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No. 88-1503
June 25, 1990
Related constitutional provision: US Constitution, Amendment XIV, Section 1. nor shall any state
deprive any person of life, liberty, or property, without due process of law
Nancy Beth Cruzan was rendered incompetent as a result of severe injuries sustained during an
automobile accident. She now lies in a Missouri state hospital in what is referred to as a persistent
vegetative state (characterized by absence of significant cognitive function). After it had become apparent
that Nancy had virtually no chance of regaining her mental faculties, her parents asked hospital
employees to terminate the artificial nutrition and hydration procedures which would ultimately cause her
death. The hospital employees refused to honor the request without court approval.
The parents then sought and received authorization from the state trial court for termination. The
court said that a person in Nancys condition has a fundamental right under the State and Federal
Constitutions to direct or refuse the withdrawal of death-prolonging procedures. Additionally, the court
found that Nancy expressed 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. Hence, the request for termination was granted.
The case then reached the State Supreme Court of Missouri. The court questioned the
applicability of the right to refuse treatment embodied in the common-law doctrine. Missouri recognized
that, under certain circumstances, a surrogate may act for the patient in electing to have hydration and
nutrition withdrawn in such a way as to cause death. But it has established a procedural safeguard to
assure the action of the surrogate conforms as best it may to the wishes expressed by the patient while he
was still competent. Missouri requires that evidence of the incompetent's wishes as to the withdrawal of
treatment be proved by clear and convincing evidence. The court held that Nancys wishes to her former
roommate did not pass the clear and convincing standard for evidence. Thus, the State Supreme Court
reversed the decision of the trial court.
Hence, this petition.
1. Whether the United States Constitution grants what is in common parlance referred to as a right to
2. Whether the United States Constitution forbids the establishment by Missouri of a procedural
requirement, such as the clear and convincing evidence standard.
1. Yes.
The Fourteenth Amendment provides that no State shall deprive any person of life, liberty, or
property, without due process of law. By applying this provision in previous cases, the Court had
consistently upheld the right to liberty of a person over the interest of the state to preserve life, thus
establishing the principle that a competent person has a constitutionally protected liberty interest in
refusing unwanted medical treatment.
Since the principle applies to a competent person, it must necessarily apply to incompetent
persons as well. However it may sometimes be unable to know the will of the incompetent person with
complete certainty. In such cases, a certain degree of standard must be followed to ascertain the will of the
incompetent person. Missouri used the clear and convincing evidence standard. Thus, it is now necessary
to inquire whether such standard of the State is allowed by the US Constitution.
2. No.

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. In order to protect its interests, Missouri established the
clear and convincing evidence standard. This standard is applied in cases where the individual interests
Prepared by: Daniel John A. Fordan


at stake are both particularly important and more substantial than mere loss of money. The current case
falls squarely in this condition, therefore the application of such standard is only appropriate.
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 life-sustaining treatment. An erroneous decision not
to terminate may 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.
In sum, Missouris proof of requirement was able to validly protect its interest and at the same
time recognize the liberty of the person. Hence, rather than deprivation of liberty, a balance of power and
right is achieved.

Prepared by: Daniel John A. Fordan