Cruzan v. Director, Missouri Department of Health
Significance: The Supreme Court ruled that the Fourteenth Amendment protects a competent adult's “liberty interest” in refusing unwanted medical treatment even if the result is death and that the U.S. Constitution permits, but does not require, state courts to demand “clear and convincing” evidence of the person's desire before terminating life support services.
In 1983 Nancy Cruzan suffered brain injuries in an automobile accident that left her in a permanent “vegetative state,” with no realistic hope for recovery. An implanted feeding tube provided her body with a constant source of nutrition and water. She was one of approximately ten thousand such cases in the United States. In 1987 Cruzan's parents sought permission to have the feeding tube removed, which would result in her death. Missouri's living will statute, however, required clear and convincing evidence that Nancy Cruzan herself would have wanted to have the tube removed. Because the parents could not produce the necessary evidence, the state courts rejected their request. By a 5-4 vote, the Supreme Court upheld the constitutionality of the Missouri law. In the majority opinion, Chief Justice William H. Rehnquist wrote that the requirement of clear and convincing evidence of a person's desire was reasonable in view of the state's interest in preserving human life. Not only was it possible for family members to be mistaken about what a person would desire, but there was also the real danger that some families might be motivated by a financial incentive to seek a person's demise. Rehnquist noted that the Court in Jacobson v. Massachusetts (1905) had balanced an individual's liberty interest in rejecting a medical procedure with the legitimate interests of the state. Rehnquist was careful not to define the extent of a person's “right to die.” Based on the Court's precedents as well as the common-law doctrine of informed consent, an 8-1 majority of the justices were willing to “assume” that the Constitution grants a competent person the right to refuse lifesaving nutrition. Justice Antonin Scalia was the only justice to reject this assumption. Rehnquist's opinion did not attempt to draw a distinction between artificial nutrition and more complex forms of medical procedures, nor did it distinguish between patients facing imminent death and patients whose lives might be preserved for many years. Thus, the decision allowed states a great deal of latitude in making laws about living wills and related matters. The Missouri courts eventually ruled that new evidence provided enough justification to honor the request of the Cruzan family. In Washington v. Glucksberg (1997), the Court unanimously agreed that the Constitution does not guarantee any right to physician assistance in ending one's life.