Docket 88-1503
Cruzan Ex Rel. Cruzan v. Director, Missouri Department of Health
DecidedJun 25, 1990
5-4decision
Source: CourtListener.
Court allows states to require clear and convincing evidence before removing life support from incompetent patients
Impact7/10
What it does
The ruling holds that states may constitutionally require clear and convincing evidence of an incompetent patient's wishes before permitting withdrawal of life-sustaining treatment, and upholds Missouri's refusal to let Nancy Cruzan's parents discontinue her feeding tube absent such evidence. It assumes, without deciding, that competent people have a constitutional liberty interest in refusing unwanted medical treatment, including artificial nutrition and hydration, but concludes states can impose heightened procedural safeguards when that person is incompetent and cannot exercise the right herself.
Who benefits
State governments seeking to regulate end-of-life decisionmaking gain constitutional room to impose strict evidentiary requirements; patients whose families disagree or whose wishes are ambiguous may have their lives preserved even against family wishes.
Who is affected
Families of incompetent, permanently unconscious patients who wish to withdraw life-sustaining treatment but cannot produce formal, clear evidence of the patient's prior wishes are affected, as are patients like Nancy Cruzan who remain on life support despite family and guardian agreement about their likely wishes.
Practical impact
States retain broad authority to set their own procedural standards, including heightened evidentiary requirements, for decisions to withdraw life-sustaining treatment from incompetent patients, and may decline to accept family consensus alone as sufficient. Families seeking to end treatment for permanently unconscious relatives without written directives may face significant evidentiary hurdles, while states may continue mandating life-sustaining treatment absent clear proof of the patient's own prior wishes. The decision spurred increased public and legal attention to living wills and durable powers of attorney for health care.
Majority reasoning
The Court reasoned that while prior cases support a general liberty interest in refusing medical treatment, this interest must be balanced against legitimate state interests, including an unqualified interest in preserving human life. Because an incompetent person cannot exercise this right herself, someone must act as a surrogate, and Missouri permissibly required clear and convincing evidence that the surrogate's decision matches what the patient would have chosen, to guard against abuse and inaccurate factfinding in potentially non-adversarial proceedings. The majority found this evidentiary standard reasonable because an erroneous decision to maintain treatment preserves the status quo and is correctable, while an erroneous decision to terminate treatment is irreversible, justifying placing a heavier burden on those seeking to end treatment. The Court also rejected the argument that Missouri must defer to family members' substituted judgment, holding that the Due Process Clause does not require the state to repose decisionmaking with anyone but the patient herself, since family views may not always reliably reflect the patient's actual wishes.
Dissent reasoning
Justice Brennan, joined by Justices Marshall and Blackmun, argued that Nancy Cruzan has a fundamental right to be free of unwanted artificial nutrition and hydration that outweighs any state interest, since Missouri's only asserted interest—an abstract preservation of life—could not override her particularized interest in avoiding treatment with no chance of benefiting her. He argued Missouri's asymmetric evidentiary rule, which required clear proof only to refuse treatment and none to continue it, and its exclusion of testimony from family, friends, and the guardian ad litem, distorted rather than served accurate factfinding, and that family members are typically the best source of evidence about a patient's wishes. Justice Stevens dissented separately, arguing that Missouri's policy failed to respect Nancy Cruzan's own best interests, wrongly treating "life" as mere biological persistence divorced from the person's own interests and reducing her right to a technical requirement of formally expressed wishes that most people never articulate, thereby abandoning the many incompetent patients including children and accident victims who never had the opportunity to state a preference.
Constitutional question
Does the Constitution's Due Process Clause forbid a state from requiring clear and convincing evidence of an incompetent, permanently unconscious patient's own prior wishes before allowing family members to withdraw artificial nutrition and hydration?