## Facts

- Nancy Beth Cruzan suffered severe oxygen deprivation in a 1983 automobile accident, resulting in permanent brain damage.
- After several weeks in a coma, she entered a persistent vegetative state, exhibiting reflexive responses without meaningful cognitive function.
- A surgically implanted gastrostomy tube provided long-term artificial nutrition and hydration.
- When her condition appeared irreversible, Cruzan’s parents (as co-guardians) requested removal of the feeding and hydration tube, which all agreed would cause her death.
- Hospital officials refused to withdraw the tube without court authorization.
- The trial court authorized withdrawal, relying on testimony that Cruzan had previously stated she would not want to live unless she could live “at least halfway normally.”
- The Missouri Supreme Court reversed, holding that withdrawal for an incompetent patient required either statutory compliance or clear and convincing evidence of the patient’s own wishes, and concluding the statements were insufficiently reliable.

## Issues

1. Whether the Due Process Clause of the Fourteenth Amendment prevents a state from requiring clear and convincing evidence of an incompetent patient’s wishes before allowing withdrawal of life-sustaining treatment.
2. Whether Missouri’s application of that heightened evidentiary standard to deny withdrawal of artificial nutrition and hydration violated the patient’s constitutional liberty interests.

## Decision

- The U.S. Supreme Court affirmed the Missouri Supreme Court in a 5–4 decision.
- The Court assumed that competent persons have a constitutionally protected liberty interest in refusing unwanted medical treatment.
- The Court held that a state may treat decisions for incompetent patients differently and may require heightened proof to reduce the risk that a surrogate’s choice does not reflect the patient’s own wishes.
- The Court concluded that Missouri’s clear and convincing evidence requirement was constitutionally permissible and that enforcing it on this record did not violate due process.

## Legal Principles

- The Due Process Clause protects a competent person’s liberty interest in refusing unwanted medical treatment, but that interest is not absolute and may be balanced against legitimate state interests.
- When a patient is incompetent and cannot make an informed, voluntary choice, a state may require reliable evidence that a surrogate’s requested withdrawal of life-sustaining treatment accords with the patient’s own prior wishes.
- A state may constitutionally require clear and convincing evidence of an incompetent patient’s wishes before authorizing withdrawal of life-sustaining measures, including artificial nutrition and hydration.
- States have legitimate interests in preserving life and in preventing error or abuse in end-of-life decision-making; these interests can justify heightened evidentiary safeguards.

## Conclusion

The Court upheld Missouri’s rule that life-sustaining treatment for an incompetent patient may be withdrawn only upon clear and convincing evidence of the patient’s own prior wishes, and it found no due process violation in denying withdrawal on the evidence presented.


Cruzan v. Dir., Mo. Dep’t of Health, 497 U.S. 261 (1990)