Cruzan v. Director, Missouri Department of Health

497 U.S. 261 (1990)

Quick Summary

Nancy Cruzan (plaintiff), incapacitated following an accident, became the subject of legal proceedings when her parents sought to remove her life support, clashing with the State of Missouri (defendant).

The case addressed whether constitutional rights extend to the refusal of life-sustaining treatment for an incompetent individual without clear evidence of their wishes. The Supreme Court upheld Missouri’s requirement for clear and convincing evidence to make such decisions on behalf of an incompetent person.

Facts of the Case

Nancy Cruzan (plaintiff) suffered catastrophic injuries in a car accident, which left her in a persistent vegetative state with no hope of regaining cognitive function. A feeding tube was installed to provide nutrition and hydration.

Over time, Cruzan’s parents (plaintiffs) concluded that their daughter would not have wanted to continue living in this condition and requested the removal of the life-sustaining tube.

The hospital, funded by the State of Missouri (defendant), refused without a court order. The trial court agreed with the parents’ request, but the Missouri Supreme Court overturned this decision, requiring clear and convincing evidence of Nancy’s wishes.

Procedural Posture and History

  1. Cruzan’s parents petitioned the trial court to have her feeding tube removed.
  2. The trial court authorized the removal, recognizing a fundamental right to refuse life-prolonging treatment.
  3. The Missouri Supreme Court reversed the trial court’s decision, citing a lack of clear and convincing evidence of Cruzan’s wishes.
  4. The case was then appealed to the United States Supreme Court.

I.R.A.C. Format


Whether the United States Constitution allows a state to require clear and convincing evidence of an incompetent person’s wishes before terminating life-sustaining treatment.

Rule of Law

The Constitution does not prohibit a state from requiring that a decision to withdraw life-sustaining treatment be made with clear and convincing evidence reflecting the patient’s wishes.

Reasoning and Analysis

The United States Supreme Court analyzed whether Nancy Cruzan, through her parents, had a constitutional right to refuse medical treatment and, by extension, end her life by withdrawing artificial nutrition and hydration. The Court recognized a competent individual’s liberty interest in refusing unwanted medical treatment but noted the complexity when dealing with an incompetent person whose decisions must be made by a surrogate.

The Court found that Missouri’s requirement for clear and convincing evidence served legitimate state interests, including the preservation of life and protection against potential abuses of surrogate decision-making.


The Supreme Court affirmed the decision of the Missouri Supreme Court, upholding the state’s requirement for clear and convincing evidence to withdraw life-sustaining treatment from an incompetent person.

Key Takeaways

  1. The right to refuse medical treatment is part of a competent individual’s liberty interest under the Constitution.
  2. An incompetent person’s right to refuse treatment must be exercised through a surrogate, creating complexities in decision-making.
  3. States can require clear and convincing evidence of an incompetent person’s wishes before allowing withdrawal of life-sustaining treatment.

Relevant FAQs of this case

What legal considerations must be taken into account when making healthcare decisions for an incompetent individual?

The law requires the consideration of an incompetent individual’s previously expressed wishes, the best interests standard, and state-specific statutes that may outline the surrogate decision-making process.

  • For example: A patient in a coma has an advance healthcare directive outlining preferences for treatment, providing clear instructions for the surrogate to follow.

How do states balance individual autonomy with the state's interest in preserving life when creating laws regarding end-of-life decisions?

States often establish strict evidentiary standards such as ‘clear and convincing evidence’ to ensure that surrogate decision makers accurately represent an incapacitated person’s desires, while also enacting laws that protect vulnerable individuals from premature withdrawal of care.

  • For example: A law that demands thorough documentation of a patient’s end-of-life preferences before honoring a Do Not Resuscitate (DNR) order.

In what ways might state interest conflict with an individual's right to refuse medical treatment, and how are such conflicts typically resolved?

Conflicts may arise when state interests in preserving life and preventing abuse conflict with personal liberty and bodily autonomy. Courts generally resolve these by upholding the state’s evidentiary requirements safeguarding against involuntary euthanasia, while recognizing documented patient autonomy.

  • For example: A court upholds a state law requiring written evidence of a patient’s end-of-life wishes before terminating treatment, even if family members claim to verbally know those wishes.


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