Cruzan v. Director, MDH
Decided on June 25, 1990; 497 US 261

A state may constitutionally oppose a family's request to terminate the life sustaining treatments of their vegetative relative for lack of evidence of a clear earlier wish by the sick relative.


A. Issues Discussed: Right to die

B. Legal Question Presented:

Does the Due Process Clause of the Fourteenth Amendment forbid Missouri to require that evidence of an incompetent's wishes as to the withdrawal of life-sustaining treatment be proved by clear and convincing evidence?


A. Background:

"Petitioner Nancy Cruzan is incompetent, having sustained severe injuries in an automobile accident, and now lies in a Missouri state hospital in what is referred to as a persistent vegetative state: generally, a condition in which a person exhibits motor reflexes but evinces no indications of significant cognitive function. The State is bearing the cost of her care.

Hospital employees refused, without court approval, to honor the request of Cruzan's parents, copetitioners her, to terminate her artificial nutrition and hydration, since that would result in death. A state trial court authorized the termination, finding that a person in Cruzan's condition has a fundamental right under the State and Federal Constitutions to direct or refuse the withdrawal of death-prolonging procedures, and that Cruzan's expression to a former housemate that she would not wish to continue her life if sick or injured unless she could live at least halfway normally suggested that she would not wish to continue on with her nutrition and hydration.

The State Supreme Court reversed. While recognizing a right to refuse treatment embodied in the common-law doctrine of informed consent, the court questioned its applicability in this case. It also declined to read into the State Constitution a broad right to privacy that would support an unrestricted right to refuse treatment and expressed doubt that the Federal Constitution embodied such a right. The court then decided that the State Living Will statute embodied a state policy strongly favoring the preservation of life, and that Cruzan's statements to her housemate were unreliable for the purpose of determining her intent. It rejected the argument that her parents were entitled to order the termination of her medical treatment, concluding that no person can assume that choice for an incompetent in the absence of the formalities required by the Living Will statute or clear and convincing evidence of the patient's wishes."

On certiorari, the US Supreme Court affirmed the judgment of the Supreme Court of Missouri.

B. Counsel of Record:
Opposing Side
Unavailable Unavailable
C. The Arguments:
Opposing Side
Unavailable Unavailable
Opposing Side
William H. Colby argued the cause for petitioners. With him on the briefs were David J. Waxse, Walter E. Williams, Edward J. Kelly III, John A. Powell, and Steven R. Shapiro.

Briefs of amici curiae urging reversal were filed for the AIDS Civil Rights Project by Walter R. Allan; for the American Academy of Neurology by John H. Pickering; for the American College of Physicians by Nancy J. Bregstein; for the American Geriatrics Society by Keith R. Anderson; for the American Hospital Association by Paul W. Armstrong; for the American Medical Association et al. by Rex E. Lee, Carter G. Phillips, Elizabeth H. Esty, Jack R. Bierig, Russell M. Pelton, Paul G. Gebhard, Laurie R. Rockett, and Henry Hart; for the Colorado Medical Society et al. by Garth C. Grissom; for Concern for Dying by Henry Putzel III and George J. Annas; for the Evangelical Lutheran Church in America by Susan D. Reece Martyn and Henry J. Bourguignon; for the General Board of Church and Society of the United Methodist Church by Thomas S. Martin and Magda Lopez; for Missouri Hospitals et al. by Mark A. Thornhill, E.J. Holland, Jr., and John C. Shepherd; for the National Hospice Organization by Barbara F. Mishkin and Walter A. Smith, Jr.; for the National Academy of Elder Law Attorneys by Robert K. Huffman; for the Society of Critical Care Medicine et al. by Stephan E. Lawton; for the Society for the Right to Die, Inc., by Fenella Rouse; for Wisconsin Bioethicists et al. by Robyn S. Shapiro, Charles H. Barr, and Jay A. Gold; for Barbara Burgoon et al. by Vicki Gottlich, Leslie Blair Fried, and Stephanie M. Edelstein; and for John E. McConnell et al. by Stephen A. Wise.

Robert L. Presson, Assistant Attorney General of Missouri, argued the cause for respondent Director, Missouri Department of Health, et al. With him on the brief were William L. Webster, Attorney General, and Robert Northcutt.

Thad C. McCanse, pro se, and David B. Mouton filed a brief for respondent guardian ad litem.

Solicitor General Starr argued the cause for the United States as amicus curiae urging affirmance. With him on the brief were Acting Assistant Attorney General Schiffer, Deputy Solicitor General Merrill, and Brian J. Martin.

Briefs of amici curiae urging affirmance were filed for Agudath Israel of America by David Zwiebel; for the American Academy of Medical Ethics by James Bopp, Jr.; for the Association of American Physicians and [497 U.S. 261, 265] Surgeons et al. by Edward R. Grant and Kent Masterson Brown; for the Association for Retarded Citizens of the United States et al. by James Bopp, Jr., Thomas J. Marzen, and Stanley S. Herr; for the Catholic Lawyers Guild of the Archdiocese of Boston, Inc., by Calum B, Anderson and Leonard F. Zandrow, Jr.; for the District Attorney of Milwaukee County, Wisconsin, by E. Michael McCann, pro se, and John M. Stoiber; for Doctors for Life et al. by David O. Danis and Gerard F. Hempstead; for Families for Life et al. by Robert L. Mauro; for Focus on the Family et al. by Clarke D. Forsythe, Paul Benjamin Linton, and H. Robert Showers; for Free Speech Advocates et al. by Thomas Patrick Monaghan and Jay Alan Sekulow; for the International Anti-Euthanasia Task Force et al. by Jordan Lorence; for the Knights of Columbus by James H. Burnley IV, Robert J. Cynkar, and Carl A. Anderson; for the National Right to Life Committee, Inc., by James Bopp, Jr.; for the New Jersey Right to Life Committee, Inc., et al. by Donald D. Campbell and Anne M. Perone; for the Rutherford Institute et al. by John W. Whitehead, James J. Knicely, David E. Morris, William B. Hollberg, Amy Dougherty, Thomas W. Strahan, William Bonner, John F. Southworth, Jr., and W. Charles Bundren; for the United States Catholic Conference by Mark E. Chopko and Phillip H. Harris; for the Value of Life Committee, Inc., by Walter M. Weber; and for Elizabeth Sadowski et al. by Robert L. Mauro.


"The United States Constitution does not forbid Missouri to require that evidence of an incompetent's wishes as to the withdrawal of life-sustaining treatment be proved by clear and convincing evidence.

Most state courts have based a right to refuse treatment on the common law right to informed consent, or on both that right and a constitutional privacy right. In addition to relying on state constitutions and the common law, state courts have also turned to state statutes for guidance. However, these sources are not available to this Court, where the question is simply whether the Federal Constitution prohibits Missouri from choosing the rule of law which it did.

A competent person has a liberty interest under the Due Process Clause in refusing unwanted medical treatment. However, the question whether that constitutional right has been violated must be determined by balancing the liberty interest against relevant state interests. For purposes of this case, it is assumed that a competent person would have a constitutionally protected right to refuse lifesaving hydration and nutrition. This does not mean that an incompetent person should possess the same right, since such a person is unable to make an informed and voluntary choice to exercise that hypothetical right or any other right. While Missouri has in effect recognized that, under certain circumstances, a surrogate may act for the patient in electing to withdraw hydration and nutrition and thus cause death, it has established a procedural safeguard to assure that the surrogate's action conforms as best it may to the wishes expressed by the patient while competent.

... Here, Missouri has a general interest in the protection and preservation of human life, as well as other, more particular interests, at stake... The State may... simply assert an unqualified interest in the preservation of human life to be weighed against the constitutionally protected interests of the individual...

The State Supreme Court did not commit constitutional error in concluding that the evidence adduced at trial did not amount to clear and convincing proof of Cruzan's desire to have hydration and nutrition withdrawn...

Nancy Cruzan's parents would surely be qualified to exercise... a right of "substituted judgment" were it required by the Constitution. However, for the same reasons that Missouri may require clear and convincing evidence of a patient's wishes, it may also choose to defer only to those wishes, rather than confide the decision to close family members."

The US Supreme Court affirmed the Supreme Court of Missouri judgment.

Justice Vote: 4 Pro vs. 5 Con
  • Brennan, W. Pro (Wrote dissenting opinion)
  • Stevens, J. Pro (Wrote dissenting opinion)
  • Marshall, T. Pro (Joined dissenting opinion)
  • Blackmun, H. Pro (Joined dissenting opinion)
  • Rehnquist, W Con (Wrote majority opinion)
  • O'Connor, S. Con (Wrote concurring opinion)
  • Scalia, A. Con (Wrote concurring opinion)
  • Kennedy, A. Con (Joined majority opinion)
  • White, B. Con (Joined majority opinion)

The ACLU, as counsel for petitioners, urged reversal of the judgment of the Supreme Court of Missouri; the Supreme Court affirmed in a 4-5 vote, giving the ACLU an apparent loss.