Legal Definitions - Cruzan v. Missouri Department of Health (1990)

The case of Cruzan v. Missouri Department of Health (1990) is a landmark United States Supreme Court decision that addressed the complex issue of an individual's "right to die," particularly when that individual is no longer able to communicate their wishes.

At its core, the Court considered whether a state could require a high standard of proof – specifically, "clear and convincing evidence" – before allowing the removal of life-sustaining treatment from a patient who is in a persistent vegetative state and cannot make decisions for themselves. The Court affirmed that while competent individuals have a constitutional right to refuse medical treatment under the Due Process Clause of the Fourteenth Amendment, states have a legitimate interest in protecting life. Therefore, for individuals who are no longer competent, states can impose a stringent requirement for evidence to ensure that decisions about ending life support truly reflect the patient's own previously expressed wishes, rather than the preferences of family members or others.

This ruling established that without "clear and convincing evidence" of an incompetent patient's specific desire to refuse life-sustaining treatment, a state is not obligated to permit its removal.

Here are some examples illustrating the principles established in Cruzan v. Missouri Department of Health:

• Example 1: Informal Statements vs. Formal Directives

  Imagine Mr. Harrison, an 85-year-old man, who suffers a severe stroke and falls into a coma with no hope of recovery. His children tell the hospital staff that their father often said, "I never want to be kept alive by machines." However, Mr. Harrison never signed an advance directive or living will. Following the precedent of Cruzan, the hospital, adhering to state law, might require more than these informal, anecdotal statements. They would seek "clear and convincing evidence" – such as a legally executed document or consistent, documented conversations with medical professionals – to be certain of Mr. Harrison's wishes before considering the removal of life support. Without such evidence, the state's interest in preserving life would likely prevail, requiring continued treatment.

• Example 2: Absence of Prior Wishes and Family Disagreement

  Consider Ms. Chen, a 30-year-old who is in a persistent vegetative state after a sudden, catastrophic accident. She had never discussed her end-of-life preferences with anyone, nor had she completed any legal documents. Her parents are deeply divided: one believes she would not want to live in this condition and advocates for removing life support, while the other insists on continuing all possible medical interventions. In this scenario, because Ms. Chen is incompetent and there is no "clear and convincing evidence" of her wishes, the principles from Cruzan would likely lead to the continuation of life support. The state's high standard of proof protects against decisions made without a clear understanding of the patient's own intent, especially when family members disagree.

• Example 3: Valid Advance Directive as Clear and Convincing Evidence

  Suppose Dr. Evans, a 70-year-old physician, was diagnosed with a progressive neurological disease. Years before becoming incapacitated, he meticulously prepared and legally executed an advance directive (often called a living will), explicitly stating that if he were to enter a persistent vegetative state with no reasonable hope of recovery, he would refuse artificial nutrition and hydration. When Dr. Evans eventually reaches this condition, his advance directive serves as the "clear and convincing evidence" of his wishes that the Cruzan decision requires. In this instance, the medical team and his family can proceed with honoring his documented choices, knowing that his explicit intent is being respected, even though he is no longer able to communicate.