''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
Incompetence is the inability to perform; lack of competence; ineptitude.
Aspects of incompetence include:
*Administrative incompetence, dysfunctional administrative behaviors that hinder attainment of organization goals
*Incompetence (law), a p ...
. The first "
right to die
The right to die is a concept based on the opinion that human beings are entitled to end their life or undergo voluntary euthanasia. Possession of this right is often understood that a person with a terminal illness, incurable pain, or without t ...
" 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
The Supreme Court of Missouri is the highest court in the state of Missouri. It was established in 1820 and is located at 207 West High Street in Jefferson City, Missouri. Missouri voters have approved changes in the state's constitution to give ...
and ruled in favor of the
State
State may refer to:
Arts, entertainment, and media Literature
* ''State Magazine'', a monthly magazine published by the U.S. Department of State
* ''The State'' (newspaper), a daily newspaper in Columbia, South Carolina, United States
* ''Our S ...
of
Missouri
Missouri is a U.S. state, state in the Midwestern United States, Midwestern region of the United States. Ranking List of U.S. states and territories by area, 21st in land area, it is bordered by eight states (tied for the most with Tennessee ...
, finding it was acceptable to require "
clear and convincing evidence
In a legal dispute, one party has the burden of proof to show that they are correct, while the other party had no such burden and is presumed to be correct. The burden of proof requires a party to produce evidence to establish the truth of facts ...
" 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
Carthage is a city in Jasper County, Missouri, United States. The population was 15,522 as of the 2020 census. It is the county seat of Jasper County and is nicknamed "America's Maple Leaf City."
History
Jasper County was formed in 1841. ...
. 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
A paramedic is a registered healthcare professional who works autonomously across a range of health and care settings and may specialise in clinical practice, as well as in education, leadership, and research.
Not all ambulance personnel are p ...
found her with no
vital signs
Vital signs (also known as vitals) are a group of the four to six most crucial medical signs that indicate the status of the body's vital (life-sustaining) functions. These measurements are taken to help assess the general physical health of a ...
, 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
A persistent vegetative state (PVS) or post-coma unresponsiveness (PCU) is a disorder of consciousness in which patients with severe brain damage are in a state of partial arousal rather than true awareness. After four weeks in a vegetative stat ...
(PVS).
[ Surgeons inserted a ]feeding tube
Eating (also known as consuming) is the ingestion of food, typically to provide a heterotrophic organism with energy and to allow for growth. Animals and other heterotrophs must eat in order to survive — carnivores eat other animals, her ...
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
Incompetence is the inability to perform; lack of competence; ineptitude.
Aspects of incompetence include:
*Administrative incompetence, dysfunctional administrative behaviors that hinder attainment of organization goals
*Incompetence (law), a p ...
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
''In re Quinlan'' (70 N.J. 10, 355 A.2d 647 (NJ 1976)) was a landmark 1975 court case in the United States in which the parents of a woman who was kept alive by artificial means were allowed to order her removal from artificial ventilation.
Kare ...
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 law, a concurring opinion is in certain legal systems a written opinion by one or more judges of a court which agrees with the decision made by the majority of the court, but states different (or additional) reasons as the basis for their deci ...
in ''Cruzan'', Justice Scalia
Antonin Gregory Scalia (; March 11, 1936 – February 13, 2016) was an American jurist who served as an associate justice of the Supreme Court of the United States from 1986 until his death in 2016. He was described as the intellectua ...
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
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 ...
, and "letting die
In non-consequentialist ethical thought, there is a moral distinction between killing and letting die. Whereas killing involves intervention, letting die involves withholding care.
Also in medical ethics there is a moral distinction between eutha ...
," 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
The right to die is a concept based on the opinion that human beings are entitled to end their life or undergo voluntary euthanasia. Possession of this right is often understood that a person with a terminal illness, incurable pain, or without t ...
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 New York Times'' (''the Times'', ''NYT'', or the Gray Lady) is a daily newspaper based in New York City with a worldwide readership reported in 2020 to comprise a declining 840,000 paid print subscribers, and a growing 6 million paid ...
'', the ''Cruzan'' case also helped increase support for the federal Patient Self-Determination Act
The Patient Self-Determination Act (PSDA) was passed by the United States Congress in 1990 as an amendment to the Omnibus Budget Reconciliation Act of 1990. Effective on December 1, 1991, this legislation required many hospitals, nursing homes, ho ...
, 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
This page serves as an index of lists of United States Supreme Court cases. The United States Supreme Court is the highest federal court of the United States.
By Chief Justice
Court historians and other legal scholars consider each Chief J ...
* Lists of United States Supreme Court cases by volume
The following is a complete list of cases decided by the United States Supreme Court organized by volume of the ''United States Reports'' in which they appear. This is a list of volumes of ''U.S. Reports'', and the links point to the contents of e ...
*
* Terri Schiavo case
The Terri Schiavo case was a series of court and legislative actions in the United States from 1998 to 2005, regarding the care of Theresa Marie Schiavo (née Schindler) (; December 3, 1963 – March 31, 2005), a woman in an irreversible ...
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