Cruzan v. Director, Missouri Dept. of Health

Following is the case brief for Cruzan v. Director, Missouri Dept. of Health, 497 U.S. 261 (1990)

Case Summary of Cruzan v. Director, Missouri Dept. of Health:

  • Nancy Cruzan was in a car accident that resulted in her being in a constant vegetative state, needing artificial means to remain alive.
  • The hospital refused to remove Cruzan’s life support at the request of Cruzan’s family without a court order.
  • Uncontested testimony at trial established that Cruzan would not have wanted to remain alive under the circumstances.
  • The trial court found for Cruzan’s family, but the Missouri Supreme Court reversed.  It held that Cruzan’s wishes were not proven by clear and convincing evidence.
  • The U.S. Supreme Court affirmed the Missouri Supreme Court’s decision, holding that the State’s interest in preserving life must be balanced against an incompetent patient’s wishes, and that a clear-and-convincing evidentiary standard does not violate the Constitution.

Cruzan v. Director, Missouri Dept. of Health Case Brief

Statement of the Facts:

In 1983, Nancy Cruzan was in a car accident.  The accident left her in a persistent vegetative state, whereby she would exhibit some motor reflexes but had no indication of brain function.  Cruzan’s family wished to take her off of life support.  Hospital employees, however, refused to remove life support without a court order.

Procedural History:

  • Following a trial, the court held that a person in Cruzan’s condition has the right to seek withdrawal of artificial means to remain alive, and that the testimony from a former housemate about Cruzan’s wishes was credible.
  • The Missouri Supreme Court reversed, finding that no person can make a choice for an incompetent person on medical treatment absent clear and convincing evidence of the patient’s wishes.
  • The U.S. Supreme Court granted certiorari.

Issue and Holding:

Does a State law that requires a patient’s family to prove the patient’s wishes to remove artificial means to sustain life by clear and convincing evidence violate the Constitution?  No.


The decision of the Missouri Supreme Court is affirmed.

Rule of Law or Legal Principle Applied:

A State may constitutionally require evidence of an incompetent patient’s wishes by clear and convincing evidence before removing life support.


The issue here is whether the Constitution prohibits Missouri from having a clear-and-convincing evidentiary standard before removing life support for an incompetent patient.  The due process right of refusal of treatment is different for incompetent patients, because it is unclear what an incompetent patient wants.  Therefore, the State’s interest in maintaining the life of the patient is a proper State interest justifying a procedural safeguard like a heightened standard of proof.  Thus, the State Supreme Court did not violate the Constitution by finding that clear and convincing evidence did not exist here. Indeed, the judgment of close family members does not become a constitutional requirement.

Concurring and Dissenting Opinions:

Concurring Opinion (O’Connor):

The refusal of artificial means of staying alive is a protected liberty interest.  Thus, the Court’s decision today does not foreclose a State from using other methods to protect the liberty interest in refusing medical treatment.

Concurring Opinion (Scalia):

The agonizing issues in this case mirror the same interests involved in the Court’s line of abortion cases.  Yet, the Court should not be in the business of making choices as to when a life is “worthless,” or when it is time for extraordinary measures to cease in keeping a patient alive.  The Constitution does not address the situation, and nine justices are no better at making those decisions than any other random person.  These questions should be left to the states.

Dissenting Opinion (Brennan):

Medical technology now allows people to be in a “twilight zone of suspended animation where death commences while life, in some form, continues.”  Cruzan has been in that state for six years.  Her wishes should be honored, and the State’s right to preserve life does not outweigh those wishes.

Dissenting Opinion (Stevens):

The Court is wrong to allow the State’s abstract interest in preserving life to outweigh Cruzan’s wishes, which were undisputed at trial.


Cruzan v. Director, Missouri Dept. of Health is a landmark case because it gave strong deference to a State’s interest in the preservation of life when balancing that interest against the wishes of an incompetent patient to remove life support.

Student Resources:

Read the Full Court Opinion

Listen to the Oral Arguments