In Cruzan v. Director, Missouri Department of Health, decided 5–4 in June 1990, the Supreme Court ruled for the first time that a competent adult has a constitutionally protected liberty interest in refusing unwanted medical treatment, including artificial nutrition and hydration. But it also held that when a patient cannot speak for herself, a state may require clear and convincing evidence of what she would have wanted before family or anyone else can end life-sustaining care on her behalf. That second half of the ruling is why advance directives became a standard part of American healthcare.
What the Supreme Court Held
Chief Justice Rehnquist wrote the majority opinion, joined by Justices White, O’Connor, Scalia, and Kennedy. The Court did two things at once.
First, it recognized the right. The majority said a competent person’s interest in refusing medical treatment “may be inferred from our prior decisions” under the Fourteenth Amendment’s Due Process Clause, and it assumed the Constitution would protect that right even when the treatment refused is food and water delivered through a tube.1Library of Congress. Cruzan v. Director, MDH, 497 U.S. 261 (1990) No prior Supreme Court decision had gone that far.
Second, it upheld Missouri’s evidentiary rule. Because Nancy Cruzan could not communicate her own wishes, someone else would have to speak for her, and the state had a legitimate interest in making sure that surrogate was accurate. Missouri could therefore demand clear and convincing evidence that the patient herself would have chosen to end treatment before allowing anyone to make that decision on her behalf.2Legal Information Institute. Cruzan v. Director, Missouri Department of Health (497 U.S. 261) The Court affirmed the Missouri Supreme Court, which had rejected the family’s request.
How the Case Reached the Court
On January 11, 1983, Nancy Cruzan’s car overturned on a rural road outside Carthage, Missouri. She was thrown from the vehicle and landed face-down in a water-filled ditch, and by the time paramedics restarted her heart her brain had been without oxygen for an estimated 12 to 20 minutes. She was left in a persistent vegetative state: cycles of sleep and wakefulness, involuntary reflexes, no awareness. A surgically implanted feeding tube kept her alive.
After years without improvement, her parents, Lester and Joyce Cruzan, asked the hospital to remove the tube. They pointed to conversations in which Nancy had said she would not want to be kept alive unless she could live “at least halfway normally.” The hospital refused without a court order. A Missouri trial judge sided with the family, but the Missouri Supreme Court reversed, finding Nancy’s informal remarks too casual to serve as reliable proof of her wishes. The Cruzans took the case to Washington.
What “Clear and Convincing Evidence” Means Here
Clear and convincing evidence is the middle tier of proof in American courts. It requires more than the “more likely than not” standard used in ordinary civil suits but less than the “beyond a reasonable doubt” standard used in criminal cases. In practice, it means a firm belief that the fact being proved is highly probable.3Ninth Circuit District & Bankruptcy Courts. Burden of Proof – Clear and Convincing Evidence
Applied to end-of-life decisions, this is a demanding threshold. A vague recollection that someone once said she “wouldn’t want to live like that” will usually not clear it. The evidence needs to be specific, consistent, and persuasive enough that a judge can be firmly convinced this particular patient would have refused this particular treatment. The Supreme Court reasoned that because the decision to withdraw care is irreversible, Missouri could place the risk of error on the people asking to end treatment rather than on the patient.2Legal Information Institute. Cruzan v. Director, Missouri Department of Health (497 U.S. 261)
One boundary worth flagging: Cruzan did not force every state to adopt Missouri’s strict rule. It held only that a state that chooses this level of proof does not violate the Constitution. Some states use a lower threshold, and many allow a designated surrogate to decide when no advance directive exists. The rules where you live may be less demanding than the rules Nancy Cruzan’s family faced.
What Happened to Nancy Cruzan
The Supreme Court’s decision sent the case back to Missouri, where the family now knew exactly what the standard required. Their attorney found additional friends of Nancy’s who had not testified at the original trial. Their accounts of conversations with Nancy were detailed and consistent: she had said clearly that she would not want to be kept alive by machines in a vegetative state.
Probate Judge Charles E. Teel Jr. heard the new testimony and ruled that it met the clear and convincing evidence standard. He authorized removal of the feeding tube on December 14, 1990. Nancy Cruzan died on December 26, 1990, nearly eight years after the accident.
How the Ruling Changed Hospital Practice
Within months of the decision, Congress passed the Patient Self-Determination Act, which took effect in December 1991. The law applies to every hospital, nursing facility, home health agency, and hospice program that accepts Medicare or Medicaid funding.4Office of the Law Revision Counsel. 42 U.S. Code 1395cc – Agreements with Providers of Services
Those facilities have to inform you at admission of your right under state law to accept or refuse treatment and to create an advance directive. They must ask whether you already have one and document your answer in your medical record. They cannot condition your care on whether you have signed one. They must follow a valid directive to the extent state law allows, or transfer you to a facility that will. And they have to educate their staff and community about these rights.4Office of the Law Revision Counsel. 42 U.S. Code 1395cc – Agreements with Providers of Services
The statute does not create advance directives itself or dictate what form they take. It only guarantees that patients hear about them. Before 1991, many people had never encountered the concept of a living will, and hospitals had no duty to raise it.
What Cruzan Means for You
The practical lesson of the case is direct. If you do not document your wishes while you are competent, the people who love you may not be legally permitted to carry them out, no matter how certain they are of what you would want. Advance directives close that gap, and they generally come in two forms.
A living will is a written document that specifies which treatments you would accept or refuse if you cannot communicate. It can address resuscitation, mechanical ventilation, and artificial nutrition and hydration. Its limitation is that no document can anticipate every diagnosis, and language that reads clearly today can turn ambiguous when applied to an unforeseen situation.
A healthcare proxy, sometimes called a durable power of attorney for healthcare, names a person you trust to make medical decisions for you. That person can respond to the actual circumstances, talk with the doctors, and exercise judgment in ways a written form cannot.
Most estate planning attorneys recommend both. The living will records your values and preferences in your own words. The proxy gives a trusted person the authority to handle situations the living will did not foresee. Together they supply exactly the kind of proof the Cruzan Court said was missing. Every state recognizes some form of advance directive, though the execution requirements, such as witnesses or notarization, vary. Signing these documents while you are healthy costs little and can spare your family the kind of years-long legal fight the Cruzans went through.