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Cruzan v. Director, Missouri Department of Health

Matthew Steinberg

InstructorMatthew Steinberg

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Cruzan v. Director, Missouri Department of Health

Citation. 497 U.S. 261, 110 S. Ct. 2841, 111 L. Ed. 2d 224, 1990 U.S.
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Brief Fact Summary.

Nancy Cruzan was involved in a car accident, which left her in a “persistent vegetative state.” After it became clear that Cruzan would not improve, her parents requested that the hospital terminate the life-support procedures the hospital was providing. The hospital and subsequently the State court refused to comply.

Synopsis of Rule of Law.

A State may condition the exercise of a patient’s right to terminate life-sustaining treatment on a showing of clear and convincing evidence of the desire of the patient to exercise such a right.


Nancy Cruzan was involved in a car accident, which left her in a “persistent vegetative state.” In order to feed her and to facilitate her recovery, surgeons implanted into her a gastronomy feeding and hydration tube. After it become apparent that Cruzan had virtually no chance for recovery, Petitioners, Cruzan’s parents, asked hospital employees to terminate the life support procedures. The State hospital employees refused to honor this request without court approval. After trial, on appeal, the Missouri Supreme Court refused to order termination of the life-support, because clear and convincing evidence was not produced to show that Cruzan herself would have chosen to refuse treatment.


Did Cruzan have a right under the United States Constitution that would require the hospital to withdraw life-sustaining treatment?

Did Missouri’s procedural requirement for clear and convincing evidence of an incompetent person’s desire to terminate life support before it is terminated violate the Constitution?


No and No. The Missouri Supreme Court is affirmed.
Prior decisions support the principle that a competent person has a constitutionally protected liberty interest in refusing medical treatment under the Due Process Clause. But incompetent persons do not enjoy the same rights, because they cannot make voluntary and informed decisions.

The right to terminate life-sustaining treatment of an incompetent, if it is to be exercised, must be done for such incompetent by a surrogate. Missouri’s interest in the preservation of life is unquestionably a valid State interest.  The Due Process Clause protects an interest in life as well as a right to refuse life-saving treatment. Missouri may legitimately safeguard these personal decisions by imposing heightened evidentiary requirements.  Moreover, even when available, family members will not always act in the best interests of a patient. The State is entitled to safeguard against such abuses.


Justice Brennan: Missouri may constitutionally impose only those requirements necessary to ascertain Cruzan’s wishes. The “safeguard” employed by the Missouri courts imposes a markedly asymmetrical evidentiary burden. No proof is required to show an incompetent person would wish to continue treatment.

Justice O’Connor: Would emphasize that the Supreme Court of the United States does not decide the issue whether a State must give effect to the decisions of a surrogate. In Justice O’Connor’s view, such a duty may well be constitutionally required to protect one’s liberty interest in refusing medical treatment.
Justice Scalia: Would have preferred that The Court announced clearly that the federal courts have no business in this field. The United States Constitution says nothing on this topic. The nine justices of this Supreme Court are not better at making this decision than nine people picked at random from the Kansas City telephone directory.


This case is labeled a “right to life case.” Most of the attention, however, is focused on burden of proof standards for showing a person’s intent with regard to a life-threatening matter. This type of case, where a person requests that her life be left to natural processes, must be distinguished from cases that involve assisted suicide, whereby a doctor will take an affirmative step to induce a person’s death.

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