497 U.S.

261
Cruzan by Cruzan v. Director, Missouri Department of Health (No. 88-1503)
Argued: Dec. 6, 1989
Decided: June 25, 1990
___

Syllabus

Opinion, Rehnquist

Concurrence, O'Connor

Concurrence, Scalia

Dissent, Brennan

Dissent, Stevens

Syllabus
Petitioner Nancy Cruzan is incompetent, having sustained severe injuries in an automobile accident, and now lies in a
Missouri state hospital in what is referred to as a persistent vegetative state: generally, a condition in which a person
exhibits motor reflexes but evinces no indications of significant cognitive function. The State is bearing the cost of her care.
Hospital employees refused, without court approval, to honor the request of Cruzan's parents, copetitioners here, to
terminate her artificial nutrition and hydration, since that would result in death. A state trial court authorized the
termination, finding that a person in Cruzan's condition has a fundamental right under the State and Federal Constitutions
to direct or refuse the withdrawal of death-prolonging procedures, and that Cruzan's expression to a former housemate
that she would not wish to continue her life if sick or injured unless she could live at least halfway normally suggested that
she would not wish to continue on with her nutrition and hydration. The State Supreme Court reversed. While recognizing
a right to refuse treatment embodied in the common-law doctrine of informed consent, the court questioned its
applicability in this case. It also declined to read into the State Constitution a broad right to privacy that would support an
unrestricted right to refuse treatment and expressed doubt that the Federal Constitution embodied such a right. The court
then decided that the State Living Will statute embodied a state policy strongly favoring the preservation of life, and that
Cruzan's statements to her housemate were unreliable for the purpose of determining her intent. It rejected the argument
that her 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 by the Living Will statute or clear and convincing
evidence of the patient's wishes.
Held:
1. The United States Constitution does not forbid Missouri to require that evidence of an incompetent's wishes as to the
withdrawal of life-sustaining treatment be proved by clear and convincing evidence. Pp. 269-285. [p262]
(a) Most state courts have based a right to refuse treatment on the common law right to informed consent, see, e.g., In re
Storar, 52 N.Y.2d 363, 438 N.Y.S.2d 266, 420 N.E.2d 64, or on both that right and a constitutional privacy right,see, e.g.,
Superintendent of Belchertown State School v. Saikewicz, 373 Mass. 728, 370 N.E.2d 417. In addition to relying on state
constitutions and the common law, state courts have also turned to state statutes for guidance, see, e.g., Conservatorship

of Drabick, 200 Cal.App.3d 185, 245 Cal.Rptr. 840. However, these sources are not available to this Court, where the
question is simply whether the Federal Constitution prohibits Missouri from choosing the rule of law which it did.
(b) A competent person has a liberty interest under the Due Process Clause in refusing unwanted medical treatment.Cf.,
e.g., Jacobson v. Massachusetts, 197 U.S. 11, 24-30. However, the question whether that constitutional right has been
violated must be determined by balancing the liberty interest against relevant state interests. For purposes of this case, it
is assumed that a competent person would have a constitutionally protected right to refuse lifesaving hydration and
nutrition. This does not mean that an incompetent person should possess the same right, since such a person is unable to
make an informed and voluntary choice to exercise that hypothetical right or any other right. While Missouri has in effect
recognized that, under certain circumstances, a surrogate may act for the patient in electing to withdraw hydration and
nutrition and thus cause death, it has established a procedural safeguard to assure that the surrogate's action conforms as
best it may to the wishes expressed by the patient while competent. Pp. 280-285,
(c) It is permissible for Missouri, in its proceedings, to apply a clear and convincing evidence standard, which is an
appropriate standard when the individual interests at stake are both particularly important and more substantial than mere
loss of money, Santosky v. Kramer, 455 U.S. 745, 756. Here, Missouri has a general interest in the protection and
preservation of human life, as well as other, more particular interests, at stake. It may legitimately seek to safeguard the
personal element of an individual's choice between life and death. The State is also entitled to guard against potential
abuses by surrogates who may not act to protect the patient. Similarly, it is entitled to consider that a judicial proceeding
regarding an incompetent's wishes may not be adversarial, with the added guarantee of accurate factfinding that the
adversary process brings with it. The State may also properly decline to make judgments about the "quality" of a
particular individual's life, and simply assert an unqualified interest in the preservation of human life to be weighed against
the constitutionally protected interests of the individual. It is self-evident that these interests are more substantial, both
on [p263] an individual and societal level, than those involved in a common civil dispute. The clear and convincing
evidence standard also serves as a societal judgment about how the risk of error should be distributed between the
litigants. Missouri may permissibly place the increased risk of an erroneous decision on those seeking to terminate lifesustaining treatment. An erroneous decision not to terminate results in a maintenance of the status quo,with at least the
potential that a wrong decision will eventually be corrected or its impact mitigated by an event such as an advancement in
medical science or the patient's unexpected death. However, an erroneous decision to withdraw such treatment is not
susceptible of correction. Although Missouri's proof requirement may have frustrated the effectuation of Cruzan's not-fullyexpressed desires, the Constitution does not require general rules to work flawlessly. Pp. 280-285.
2. The State Supreme Court did not commit constitutional error in concluding that the evidence adduced at trial did not
amount to clear and convincing proof of Cruzan's desire to have hydration and nutrition withdrawn. The trial court had not
adopted a clear and convincing evidence standard, 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. P. 285.
3. The Due Process Clause does not require a State to accept the "substituted judgment" of close family members in the
absence of substantial proof that their views reflect the patient's. This Court's decision upholding a State's favored
treatment of traditional family relationships, Michael H. v. Gerald D., 491 U.S. 110, may not be turned into a constitutional
requirement that a State must recognize the primacy of these relationships in a situation like this. Nor may a decision
upholding a State's right to permit family decisionmaking, Parham v. J.R., 442 U.S. 584, be turned into a constitutional
requirement that the State recognize such decisionmaking. Nancy Cruzan's parents would surely be qualified to exercise
such a right of "substituted judgment" were it required by the Constitution. However, for the same reasons that Missouri
may require clear and convincing evidence of a patient's wishes, it may also choose to defer only to those wishes, rather
than confide the decision to close family members. Pp. 285-287.
760 S.W.2d 408, affirmed.
REHNQUIST, C.J., delivered the opinion of the Court, in which WHITE, O'CONNOR, SCALIA, and KENNEDY, JJ., joined.
O'CONNOR, J., post, p. 287, and SCALIA, J., post, p. 292, filed concurring opinions. BRENNAN, J., filed a dissenting
opinion, in which MARSHALL and BLACKMUN, [p264] JJ., joined, post, p. 301. STEVENS, J., filed a dissenting
opinion,post, p. 330. [p265]

Cruzan v missouri