Cruzan Ex Rel. Cruzan v. Director, Missouri Department of Health
The Supreme Court ruled that Missouri could lawfully require clear and convincing evidence of an incapacitated patient's own wishes before allowing her family to stop artificial feeding and hydration, and it upheld Missouri's refusal to end Nancy Cruzan's tube feeding based on the evidence presented.
The decision was the Court's first recognition that people have a constitutional liberty interest in refusing unwanted medical treatment, but it also confirmed that states can set tough evidentiary rules for family members deciding on behalf of an incapacitated loved one, shaping how end-of-life decisions are made nationwide.
“we conclude that a State may apply a clear and convincing evidence standard in proceedings where a guardian seeks to discontinue nutrition and hydration of a person diagnosed to be in a persistent vegetative state.”
The Court's core holding upholding Missouri's heightened evidence standard.
How it got here: A Missouri trial court authorized removing the feeding tube; the Missouri Supreme Court reversed, finding insufficient clear and convincing evidence of Nancy's wishes; her parents sought Supreme Court review.
The Case in Depth
What happened
Nancy Cruzan was left permanently unconscious after a 1983 car accident and was kept alive by a surgically implanted feeding tube in a Missouri state hospital. Her parents, convinced she would not want to continue in this condition based on statements she made before the accident, asked the hospital to remove the tube. The hospital refused without a court order.
The question before the Court
Could Missouri require clear and convincing proof of a permanently unconscious patient's own wishes before letting her family end her artificial feeding?
The Court's answer
Partly — the Court assumed, without fully deciding, that a competent person has a constitutional right to refuse life-sustaining food and water, but it held Missouri did not violate the Constitution by requiring clear and convincing evidence of an incapacitated patient's own wishes before her family could act on her behalf. Because an incapacitated person cannot exercise that right personally, the Court said states may set procedural safeguards to make sure a surrogate's decision truly reflects what the patient herself would have chosen.
Weighing Nancy Cruzan's interests against Missouri's interest in protecting life and guarding against mistaken or self-interested family decisions, the Court found the heightened evidence standard reasonable, partly because a wrongful decision to end treatment can never be undone. Since the only evidence of her wishes was informal, indirect statements, the Court upheld Missouri's conclusion that this evidence was not clear and convincing enough.
Curious how the Court got there? See the step-by-step legal reasoning →
Why it matters
The ruling gave states broad room to set strict rules for end-of-life decisions made on behalf of incapacitated patients, encouraging the spread of living wills and health care proxies so people's wishes are documented in advance. Families without such documents may face a heavier burden in court to stop unwanted life-sustaining treatment for a loved one.
What changes now
The ruling is a final decision on the merits, not a temporary order. It left Missouri's judgment against removing the feeding tube in place, though the case did not end there in practice — new evidence about Nancy Cruzan's wishes was later presented to Missouri courts, which permitted the feeding tube's removal after this decision. More broadly, the case set the constitutional floor for how states may regulate end-of-life decisions for incapacitated patients going forward.
What this does not decide
The Court expressly did not decide whether the Constitution requires a state to honor decisions made by a health care proxy or surrogate the patient herself appointed, or whether a state must defer to family members' substituted judgment when there is some, but not clear and convincing, evidence of the patient's wishes. States remain free to adopt different approaches to these questions.
Concurrences and dissents
Concurrence — Justice O'Connor
Justice O'Connor agreed the liberty interest covers artificial feeding but wrote to explain why: state incursions into the body have long been treated as intrusions on constitutionally protected liberty. She also stressed that the Court had not decided whether states must honor surrogate decisionmakers or durable-power-of-attorney appointees, suggesting such a duty might well be constitutionally required in the future.
Concurrence — Justice Scalia
Justice Scalia joined the majority in full but wrote separately to argue the federal courts have no business in this area at all. He contended American law has always let states treat refusal of life-sustaining care as a form of suicide that states may prevent, and that no constitutional line exists for when life becomes not worth preserving, leaving that choice to state legislatures.
Dissent — Justice Brennan
“Nancy Cruzan is entitled to choose to die with dignity.”Justice Brennan's summary of why he would have ruled for Cruzan's family.
Justice Brennan argued Nancy Cruzan has a fundamental right to be free of unwanted artificial nutrition and hydration that outweighs any state interest, since Missouri's only interest was an abstract preservation-of-life interest with no third party affected. He would have struck down Missouri's evidentiary rule as impermissibly biased against terminating treatment and would have credited the family's and guardian's uncontradicted views of her wishes.
Dissent — Justice Stevens
Justice Stevens argued the majority wrongly let Missouri's abstract interest in preserving biological life override Nancy Cruzan's own best interests, which the trial court had found would be served by ending treatment. He contended the state was effectively imposing its own definition of what counts as a meaningful life rather than protecting Cruzan's actual interests, and would have required the state to respect the uncontested best-interests finding.
How the Court got there
The legal reasoning, step by step
- The Court first asked whether a competent person has a liberty interest, protected by the Due Process Clause, in refusing unwanted medical treatment, and concluded that such an interest can be inferred from earlier cases about bodily intrusion and forced medical care, and that it would extend to refusing artificial food and water.
- For purposes of the case, the Court assumed a competent person would have a constitutional right to refuse life-sustaining hydration and nutrition, but noted that an incapacitated person cannot exercise that right personally and must act through a surrogate, which raises the separate question of what process a state may require before honoring a surrogate's choice.
- The Court then balanced the patient's liberty interest against the state's interests, including protecting life, guarding against family members whose views might not truly reflect the patient's own wishes, and avoiding factfinding proceedings that lack the safeguards of a normal adversarial trial.
- Applying a framework used in other cases involving important individual interests, the Court held that Missouri could constitutionally choose a heightened 'clear and convincing evidence' standard of proof, reasoning that an erroneous decision to keep treatment going can be undone later, while an erroneous decision to withdraw it cannot.
- Because Missouri could require this heightened standard, and because the evidence of Nancy Cruzan's wishes consisted mainly of informal statements to a former housemate that did not directly address withdrawing tube feeding, the Court found no constitutional error in the state court's conclusion that the evidence fell short.
- The Court separately rejected the argument that the Constitution forces a state to accept family members' own judgment about what an incapacitated patient would have wanted, holding that a state may instead choose to honor only the patient's own clearly expressed wishes.