497 U.S.

261 (1990)

Tracy Nguyen

a) The complete title and citation for the case: Cruzan, By Her Parents and Co-Guardians, Cruzan
ET UX. v. Director, Missouri Department of Health, ET AL., 497 U.S. 261 (1990)
b) Explain which court decided this case: Missouri district court first took on the case by the
request of the Cruzan family. The case was soon appealed to the Missouri Supreme Court by the
director of the Missouri Department of Health. Because they were unsatisfied with the ruling
from the Missouri Supreme Court, the Cruzan family appealed the case to the U.S. Supreme
Court but lost the case again. Four months later, the Cruzan’s renewed the case and brought it
up to the Missouri district court again. (Gaudin, 1991).
c) How did the case get to the court? Discuss the procedural history of the case: Nancy Cruzan
was in a car accident on January 11, 1983 in Jasper County, Missouri and was found faced down
in a ditch unbreathing with no cardiac movement. When the paramedics arrived, they were able
to restore her breathing and heartbeat but when she was brought to the hospital, the attending
neurosurgeon reported Nancy Cruzan had no oxygen flow to her brain for approximately 12 to
14 minutes. Cruzan soon fell into a comatose state for three weeks and progressed into a
vegetative state in which she was only able to orally consume nutrients. By the consent of her
then husband, surgeons were able to place a gastrostomy feeding and hydration tube in her.
Nancy Cruzan was only able to live by her feeding and hydration tube and continued to stay in a
vegetative state with no signs of cognitive function at a Missouri state hospital. She could
occasionally open and moved her eyes but there were no signs of recognizing her family and she
constantly had occasional seizures, vomits, and diarrhea from bad bowel movements. The State
of Missouri had to pay for all of Nancy Cruzan’s medical expenses. After five years in a
vegetative state, Nancy’s parents asked if the hospital could take out Nancy’s feeding and
hydration tube and let Nancy pass away. The hospital declined this request because no medical
procedures will be active unless consent is given by the patient. Unfortunately, in Nancy’s state,
she is unable to give consent and the hospital stated that health providers will not pull out the
tubes without court approval. Thus, the Cruzan’s brought this case up to the Missouri district
court for court approval. (Cruzan v. Director, Section 266, 1990).
d) What legal issues were decided by this case?: Because of the 14th Amendment, no one can be
forced into any decision without their consent or a fair trial of the due process law. Therefore,
the Cruzan’s received so much trouble in trying to pull the feeding and hydration tube, the
hospital has not received consent from Nancy Cruzan. (Cruzan v. Director, Section 278, 1990).
e) Discuss the facts of the case. (Who are the parties? What happened?: Cruzan, represented by
her parents, is the plaintiff and the director of the Missouri Department of Health is the
defendant. Thad C. McCanse is the attorney for Cruzan and William L. Webster is the attorney
for the director of the Missouri Department of Health, Dr. John R. Bagby. When the case was
brought to district court, Nancy Cruzan’s housemate testified that Nancy did say that if she were
ever injured or sick and could not live her life at least half way normally, she would not want to
continue her life. Given this statement, in Nancy’s vegetative condition, Nancy would not want
to continue her life with the feeding and hydration tubes. Judge Charles E. Teel, judge of the
district court, gave order to remove the feeding and hydration tubes based on this testimony.
Unsatisfied with the ruling, the director appealed the case to the Supreme Court of Missouri.
The director argued that the Cruzan family does not have “clear and convincing evidence” of the
497 U.S. 261 (1990)

testimony and Nancy might not want her feeding and hydration tube to be pulled. Nancy’s only
statement was that she would not like to live as a vegetable not, she would want her feeding
and hydration tube to be pulled. To have clear and convincing evidence, the state of Missouri
requires patients to verbally state what they want in detail or write down exactly what they
want. Both request must be made by the patient while they are competent. This case soon
became a controversy because the right to live or die is not under the ruling of the U.S.
Constitution but under each state’s law. Under Missouri law, removing feeding tubes would be
considered as murder. The Supreme Court of Missouri recognizes that patients have the right to
refuse treatment but is doubtful the right is in the U.S. constitution. Since the right to refuse
treatment is not under the U.S. constitution, the court will have to rule through the Missouri
Living will statue which states that Missouri is strongly in favor of the preservation of life. The
Supreme Court of Missouri also did not agree with Cruzan arguments, because they are her
parents, they should know what is best for her. The Supreme Court reasoned that though
Nancy’s parents may seem caring and seem to be thinking about what is best for Nancy, this
does not guarantee what Nancy’s parents say is true. Unfortunately, some parents have bad
intentions and may want to pull the plug only based on the interest of ending the patient’s life.
The court determined Missouri state is not under the U.S. Constitution when considering the
right to refuse treatment and allowing Nancy to have a surrogate, thus, the Supreme Court of
Missouri reversed the decision made in the district court. The Cruzan’s appealed the case again
to the U.S. Supreme Court. Unfortunately for the Cruzan’s, the U.S. Supreme Court upheld the
ruling the Missouri Supreme Court stating that the state of Missouri could deny request of
pulling out the feeding and hydration tube because there was not enough evidence to prove
that Nancy Cruzan wanted the feeding and hydration tube to be pulled. Four months later, the
Cruzan family renewed the case and brought it back to district court under Judge Charles E. Teel
again. (Cruzan v. Director, Section 284, 1990).
f) What did the court decide? Give its holding (decision) and the reasons it gave for the decision
(reasoning)?: Within the four months between the case in the U.S. Supreme Court and renewing
the case again, the Cruzan’s were able to bring in three more friends of Nancy Cruzan to offer
new testimonies. All three friends said Nancy Cruzan specifically said she did not want to live in
a vegetative state on medical machines. The director of Missouri department of health and his
attorney decided to withdraw from the case because they had won the constitutional issue of
whether the state had the authority to decide if patients had the right to live or die and “had
vowed to comply with whatever new lower court order, if any, emerges” (Lewin, 1990) for
Cruzan’s case. Thad C. McCanse, the court-appointed guardian, spent two hours questioning
Nancy Cruzan’s doctor, Dr. James C. Davis, who was opposed to pulling the tube when the case
first appeared at court. After questioning Dr. Davis, Dr. Davis admitted that it is Nancy’s best
interest to die peacefully and it is appropriate to pull the feeding and hydration tube. Dr. Davis
stated that “it would be personally a living hell” (Lewin 1990). to let Nancy continue living in her
current vegetative state. In a previous hearing in March 1988, Judge Teel heard testimonies
from Nancy’s sister and friend of Nancy. Both stated Nancy “would not want to live if she was
unable to do anything for herself” (Lewin, 1990). After hearing these testimonies, Judge Teel felt
there was enough evidence of Nancy’s opinion and authorized on December 14, 1990 for Nancy
to be pulled from the feeding and hydration tube. On Friday December 14, 1990, Nancy was
497 U.S. 261 (1990)

pulled from her feeding and hydration tube and died the following Wednesday at 3 am in the
morning. (Lewin, 1990).
g) Was the decision unanimous? If not, who dissented and why did they dissent?: When the case
was brought to the U.S. Supreme Court, the decision was 5 to 4 in favor of Director of Missouri
department of health. Justice Brennan, Justice Marshal, and Justice Blackmun dissented because
they reasoned that Nancy Cruzan had the liberty to refuse medical treatment and Justice
Stevens dissented because he reasoned that the hospital was illegally taking away Nancy
Curzan’s rights (Gaudin, 1991).
h) Why is this case important for health care administrators?: The U.S. Supreme Court ruled the
right to die is within each state’s law, therefore it is different for people across the country. It is
important for health care administrators to understand what each state’s ruling is on the right
to die so administrators can act on correct decisions based on the law. In states like California,
family members can be surrogates and make the immediate decision if they feel like the patient
rather continue to live by life support or pass away naturally without any medical support. In
states like Missouri, administrators can implement a procedure for competent patients who are
admitted into the hospital to fill out documents to instruct health providers the procedures the
patient wants the health providers to follow if such an unfortunate case were to occur. If a
patient that has been admitted into the hospital as incompetent, administrators can quickly
inform family members to gather enough evidence to support what they think the patient would
want to happen to them. Health care administrators working in insurance can implement a rule
that all insurers must complete a document stating what would happen to them if they were to
fall into a vegetative state. Health care administrators can also educate communities to create a
will or document with set instructions so health providers can act without any doubts. Because
the right to die is such a controversial topic and situation, it is difficult for health care
administrators to follow a set law that is different for each state. This case led many health
providers and administrators to create plans to ensure patients that they will never fall into the
same situation as Nancy Cruzan. (Cruzan v. Director, Section 280, 1990).
i) What do you think about the decision?: I agree that Nancy’s family should make the decision
that is in the best interest of Nancy. The Cruzan’s did wait five years before asking to pull the
feeding and hydration tube from Nancy, giving Nancy a long time and chance to recover. They
also had evidence in their knowledge that Nancy did not want to continue to live in a vegetative
state where she is not able to take care of herself. Seeing that Nancy fell into a state where she
can not comprehend anything about her surroundings and having her suffer through vomits,
seizures, and diarrhea, I agree with the Cruzan’s that Nancy was unnecessarily suffering and
could not die in peace because of the feeding and hydration tube. I did not think it was fair on
the Cruzan family’s behalf that the case had to go through many appeals to have the same
outcome as the first ruling at the district court. I am sorry that the case had to go through so
many obstacles but content that the Cruzan’s could finally see Nancy die in peace.
497 U.S. 261 (1990)

References

Cruzan v. Director, Missouri Department of Health. 497 U.S. 261 (1990). Retrieved September 24, 2017,

from Google Scholar.

Gaudin, A. M. (1991, July). Cruzan by Cruzan v. Director, Missouri Department of Health. Retrieved

September 24, 2017, from https://www.law.cornell.edu/supremecourt/text/497/261

Lewin, T. (1990, December 26). Nancy Cruzan Dies, Outlived by a Debate Over the Right to Die.

Retrieved September 24, 2017, from http://www.nytimes.com/1990/12/27/us/nancy-cruzan-

dies-outlived-by-a-debate-over-the-right-to-die.html?mcubz=0