient's continued life support.

For the State of Missouri: The State of Missouri has an unqualified interest in the preservation of life. Regardless of the condition of the patient, the overt action of removing feeding tubes constitutes murder under Missouri law. To permit any life-threatening action by a medical caregiver is to violate Missouri criminal law. The action of the Missouri Supreme Court, in staying the order of the district court, was wise and appropriate.

When the Court considered the problems of death and medical technology in this case, the vote was 5-4 to uphold Missouri's stand. The Court felt that the Cruzan case was best explored in the area of “liberty“ rather than “privacy.“ The Supreme Court upheld the authority of States to demand “clear and convincing“ evidence of the injured person's wishes.

The Court ruled that the State of Missouri could prohibit the Cruzan family from removing feeding tubes from Nancy because there was no clear evidence that she would have wanted medical treatment stopped. The majority's main problem was that of trust in the judgment of close family members. Chief Justice Rehnquist noted that “Close family members may have a strong feeling-a feeling not at all ignoble or unworthy, but not entirely disinterested, either-that they do not wish to witness the continuation of the life of a loved one which they regard as hopeless.“ The decision of the Court in Cruzan indicated the Court's primary concern with the preservation of life, even at the expense of “family sovereignty.“

Justice Brennan dissented, with Justices Marshall and Blackmun joining. They also cited the idea of liberty in their argument, but stated that Cruzan's entitlement to liberty-in this case, the liberty to refuse medical treatment-outweighed any interests of the State. Justice Stevens' dissent also argued that the State was usurping Cruzan's rights. He wrote: “The meaning and completion of her life should be controlled by persons who have her best interests at heart-not by a state legislature concerned only with the 'preservation of human life.'“ Since the Cruzan decision, which upheld the prerogative of States to demand “clear and convincing evidence,“ there has been a great interest in “living wills.“ In these documents, signed before witnesses, citizens may record a legal statement indicating their wishes should they become catastrophically injured. A living will may prohibit prolonged tube feeding and mechanical respiration, or resuscitation-restarting the heart by artificial means. In many States, a legal order called a “power of attorney“ allows a friend or relative to speak on a person's behalf when a traumatic injury occurs.

After the Court upheld the right of Missouri to demand “clear and convincing evidence,“ a new hearing was held before a Missouri court to determine Nancy Cruzan's fate. After hearing testimony, a State judge authorized the disconnecting of the feeding tubes. Nancy Cruzan died several days later.