Science and Law: Cruzan v. Director, Missouri Department of Health: The right to refuse medical treatment

March 14, 2015

Science and Law


497 U.S. 261 (1990)

This case, which came before the Supreme Court in 1990, discusses the ethics of providing life-sustaining treatment to incompetent patients, and became an important precedent for future cases discussing the right to die.

Case Background

  • On January 11, 1983 Nancy Beth Cruzan’s car overturned when she was driving home from her job at a cheese factory. She was found face down in a ditch, and although paramedics restarted her heart, 15 minutes without oxygen left her with severe brain damage.
  • Cruzan was left in a “persistent vegetative state,” in her case meaning that she was considered conscious without any ability to interact with her environment or recover.
  • Cruzan was kept alive in the Missouri hospital with a surgically implanted gastronomic feeding tube and hydration tube.
  • Cruzan’s parents requested that the hospital terminate life-support.
  • The hospital, and later the Missouri State Supreme Court both refused to comply, in part because Cruzan did not leave evidence of her wishes should she end up in this state.
  • Because of this, the parents appealed the court’s ruling until it reached the U.S. Supreme Court.

What issues are being debated?

  • Does Cruzan (compared to the parents) have the right under the constitution to force the hospital to stop her treatment?
  • Can the state require evidence of an incompetent patient’s desire to terminate life support?
  • What interest does the state have in keeping Cruzan (or any patient in a similar state) alive?
  • Who can act in Cruzan’s best interest?
  • How does the idea of medical futility factor into this case?

How was the law interpreted and applied?

  • In a 5-4 decision, the court ruled in favor of the Missouri Department of Health, with Chief Justice Rehnquist writing the majority opinion.
  • The competency of the patient was a deciding factor. The court ruled that a competent person can refuse care, but a person rendered incompetent cannot make voluntary and informed decisions regarding life support.
  • The court valued the state’s interest in preservation of life over the next of kin’s (the parents’) authority as a surrogate.
  • The court also worried about setting a dangerous precedent, considering the fact that family members may not necessarily act in the best interest of a patient.

Looking at the dissent as well:

  • Justice Brennan argued that Missouri could only impose requirements for ascertaining Cruzan’s wishes, since the state’s safeguard imposed an imbalanced evidentiary burden. Proof was only required to show that the patient would not want to continue treatment, while no proof was necessary to show that they would wish to.
  • Justice O’Connor felt that the constitution gives individuals the right to a surrogate, but that the surrogate must be officially appointed through a process such as durable power of attorney.
  • Justice Scalia felt that the federal courts should not interfere with this issue.

What happened after this case?

  • In December of 1990, six months after the court ruling, the parents finally convinced the hospital to allow Cruzan to pass away. Nancy Beth Cruzan died at the age of 33 with her family at her bedside.
  • The ruling increased public interest in living wills and other types of advance directives giving decision-making power to another in case they too became unable to express their desire to have treatment ended.
  • The Society for the Right to Die received around 300,000 requests for advance-directive forms.
  • The case also contributed to the push to pass the Patient Self-Determination Act, effective in November of 1991, requiring hospitals receiving Medicare/Medicaid funds to give patients information about advance directives.

Further analysis

I understand the court’s opinion that they cannot allow medical decisions to be made for incompetent patients, but I still feel that this ignores the problem of medical futility. The court realizes that neither the state nor the family would necessarily act in the patient’s best interest, and thus rule in favor of preservation of life, but that is assuming that the patient can “enjoy” rights. While I realize that in this particular instance, it is sensible to prevent third parties from making decisions on behalf of incompetent patients, I am glad that this case spurred increased interest in advanced directives. These prevent the legal and ethical dilemmas that accompany end of life care, and will be necessary in an age of advanced but sometimes cumbersome medicine that can sustain life without necessarily maintaining quality of that life.

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About jslachman381

I'm a Yale graduate who majored in History of Science, Medicine, and Public Health.

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  1. Science and Law: Quinlan v. State of New Jersey: Do patients have the right to end life-sustaining care based on the U.S. Constitution? | The Science Writing Blog - May 9, 2015

    […] a precedent for all future cases involving end of life care and medical futility, such as Cruzan v. Director and the Terry Schiavo […]


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