Courts and the End of Life - The Case Of Nancy Cruzan

missouri supreme feeding evidence

While O'Connor set a rigorous standard of proof for the state of New York, Cruzan was the first right-to-die case heard by the U.S. Supreme Court. It confirmed the legality of such strict standards for the entire country.

Cruzan, by Cruzan v. Harmon

In January 1983 twenty-five-year-old Nancy Beth Cruzan lost control of her car. A state trooper found her lying face-down in a ditch. She was in cardiac and respiratory arrest. Paramedics were able to revive her, but a neurosurgeon diagnosed "a probable cerebral contusion compounded by significant anoxia." The final diagnosis estimated she suffered anoxia (deprivation of oxygen) for twelve to fourteen minutes. At the trial the judge stated that after six minutes of oxygen deprivation, the brain generally suffers permanent damage.

At the time of the U.S. Supreme Court hearing in 1990, Cruzan was able to breathe on her own but was being nourished with a gastrostomy feeding tube. Doctors had surgically implanted the feeding tube about a month after the accident, following the consent of her then-husband. Medical experts diagnosed the thirty-three-year-old patient to be in a PVS, capable of living another thirty years. Cruzan had been a ward of the state of Missouri since January 1986.

Cruzan's case was first heard by a Missouri trial court, which gave her parents, Joyce and Lester Cruzan, Jr., the right to terminate artificial nutrition and hydra-tion. The state and the court-appointed guardian ad litem appealed to the Missouri Supreme Court (Nancy Beth Cruzan, By Co-guardians, Lester L. Cruzan, Jr., and Joyce Cruzan v. Robert Harmon, 760 S.W.2d 408 [Mo.banc 1988]). The guardian ad litem believed it was in Cruzan's best interests to have the artificial feeding tube removed. However, he felt it was his duty as her attorney to take the case to the state supreme court because "this is a case of first impression in the state of Missouri." (A case of first impression is one without a precedent.)


The Missouri Supreme Court stressed that the state Constitution did not expressly provide for the right of privacy, which would support an individual's right to refuse medical treatment. While the U.S. Supreme Court had recognized the right of privacy in such cases as Roe v. Wade and Griswold v. Connecticut, this right did not extend to the withdrawal of food and water. In fact, the U.S. Supreme Court, in Roe v. Wade, stressed that it "has refused to recognize an unlimited right of this kind in the past."


In Cruzan's case the Missouri Supreme Court majority confirmed that the state's interest in life encompassed the sanctity of life and the prolongation of life. The state's interest in the prolongation of life was especially valid in Cruzan's case. She was not terminally ill and, based on medical evidence, would "continue a life of relatively normal duration if allowed basic sustenance." Furthermore, the state was not interested in the quality of life. The court was mindful that its decision would apply not only to Cruzan and feared treading a slippery slope. "Were the quality of life at issue, persons with all manner of handicaps might find the state seeking to terminate their lives. Instead, the state's interest is in life; that interest is unqualified."


The Missouri Supreme Court ruled that Cruzan had no constitutional right to die and that there was no clear and convincing evidence that she would not wish to continue her vegetative existence. The majority further found that her parents, or guardians, had no right to exercise substituted judgment on their daughter's behalf. The court concluded:

We find no principled legal basis which permits the co-guardians in this case to choose the death of their ward. In the absence of such a legal basis for that decision and in the face of this State's strongly stated policy in favor of life, we choose to err on the side of life, respecting the rights of incompetent persons who may wish to live despite a severely diminished quality of life.

The Missouri Supreme Court, therefore, reversed the judgment of the Missouri trial court that had allowed discontinuance of Cruzan's artificial feeding.


In his dissent Missouri Supreme Court Judge Blackmar indicated that the state should not be involved in cases such as Cruzan's. He was not convinced that the state had spoken better for Cruzan's interests than did her parents. The judge also questioned the state's interest in life in the context of espousing capital punishment, which clearly establishes "the proposition that some lives are not worth preserving."

Judge Blackmar did not share the majority's opinion that acceding to the guardians' request would lead to the mass euthanasia of handicapped people whose conditions did not come close to Cruzan's. He stressed that a court ruling is precedent only for the facts of that specific case. Besides, one of the very purposes of courts is to protect incompetent people against abuse. He claimed:

The principal opinion attempts to establish absolutes, but does so at the expense of human factors. In so doing, it unnecessarily subjects Nancy and those close to her to continuous torture, which no family should be forced to endure.


Missouri Supreme Court's Judge Higgins, also dissenting, mainly disagreed with the majority's basic premise that the more than fifty precedent-setting cases from sixteen other states were based on an "erroneous declaration of law." And yet, Judge Higgins noted, all cases cited by the majority upheld an individual's right to refuse life-sustaining treatment, either personally or through the substituted judgment of a guardian. The judge could not understand the majority's contradiction of its own argument.

Cruzan v. Director, Missouri Department of Health

Cruzan's father appealed the Missouri Supreme Court's decision and, in December 1989, the U.S. Supreme Court heard arguments in the case (Nancy Beth Cruzan, by her Parents and Co-Guardians, Lester L. Cruzan et ux v. Director, Missouri Department of Health et al, 497 US 261, 1990). This was the first time the right-to-die issue had been brought before the U.S. Supreme Court, which chose not to rule on whether Cruzan's parents could have her feeding tube removed. Instead, it considered whether the U.S. Constitution prohibited the state of Missouri from requiring clear and convincing evidence that an incompetent person desires withdrawal of life-sustaining treatment. In a five-to-four decision the Supreme Court held that the U.S. Constitution did not prohibit the state of Missouri from requiring convincing evidence that an incompetent person wants life-sustaining treatment withdrawn.

Chief Justice William Rehnquist wrote the opinion, with Justices White, O'Connor, Scalia, and Kennedy joining. (Justices Brennan, Marshall, Blackmun, and Stevens dissented.) The court majority believed that its rigorous requirement of clear and convincing evidence that Cruzan had refused termination of life-sustaining treatment was justified. An erroneous decision not to withdraw the patient's feeding tube meant that the patient would continue to be sustained artificially. Possible medical advances or new evidence of the patient's intent could correct the error. An erroneous decision to terminate the artificial feeding could not be corrected, because the result of that decision—death—is irrevocable. The chief justice concluded:

No doubt is engendered by anything in this record but that Nancy Cruzan's mother and father are loving and caring parents. If the State were required by the United States Constitution to repose a right of "substituted judgment" with anyone, the Cruzans would surely qualify. But we do not think the Due Process Clause requires the State to repose judgment on these matters with anyone but the patient herself. [The Due Process clause of the Fourteenth Amendment provides that no state shall "deprive any person of life, liberty, or property, without due process of law."]


Justice Brennan, dissenting, pointed out that the state of Missouri's general interest in the preservation of Cruzan's life in no way outweighed her freedom of choice—in this case the choice to refuse medical treatment. "The regulation of constitutionally protected decisions … must be predicated on legitimate state concerns other than disagreement with the choice the individual has made….Otherwise, the interest in liberty protected by the Due Process Clause would be a nullity."

Justice Brennan believed the state of Missouri had imposed an uneven burden of proof. The state would only accept clear and convincing evidence that the patient had made explicit statements refusing artificial nutrition and hydration. However, it did not require any proof that she had made specific statements desiring continuance of such treatment. Hence, it could not be said that the state had accurately determined Cruzan's wishes.

Justice Brennan disagreed that it is better to err on the side of life than death. He argued that, to the patient, erring from either side is "irrevocable." He explained:

An erroneous decision to terminate artificial nutrition and hydration, to be sure, will lead to failure of that last remnant of physiological life, the brain stem, and result in complete brain death. An erroneous decision not to terminate life support, however, robs a patient of the very qualities protected by the right to avoid unwanted medical treatment. His own degraded existence is perpetuated; his family's suffering is protracted; the memory he leaves behind becomes more and more distorted.


Justice Stevens, in a separate dissenting opinion, believed the state of Missouri was using Cruzan for the "symbolic effect" of defining life. The state sought to equate Nancy's physical existence with life. But Justice Stevens pointed out that life is more than physiological functions. In fact, life connotes a person's experiences that make up his or her whole history, as well as "the practical manifestation of the human spirit."

Justice Stevens viewed the state's refusal to let Cruzan's guardians terminate her artificial feeding as ignoring their daughter's interests, and therefore, "unconscionable":

Insofar as Nancy Cruzan has an interest in being remembered for how she lived rather than how she died, the damage done to those memories by the prolongation of her death is irreversible. Insofar as Nancy Cruzan has an interest in the cessation of any pain, the continuation of her pain is irreversible. Insofar as Nancy Cruzan has an interest in a closure to her life consistent with her own beliefs rather than those of the Missouri legislature, the State's imposition of its contrary view is irreversible. To deny the importance of these consequences is in effect to deny that Nancy Cruzan has interests at all, and thereby to deny her personhood in the name of preserving the sanctity of her life.


On December 14, 1990, nearly eight years after Cruzan's car accident, a Missouri circuit court ruled that new evidence presented by three more friends constituted "clear and convincing" evidence that she would not want to continue existing in a persistent vegetative state. The court allowed the removal of her artificial feeding. Within two hours of the ruling, Cruzan's doctor removed the tube. Cruzan's family kept a twenty-four-hour vigil with her, until she died on December 26, 1990. Cruzan's family, however, believed she had left them many years earlier.

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