Cruzan v. Director, Missouri Department of Health
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''Cruzan v. Director, Missouri Department of Health'', 497 U.S. 261 (1990), was a
landmark decision Landmark court decisions, in present-day common law legal systems, establish precedents that determine a significant new legal principle or concept, or otherwise substantially affect the interpretation of existing law. "Leading case" is commonly u ...
of the
Supreme Court of the United States The Supreme Court of the United States (SCOTUS) is the highest court in the federal judiciary of the United States. It has ultimate appellate jurisdiction over all U.S. federal court cases, and over state court cases that involve a point o ...
involving a young adult incompetent. The first " right to die" case ever heard by the Court, ''Cruzan'' was argued on December 6, 1989, and decided on June 25, 1990. In a 5–4 decision, the Court affirmed the earlier ruling of the Supreme Court of Missouri and ruled in favor of the State of Missouri, finding it was acceptable to require " clear and convincing evidence" of a patient's wishes for removal of
life support Life support comprises the treatments and techniques performed in an emergency in order to support life after the failure of one or more vital organs. Healthcare providers and emergency medical technicians are generally certified to perform basic ...
. A significant outcome of the case was the creation of advance health directives.


Background

On January 11, 1983, then-25-year-old Nancy Cruzan (born July 20, 1957) lost control of her car while driving at nighttime near Carthage, Missouri. She was thrown from the vehicle and landed face-down in a water-filled ditch.Cruzan v. Harmon, 760 S.W.2d 408, 430–433 (Mo. 1988) (en banc) (Higgins, J., dissenting)
Paramedics found her with no vital signs, but they resuscitated her. After three weeks in a
coma A coma is a deep state of prolonged unconsciousness in which a person cannot be awakened, fails to respond normally to painful stimuli, light, or sound, lacks a normal wake-sleep cycle and does not initiate voluntary actions. Coma patients exhi ...
, she was diagnosed as being in a persistent vegetative state (PVS). Surgeons inserted a feeding tube for her long-term care. In 1988, Cruzan's parents asked her doctors to remove her feeding tube. The hospital refused to do so without a court order, since removal of the tube would cause Cruzan's death. The Cruzans filed for and received a court order for the feeding tube to be removed.Estate of Cruzan, Estate No. CV384-9P (P. Div. Cir. Ct., Jasper County, Mo., July 27, 1988). The trial court ruled that constitutionally, there is a "fundamental natural right ... to refuse or direct the withholding or withdrawal of artificial life-prolonging procedures when the person has no more cognitive brain function ... and there is no hope of further recovery."Cruzan v. Harmon, 760 S.W.2d 408, 434 (Mo. 1988) (en banc) (Higgins, J., dissenting)
(quoting the lower trial court)
The court ruled that Cruzan had effectively 'directed' the withdrawal of life support by telling a friend earlier that year that if she were sick or injured, "she would not wish to continue her life unless she could live at least halfway normally." The state of Missouri and Cruzan's guardian ''ad litem'' both appealed this decision. In a 4–3 decision, the Supreme Court of Missouri reversed the trial court's decision. It ruled that no one may refuse treatment for another person, absent an adequate living will "or the clear and convincing, inherently reliable evidence absent here." The Cruzans appealed, and in 1989 the Supreme Court of the United States agreed to hear the case.


Issues

The legal question was whether the State of Missouri had the right to require "clear and convincing evidence" for the Cruzans to remove their daughter from life support. Specifically, the Supreme Court considered whether Missouri was violating the
Due Process Clause In United States constitutional law, a Due Process Clause is found in both the Fifth and Fourteenth Amendments to the United States Constitution, which prohibits arbitrary deprivation of "life, liberty, or property" by the government except as ...
of the Fourteenth Amendment by refusing to remove Nancy's feeding tube. The Due Process Clause provides: " r shall any State deprive any person of life, liberty, or property, without due process of law The Cruzans' lawyer summarized the constitutional basis for his appeal thusly:


Decision

''Cruzan'' was the first "right to die" case the Supreme Court had ever heard, and it proved divisive for the Court.p. 27 In a 5–4 decision, the Court found in favor of the Missouri Department of Health and ruled that nothing in the Constitution prevents the state of Missouri from requiring "clear and convincing evidence" before terminating life-supporting treatment,Cruzan v. Director, Missouri Dept. of Health, 110 S. Ct. 2841 (1990).
/ref> upholding the ruling of the Missouri Supreme Court. Reflecting the controversiality of the "end of life" issue, five Justices wrote separate opinions about the case. In a majority opinion by
Chief Justice Rehnquist William Hubbs Rehnquist ( ; October 1, 1924 – September 3, 2005) was an American attorney and jurist who served on the Supreme Court of the United States, U.S. Supreme Court for 33 years, first as an Associate justice of the Supreme Court of ...
, the Court ruled that
competent Competence may refer to: *Competence (geology), the resistance of a rock against deformation or plastic flow. *Competence (human resources), a standardized requirement for an individual to properly perform a specific job *Competence (law), the me ...
individuals have the right to refuse medical treatment under the Due Process Clause. However, with incompetent individuals, the Court upheld the state of Missouri's higher standard for evidence of what the person would want if they were able to make their own decisions. This higher evidentiary standard was constitutional, the Court ruled, because family members might not always make decisions that the incompetent person would have agreed with, and those decisions might lead to actions (like withdrawing life support) that would be irreversible.


Right to die vs. suicide

In court cases, like the Karen Ann Quinlan case and the
Elizabeth Bouvia Elizabeth Bouvia (born c. 1958) is a figure in the American right-to-die movement. Her case attracted nationwide attention in this area as well as in medical ethics. History On September 3, 1983, Bouvia, at the age of 26, admitted herself into th ...
cases, the courts had highlighted the differences between dying from refusing treatment, and dying from
suicide Suicide is the act of intentionally causing one's own death. Mental disorders (including depression, bipolar disorder, schizophrenia, personality disorders, anxiety disorders), physical disorders (such as chronic fatigue syndrome), and s ...
. However, in his concurring opinion in ''Cruzan'', Justice Scalia noted that this distinction could be "merely verbal" if death is sought "by starvation instead of a drug." Justice Scalia argued that refusing medical treatment, if doing so would cause a patient's death, was equivalent to the right to commit suicide. The right to commit suicide, he added, was not a due process right protected in the Constitution. As legal scholar Susan Stefan writes: " ustice Scaliaargued that states had the right to 'prevent, by force if necessary,' people from committing suicide, including refusing treatment when that refusal would cause the patient to die."p. 28 Justice Scalia's opinion raised important questions about the legal differences between refusal of treatment, suicide,
assisted suicide Assisted suicide is suicide undertaken with the aid of another person. The term usually refers to physician-assisted suicide (PAS), which is suicide that is assisted by a physician or other healthcare provider. Once it is determined that the p ...
, physician-assisted suicide, and " letting die," and the state's responsibility in preventing these, which would prove crucial issues in right to die and right to life cases to come.pp. 31–33


Aftermath


The Cruzans

After the Supreme Court's decision, the Cruzans gathered additional evidence that Cruzan would have wanted her life support terminated. The State of Missouri withdrew from the case in September 1990 since its law had been upheld and it had won the larger constitutional issue being considered.p. 29 With the Cruzans facing no opposition, Jasper County Probate Judge Charles Teel ruled that the Cruzans had met the evidentiary burden of "clear and convincing evidence." He issued a court order to remove Cruzan's feeding tube. On December 14, 1990, the feeding tube was removed, and Cruzan died on December 26, 1990. Cruzan's case had attracted national interest, and right-to-life activists and organizations filed seven separate petitions with the court asking to resume feeding, but were found to have no legal standing for intervention. At Cruzan's funeral, her father told reporters, "I would prefer to have my daughter back and let someone else be this trailblazer."p. 29 Six years later, on August 17, 1996, he killed himself.


Significance

The ''Cruzan'' case set several important precedents:pp. 27–28 * It established that the right to die was not a right guaranteed by the Constitution. * It set out rules for what was required for a third party to refuse treatment on behalf of an incompetent person. * It established that absent a living will or clear and convincing evidence of what the incompetent person would have wanted, the state's interests in preserving life outweigh the individual's rights to refuse treatment. * It left it to the states to determine their own right-to-die standards, rather than creating a uniform national standard. It also generated a great deal of interest in living wills and advance directives. For example, just one month after the Supreme Court ruling in ''Cruzan'', the
Society for the Right to Die The Euthanasia Society of America was founded in 1938 to promote euthanasia. It was co-founded by Charles Francis Potter and Ann Mitchell. Alice Naumberg (mother of Ruth P. Smith) also helped to found the group. The group initially supported bo ...
had received some 300,000 requests for advance directive forms. According to an article in '' The New York Times'', the ''Cruzan'' case also helped increase support for the federal Patient Self-Determination Act, which became effective just under a year after Nancy Cruzan's death. The Act required hospitals and nursing homes that received federal funding to give patients advance-directive information and explain right-to-die options that are available under the laws of their states.


See also

*
List of United States Supreme Court cases, volume 497 This is a list of all the United States Supreme Court cases from volume 497 of the ''United States Reports The ''United States Reports'' () are the official record ( law reports) of the Supreme Court of the United States. They include rulings, ...
* List of United States Supreme Court cases * Lists of United States Supreme Court cases by volume * List of United States Supreme Court cases by the Rehnquist Court * Terri Schiavo case


References


External links

*
Summary of the ''Cruzan'' case with links to information about Missouri's health care laws



Living Wills and Advance Directives for Medical Decisions
(from the
Mayo Clinic The Mayo Clinic () is a nonprofit American academic medical center focused on integrated health care, education, and research. It employs over 4,500 physicians and scientists, along with another 58,400 administrative and allied health staff, ...
) {{US14thAmendment, dueprocess United States Supreme Court cases United States Supreme Court cases of the Rehnquist Court United States substantive due process case law 1990 in United States case law Legal history of Missouri Medical controversies in the United States Euthanasia in the United States Medical lawsuits People with disorders of consciousness