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Nancy Cruzan

Cruzan v. Director, Missouri Department of Health, et al, 497 U.S. 261; 110 S. Ct. 2841; 111 L. Ed. 2d 224; 1990 U.S. Lexis

In January 1983, twenty-five-year old Nancy Cruzan lost control of her car as she traveled down a Missouri road. The car overturned, and she was discovered, lying face down in a ditch, without detectable respiratory or cardiac function. Emergency medical technicians were able to restore her breathing and heartbeat, and she was transported to a hospital in an unconscious state. A neurosurgeon there diagnosed her as having sustained probable brain damage, compounded by significant oxygen deprivation. The estimated length of the period without oxygen was twelve to fourteen minutes. (Permanent brain damage generally results after six minutes without oxygen.) Cruzan remained in a coma for approximately three weeks, and then progressed to an unconscious state in which she was able to orally ingest some nutrition. In order to ease feeding and further her recovery, surgeons implanted a feeding and hydration tube with the consent of her then husband. In October 1983, she was admitted to a state hospital. Subsequent rehabilitative efforts proved unsuccessful. It became apparent that she had virtually no chance of regaining her mental faculties, and her parents—who had been appointed as her coguardians—asked the hospital to terminate the medically assisted nutrition and hydration procedures. The hospital refused to honor the request without court approval.

The Cruzans then filed a declaratory judgment action in a Missouri trial court, in which they sought judicial authorization of their request. A guardian ad litem was appointed for Nancy. The trial court, following a hearing, entered an order directing the hospital to follow the parent's instructions, based upon its findings on (1) the permanent and irreversible damage that she had suffered as a result of prolonged oxygen deprivation; (2) its belief that a person in Cruzan's condition had a fundamental right under the Missouri and Federal Constitutions to refuse or direct the withdrawal of "death prolonging procedures"; and (3) her expressed thoughts at age twenty-five, in somewhat serious conversation with her housemate, that if sick or injured, she would not wish to continue her life unless she could live at least halfway normally, suggested that she would not wish to continue on with her nutrition and hydration given her present condition.

Both the state and the guardian ad litem appealed. The Supreme Court of Missouri, reversing the lower court, expressed the view that (1) although Cruzan was in a "persistent vegetative state," she was neither dead within the meaning of Missouri's statutory definition of death nor terminally ill; (2) Cruzan's right to refuse treatment—whether such right proceeded from a constitutional right of privacy or a common-law right to refuse treatment—did not outweigh Missouri's strong policy favoring the preservation of life, as embodied in the Missouri living will statute; (3) her conversation with her housemate was unreliable for the purpose of determining her intent, and thus insufficient to support the parents' claim to exercise substituted judgment on her behalf; and (4) no person could assume the choice of terminating medical treatment for an incompetent person in the absence of either the formalities required under the living will statute or "clear and convincing, inherently reliable evidence," which was absent in Cruzan's case.

The United States Supreme Court upheld that ruling. It found that due process was not violated by the Missouri requirement that an incompetent person's wishes in regard to the withdrawal of life-sustaining treatment be proved by clear and convincing evidence. In the end, however, further witnesses satisfied Missouri courts that such clear and convincing evidence of her wishes did exist, and medically assisted nutrition and hydration were removed in December of 1990. Cruzan died two weeks later. Missouri now allows health care directives (though not living wills) to instruct that medically assisted nutrition and hydration be removed after a diagnosis of permanent or persistent vegetative state has been made. (See Withholding and Withdrawing Treatment, the Principle of Respect for Autonomy, and Surrogate Decision Making.)

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