Petitioner
Nancy Beth Cruzan, by her parents and co-guardians, Lester L. Cruzan, et ux.
Respondent
Director, Missouri Department of Health, et al.
Petitioner's Claim
That the state of Missouri had no authority to interfere with the parents' wish to remove the tube that supplied food and water to Nancy Cruzan.
Chief Lawyer for Petitioner
William H. Colby
Chief Lawyer for Respondent
Robert L. Presson, Attorney General of Missouri
Justices for the Court
Anthony M. Kennedy, Sandra Day O'Connor, William H. Rehnquist (writing for the Court), Antonin Scalia, Byron R. White
Justices Dissenting
Harry A. Blackmun, William J. Brennan, Jr., Thurgood Marshall, John Paul Stevens
Place
Washington, D.C.
Date of Decision
25 June 1990
Decision
The Court upheld the Missouri State Supreme Court's decision rejecting the Cruzans' petition to withdraw food and water from their daughter.
Significance
In a first for the U.S. Supreme Court, it entered into the debate surroundingthe right-to-die argument, and concluded that the state, in the interests ofsafeguarding human life at all costs, may overrule relatives and medical professionals on specific human life issues. Some analysts tied the Cruzan case--and its appearance at the High Court--to the abortion question, pointing out that it paved the way for increasing judicial intrusions into citizens' privacy.
The Accident
Nancy Beth Cruzan was 25 years old when her car slid out of control on an icyMissouri road and rolled over one January night in 1983. Ejected from the car, she landed in a ditch, and by the time an ambulance arrived and restored vital signs, her brain had been without necessary oxygen for an estimated 12 to 14 minutes; brain damage occurs after six minutes without oxygen. This lefther in what doctors defined as a "permanent vegetative state"--she was awake, but unaware; she had some motor reflexes but showed no evidence of cognitive abilities. She could not move, speak, or communicate in any way, though nurses at the Missouri Rehabilitation Center did report that Cruzan was able toturn her body toward someone who spoke to her, and cried on one occasion whena valentine card was read aloud to her. The rest of her body survived the accident relatively intact and, to ease care, doctors surgically implanted a tube in her stomach that provided food and water. Cruzan's life expectancy in this condition was estimated at another 30 years.
By 1988, Cruzan's family had lost hope that their daughter might emerge fromher vegetative state. Her parents, Lester and Joyce Cruzan, asked doctors atthe center to disconnect the feeding tube, on the grounds that their daughterhad, as an adult, made definite statements that if she were to become chronically ill or seriously injured she would not want to live, unless she could get by at least somewhat normally. A local probate court granted authorizationto remove the tube, but the state's attorney general, William L. Webster, filed an appeal on the grounds that the parents and a court-appointed legal guardian had not sufficiently proved that Cruzan had once made such statements about refusing medical treatment. The Missouri State Supreme Court reversed the lower court's decision, and the Cruzans appealed to the U.S. Supreme Court.
Who Decides?
It was the first time the High Court had entered into the right-to-die question, treading waters customarily the domain of theologians and philosophers. (The question had arisen in the courts before, most notably with In the Matter of Quinlan (1976), but the High Court had declined to review the NewJersey State Supreme Court decision.) Conservatives and the spiritually devout offered the argument that life is precious, and must be preserved at all costs. The state arugued that it is required to protect all life, which negatesany wishes of Cruzan or her parents. The Cruzan case was often twinned in discussions with another significant case pending before the court regarding abortion. In each issue, the justices discussed the constitutional rightto privacy and which person or party could carry out such decisions on behalf of another.
The family's lawyer, William H. Colby, presented the argument that Cruzan hadsaid on several occasions that in the case of illness or accident, she wouldprefer not to live her remaining days on a life-support system, as many people often remark when the issue arises in conversation. Arguing the issue forthe Missouri Department of Health, Assistant State Attorney General Robert L.Presson contended that Cruzan's utterances were not specific enough, and were inadmissible as reliable statements in a court of law. Presson asserted that Missouri was acting in Cruzan's best interest in keeping her alive and nourished, and furthermore, that her parents, even as guardians, did not possessany constitutional right to end her life. The Court's role was to determine whether the secondhand oral testimony was indeed sufficient evidence, and ultimately, since Cruzan was unable to communicate her wishes, whether her familyor the state had jurisdiction over her life.
Defining Life
Another side of the Cruzan question concerned advances in medical technology late in the twentieth century. Medical advances created machines thatcould perform essential respiratory and cardiac functions. In such situations, some argue, a clearer definition of "life" should be put forward--is the person a thinking, viable being, capable of surviving with no outside assistance? Countering that argument against the "quality" versus the mere "presence"of life are deeper religious beliefs; many argue that a supreme being is thegiver of life, and as such should be the only one able to end it. In this case, however, Cruzan was assisted by a surgically implanted feeding tube. Thismeasure, according to the American Medical Association, is classified as "medical treatment," and thus may be refused.
On the other hand, some medical ethicists argue that food and water comprise"basic care" and thus fall under the standard extension of kindness that humans must give one another. The Justice Department prepared a brief on the issue prior to the arguments presented for the Cruzan case, and conceded that current government policy allowed family members, in consultation with staff physicians, to decide whether or not to continue life-support measures for permanently incapacitated patients in veterans and army hospitals.
The Cruzan case also tackled the issue of "informed consent," or a person's ability to understand issues related to their medical care, and with that the granting of permission to doctors to carry them out. Yet this does notaddress the person who is unable to make decisions. One legal precedent in this area came with a decision made by the New York State Supreme Court in 1980, in which presiding Judge Sol Wachtler ruled that medical treatment could be withdrawn at the request of a patient's legal guardian, if the incapacitated person had made clear statement that he did not wish to be kept alive by heroic measures.
Court Rejects Parents' Appeal
Cruzan v. Director, Missouri Department of Health was argued in December of 1989 and seven months later, Chief Justice Rehnquist delivered a majority opinion supporting the 5-4 decision of the Missouri Supreme Court, declaring that the state did indeed have the right to preserve life at all costs. Rehnquist noted in his opinion that the oral evidence presented to the Court byCruzan's roommate, relating remarks Cruzan had made about not wishing to live life in a hospital bed, did not offer convincing proof of her wishes, and that her parents, as legal guardians, could not overrule. Rejecting the precedent set by the New York case, the Rehnquist opinion asserted that statementsmade by a healthy person could not constitute what that same person may havewished under other circumstances--in other words, that a competent person would not decide to starve.
A few months after the Supreme Court ruling in June of 1990, the Cruzan family again went before the original local court in Missouri to present more concrete testimony from witnesses regarding statements their daughter had made, and this time the court granted permission to remove the feeding tube. Nursesat the Missouri Rehabilitation Center opposed the decision, and spoke out publicly, noting that it was illegal to withhold food from a dog, and that theydid not wish to have Cruzan's death occur willfully while under their care. Cruzan passed away 12 days later with her parents at her bedside.
Related Cases
Discontinuance of Life-support v. Assisted Suicide
The right to refuse medical treatment is a constitutionally protected libertyinterest. Unlike assisted suicide, it lacks the potential element of abuse because patients can establish future previsions to discontinue life support systems such as a living will. Additionally, if the patient is unable to articulate his views or has not signed a living will, family members can express the patient's desire to discontinue life support. Family members can recall conversations during which the patient expressed a desire not to continue withlife support. Furthermore, if there is a disagreement among family members about the patient's desire it is easier to determine which side of the family is correctly expressing the patient's wishes.
Yet some argue there is little difference between ending life support and intervening to promote death. Others assert that a patient's physician can moreaccurately reflect and act on the patient's desire without the emotional entanglements that could hinder the family's judgement. Just as the family membercan discuss the patients' wishes, the doctor based on his relationship withthe patient prior to the illness, would have the same information.
Sources
Constitutional Law: Thirteenth Edition New York City, NY: The Foundation Press Inc., 1997.
Nancy Beth Cruzan, by her parents and co-guardians, Lester L. Cruzan, et ux.
Respondent
Director, Missouri Department of Health, et al.
Petitioner's Claim
That the state of Missouri had no authority to interfere with the parents' wish to remove the tube that supplied food and water to Nancy Cruzan.
Chief Lawyer for Petitioner
William H. Colby
Chief Lawyer for Respondent
Robert L. Presson, Attorney General of Missouri
Justices for the Court
Anthony M. Kennedy, Sandra Day O'Connor, William H. Rehnquist (writing for the Court), Antonin Scalia, Byron R. White
Justices Dissenting
Harry A. Blackmun, William J. Brennan, Jr., Thurgood Marshall, John Paul Stevens
Place
Washington, D.C.
Date of Decision
25 June 1990
Decision
The Court upheld the Missouri State Supreme Court's decision rejecting the Cruzans' petition to withdraw food and water from their daughter.
Significance
In a first for the U.S. Supreme Court, it entered into the debate surroundingthe right-to-die argument, and concluded that the state, in the interests ofsafeguarding human life at all costs, may overrule relatives and medical professionals on specific human life issues. Some analysts tied the Cruzan case--and its appearance at the High Court--to the abortion question, pointing out that it paved the way for increasing judicial intrusions into citizens' privacy.
The Accident
Nancy Beth Cruzan was 25 years old when her car slid out of control on an icyMissouri road and rolled over one January night in 1983. Ejected from the car, she landed in a ditch, and by the time an ambulance arrived and restored vital signs, her brain had been without necessary oxygen for an estimated 12 to 14 minutes; brain damage occurs after six minutes without oxygen. This lefther in what doctors defined as a "permanent vegetative state"--she was awake, but unaware; she had some motor reflexes but showed no evidence of cognitive abilities. She could not move, speak, or communicate in any way, though nurses at the Missouri Rehabilitation Center did report that Cruzan was able toturn her body toward someone who spoke to her, and cried on one occasion whena valentine card was read aloud to her. The rest of her body survived the accident relatively intact and, to ease care, doctors surgically implanted a tube in her stomach that provided food and water. Cruzan's life expectancy in this condition was estimated at another 30 years.
By 1988, Cruzan's family had lost hope that their daughter might emerge fromher vegetative state. Her parents, Lester and Joyce Cruzan, asked doctors atthe center to disconnect the feeding tube, on the grounds that their daughterhad, as an adult, made definite statements that if she were to become chronically ill or seriously injured she would not want to live, unless she could get by at least somewhat normally. A local probate court granted authorizationto remove the tube, but the state's attorney general, William L. Webster, filed an appeal on the grounds that the parents and a court-appointed legal guardian had not sufficiently proved that Cruzan had once made such statements about refusing medical treatment. The Missouri State Supreme Court reversed the lower court's decision, and the Cruzans appealed to the U.S. Supreme Court.
Who Decides?
It was the first time the High Court had entered into the right-to-die question, treading waters customarily the domain of theologians and philosophers. (The question had arisen in the courts before, most notably with In the Matter of Quinlan (1976), but the High Court had declined to review the NewJersey State Supreme Court decision.) Conservatives and the spiritually devout offered the argument that life is precious, and must be preserved at all costs. The state arugued that it is required to protect all life, which negatesany wishes of Cruzan or her parents. The Cruzan case was often twinned in discussions with another significant case pending before the court regarding abortion. In each issue, the justices discussed the constitutional rightto privacy and which person or party could carry out such decisions on behalf of another.
The family's lawyer, William H. Colby, presented the argument that Cruzan hadsaid on several occasions that in the case of illness or accident, she wouldprefer not to live her remaining days on a life-support system, as many people often remark when the issue arises in conversation. Arguing the issue forthe Missouri Department of Health, Assistant State Attorney General Robert L.Presson contended that Cruzan's utterances were not specific enough, and were inadmissible as reliable statements in a court of law. Presson asserted that Missouri was acting in Cruzan's best interest in keeping her alive and nourished, and furthermore, that her parents, even as guardians, did not possessany constitutional right to end her life. The Court's role was to determine whether the secondhand oral testimony was indeed sufficient evidence, and ultimately, since Cruzan was unable to communicate her wishes, whether her familyor the state had jurisdiction over her life.
Defining Life
Another side of the Cruzan question concerned advances in medical technology late in the twentieth century. Medical advances created machines thatcould perform essential respiratory and cardiac functions. In such situations, some argue, a clearer definition of "life" should be put forward--is the person a thinking, viable being, capable of surviving with no outside assistance? Countering that argument against the "quality" versus the mere "presence"of life are deeper religious beliefs; many argue that a supreme being is thegiver of life, and as such should be the only one able to end it. In this case, however, Cruzan was assisted by a surgically implanted feeding tube. Thismeasure, according to the American Medical Association, is classified as "medical treatment," and thus may be refused.
On the other hand, some medical ethicists argue that food and water comprise"basic care" and thus fall under the standard extension of kindness that humans must give one another. The Justice Department prepared a brief on the issue prior to the arguments presented for the Cruzan case, and conceded that current government policy allowed family members, in consultation with staff physicians, to decide whether or not to continue life-support measures for permanently incapacitated patients in veterans and army hospitals.
The Cruzan case also tackled the issue of "informed consent," or a person's ability to understand issues related to their medical care, and with that the granting of permission to doctors to carry them out. Yet this does notaddress the person who is unable to make decisions. One legal precedent in this area came with a decision made by the New York State Supreme Court in 1980, in which presiding Judge Sol Wachtler ruled that medical treatment could be withdrawn at the request of a patient's legal guardian, if the incapacitated person had made clear statement that he did not wish to be kept alive by heroic measures.
Court Rejects Parents' Appeal
Cruzan v. Director, Missouri Department of Health was argued in December of 1989 and seven months later, Chief Justice Rehnquist delivered a majority opinion supporting the 5-4 decision of the Missouri Supreme Court, declaring that the state did indeed have the right to preserve life at all costs. Rehnquist noted in his opinion that the oral evidence presented to the Court byCruzan's roommate, relating remarks Cruzan had made about not wishing to live life in a hospital bed, did not offer convincing proof of her wishes, and that her parents, as legal guardians, could not overrule. Rejecting the precedent set by the New York case, the Rehnquist opinion asserted that statementsmade by a healthy person could not constitute what that same person may havewished under other circumstances--in other words, that a competent person would not decide to starve.
A few months after the Supreme Court ruling in June of 1990, the Cruzan family again went before the original local court in Missouri to present more concrete testimony from witnesses regarding statements their daughter had made, and this time the court granted permission to remove the feeding tube. Nursesat the Missouri Rehabilitation Center opposed the decision, and spoke out publicly, noting that it was illegal to withhold food from a dog, and that theydid not wish to have Cruzan's death occur willfully while under their care. Cruzan passed away 12 days later with her parents at her bedside.
Related Cases
- In the Matter of Quinlan, 355 A.2d 647 (1976).
- Compassion In Dying v. State of Washington, 49 F.3d 586 (1995).
Discontinuance of Life-support v. Assisted Suicide
The right to refuse medical treatment is a constitutionally protected libertyinterest. Unlike assisted suicide, it lacks the potential element of abuse because patients can establish future previsions to discontinue life support systems such as a living will. Additionally, if the patient is unable to articulate his views or has not signed a living will, family members can express the patient's desire to discontinue life support. Family members can recall conversations during which the patient expressed a desire not to continue withlife support. Furthermore, if there is a disagreement among family members about the patient's desire it is easier to determine which side of the family is correctly expressing the patient's wishes.
Yet some argue there is little difference between ending life support and intervening to promote death. Others assert that a patient's physician can moreaccurately reflect and act on the patient's desire without the emotional entanglements that could hinder the family's judgement. Just as the family membercan discuss the patients' wishes, the doctor based on his relationship withthe patient prior to the illness, would have the same information.
Sources
Constitutional Law: Thirteenth Edition New York City, NY: The Foundation Press Inc., 1997.
Further Readings
- Kinsley, Michael. "To Be Or Not to Be." New Republic, 27 November 1989, p. 6.
- "Right-to-Die Case Argued." Congressional Quarterly Weekly Report,9 December 1989, p. 3370.
- Sanders, Alain L. "Whose Right to Die?" Time, 11 December 1990, p.80.
- Urofsky, Melvin I. Letting Go: Death, Dying, and the Law. New York: Charles Scribner's Sons, 1993.
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