Landmark case law

Cruzan v. Director, Missouri Department of Health

U.S. 261 (1990) was a United States Supreme Court case argued on December 6, 1989 and decided on June 25, 1990. In a 5-4 court decision, the court found in favor of the Missouri Dept. of Health. The court affirmed the ruling of the Supreme Court of Missouri. However, it upheld the legal standard that competent persons are able to exercise the right to refuse medical treatment under the Due Process Clause and its implied right to privacy. Because there was no “clear and convincing evidence” of what Nancy Cruzan wanted, the court upheld the state’s policy.

Background
On the night of January 11, 1983, Nancy Cruzan lost control of her vehicle while traveling down Elm Road in Jasper County, Missouri. Cruzan’s vehicle had overturned, ejecting her from it, and Cruzan was discovered lying face down in a ditch. At the time of discovery, she was found to have no pulse or respirations. However, paramedics were able to restore her breathing and heartbeat at the accident site. She was then transported to the hospital in an unconscious state. The attending Neurologist diagnosed Cruzan of sustaining probable cerebral contusions stating that her upper brain, or the cerebral hemispheres, were too damaged to function. The part of the brain that controls thinking and feeling, the ability to move purposefully, compounded by a significant lack of oxygen, estimating that she was deprived of oxygen from between 12 to 14 minutes. After 3 weeks in a coma she progressed into an unconscious state, but in order to provide nutrition and fluids, with the written permission of her then husband, surgeons implanted a gastrostomy feeding and hydration tube. All other rehabilitative services were unsuccessful, Cruzan was in a vegetative state and the decision to move her to a Missouri State hospital was made with Missouri covering the cost of her care after her insurance run out. Nancy’s husband had their marriage dissolved by a court, and her parents became co-guardians.

History of the Case- State Trial Court 1987
After 5 years it became apparent to Cruzan’s parents that Cruzan had no chance of regaining her mental capabilities, that she would remain in a vegetative state, and that the only thing keeping her alive was the nutrition being provided by the feeding/hydration tubes. They asked hospital employees to terminate the artificial feedings and hydration, which was refused by the hospital, unless they could obtain court approval. Her parents, acting as co-guardians, filed a declaratory judgment action seeking authorization of termination from the State Trial Court. The State Trial Court found that a person in Nancy’s condition had a fundamental right under the State and Federal Constitutions to refuse or direct the withdrawal of “death prolonging procedures.” The State Trial Court also found that Nancy’s “expressed thoughts at age twenty-five in a somewhat serious conversation with a housemate friend, that if sick or injured, she would not wish to continue her life unless she could live at least halfway normally, suggests that given her present condition she would not wish to continue on with the nutrition and hydration. (Supreme Court 1990-Google Scholar)

Supreme Court of Missouri 1988
The Supreme Court of Missouri reversed the decision of the State Trial Court, by a 4-3 divided vote. It granted certiorari based on utilizing cases such as, but not limited to, Schloendorffv.Society of New York Hospital, Belchertown State School v. Saikewicz and McConnell v. Beverly Enterprises-Connecticut to consider the question of whether or not Cruzan has the right under the United States Constitution, requiring the hospital to withdraw life-sustaining treatment from her under these circumstances. The four factors pertaining to the case were (1) The court acknowledged a right to refuse treatment represented in the “Common-Law Doctrine of informed consent, but conveyed skepticism about the claim of the doctrine in this case. (2) The court also declined to read a broad right of privacy into the State Constitution, which would “support the right of a person to refuse medical treatment” in every circumstance, expressing doubt as to whether or not such a right existed under the United States Constitution. It then decided that the Missouri Living Will statute embodied a state policy strongly favoring the preservation of life. (3) The court found that Cruzan’s statements to her roommate regarding her desire to live or die under certain conditions were “unreliable for the purpose of determining her intent,” making the statement “insufficient to support the co-guardians (her parents) claim” on Nancy’s behalf. (4) The court rejected the argument that Cruzan’s parents were entitled to order the termination of her medical treatment, concluding that “no person can assume that choice for an incompetent in the absence of the formalities required under Missouri’s Living Will statutes or the clear and convincing, essentially reliable evidence absent here.”

United States Supreme Court 1990
The question put before the United States Supreme Court was, “Did the Due Process Clause of the Fourteenth Amendment permit Cruzan’s parents to refuse life sustaining treatment on their daughter’s behalf?
In a 5 to 4 decision, the Court held that while individuals appreciated the right to refuse medical treatment under the Due Process Clause, incompetent persons were not able to exercise such rights. Absent “clear and convincing” evidence that Cruzan desired treatment to be withdrawn, and Cruzan’s observations that she did not want to live life as a “vegetable” did not deal in terms with withdrawal of medical treatment or of hydration and nutrition, the Court found the State of Missouri’s actions designed to preserve human life to be constitutional. Because there was no guarantee family members would always act in the best interests of incompetent patients, and because erroneous decisions to withdraw treatment were irreversible, the Court upheld the State’s heightened evidentiary requirements. The tubes would not be removed. (http://www.oyez.org/cases) The Question is… If we are living, breathing, functioning day to day people, what right do we have to decide if someone else is not? Who are we to question what another person’s living is? When do we say its “letting go” of a loved one, or terminating the existence of a human being? Do the courts have the right or power to make these decisions for us?

Opinions of the Case
Choosing the Cruzan v. Director, Missouri Department of Health is based on a relatable, personal level for me in two different manners. The first being about myself and the second, my son. At twenty-three years old, I was pregnant for our now twenty-one year old son and had become extremely ill, I had gone into full arrest on two occasions. The doctors had told my husband that one or both of us would not make it, and at one point, had told him that he would have to choose. I had always told him, baby comes first. The second, was last year my son, Stephan whom has Cerebral Palsy, as well as many other illnesses, had a full blown seizure which caused him to stop breathing. My husband and I had to administer CPR to “get him back.” This was not the only time that we have almost lost him, but definitely one of the hardest.
In this case, Nancy Cruzan’s parents had held vigil at their daughter’s bed side for five years. They decorated her hospital room each holiday, talked to her, prayed for her, and regularly spoke with her neurologists and other physicians, hoping that there would be good news. They waited five years for her to respond to them, show signs, reactions, or “wake up.” None of these things occurred. She was a shell with no “life.”
When we look at life, or living I think most of us would say that living is not just being alive, but existing in the world. We put our spirit, emotions, drive, and lust for life out there for the ones we know and love to see and, be a part of. The Cruzan’s had stated that they, along with Nancy were “caught in limbo,” the time between the death of Nancy’s “living” and the funeral. When viewed from an emotional perspective, it is easy to understand the Cruzan’s appeals, which were focused on protecting their daughter’s wishes at all costs. The legal perspective of the case, however, focuses solely on Missouri’s laws, and the Due Process Clause which was created to act as a safeguard from arbitrary denial and preserve the right to life, liberty, or property for its people. The courts stated that there was no guarantee that family members would act in the best interest of an incompetent patient. I disagree with the courts based on the fact that the Cruzan’s did not “rush” to have their daughters life terminated, they held on to hope for more than five years before they made the agonizing decision to even attempt to petition the courts. Doctors stated that Nancy could remain in her vegetative state for 30 years. That to me would mean preserving her shell, or lifeless body. That does not mean she was living. Secondly, before the accident had occurred, Nancy herself had stated that she would not want to live if she would not be able to actively care for herself. The Cruzan’s, while grieving themselves, fought to fulfill their daughters wish. Carol Colley, one of the nurses whom provided some of Nancy’s long term care stated, “You can see the hurt and pain and sorrow in their eyes. Too much love, certainly, to regard any verdict in court as a victory.”
If my husband had to make the choice I believe he would have done so according to my wishes, but, I now know that my wishes must be in writing. As my son’s legal guardians, would we be able to make such a decision if he was no longer able to be the lively, bright, smiling, and life loving young man that he is today? We all have the right to a peaceful and dignified death.

Conclusion
Nancy Cruzan’s case was the first right-to die case to be heard by the United States Supreme Court. After the case was decided the family went back and found more proof that Nancy Cruzan would have wanted her life support terminated and eventually won a court order to have her removed from life support. Cruzan died 11 days later on December 26, 1990. (“The Right to Die and Assisted Suicide”)
This case introduced the concept of a person’s right to control his or her death, causing the U.S. public to assert their position on the true value of life. It motivated people to create written wills and take caution when leaving advance instructions, in case they ever found themselves in a state like Nancy Cruzan, since people now recognized that the courts would uphold them, so long as the will met the “clear and convincing” requirements.