The Cruzan case began in a Missouri public hospital. Nancy Cruzan was in a persistent vegetative state secondary to anoxia suffered during an automobile accident in 1983. She maintained sufficient brain function to breathe on her own and to respond to painful stimuli. She was fed through a gastrostomy tube but was not otherwise medicated or instrumented. Her parents, who had been appointed her legal guardians, sought to have her nutrition and hydration terminated. The state hospital, in consultation with the attorney general, opposed this request. A case was initiated in state trial court, and a guardian ad litem was appointed to protect the patient’s interests.

The trial court sought to determine Nancy Cruzan’s wishes. Since she had neither executed a living will nor used a durable power of attorney to appoint a surrogate to make decisions in her stead, there was no formal record of her intent. The trial court did find that she had once discussed termination of life support with a roommate, indicating in a general way that she did not want to live in a vegetative state. The trial court accepted this conversation as sufficient evidence of Nancy Cruzan’s wish not to be maintained in a persistent vegetative state and authorized the termination of her feedings.

The Missouri Supreme Court accepted the guardian ad litem’s appeal of the trial court’s decision. The Missouri Supreme Court reversed the trial court’s authorization to terminate Nancy Cruzan’s nutrition and hydration. This opinion addressed two central points: Were Nancy Cruzan’s wishes knowable, and, if not, did her parents have the authority to terminate her life support as an independent decision?

The court found that Missouri law did not give Nancy Cruzan’s parents, as guardians, the right to authorize the termination of her nutrition and hydration. The court did not find that such authority would be constitutionally impermissible, only that it was not explicitly provided in the state’s guardianship statute. Having determined that Cruzan’s parents did not have the authority to discontinue her life support, the Missouri Supreme Court sought to determine whether Nancy’s own wishes were knowable.

The Missouri Supreme Court started with the premise that the traditional concept of informed consent applied to decisions to refuse care, as well as decisions to accept care. Under this standard, there would have to be evidence that Nancy Cruzan did not want to be maintained in a vegetative state and appreciated the significance of terminating her nutrition and hydration. The court also required that the patient’s intentions be proved by “clear and convincing evidence.” This is a standard that is stricter than the preponderance- of-the- evidence rule (51%) used in most civil cases but less strict than the beyond-a-reasonable-doubt rule required to prove guilt in criminal cases.

The clear-and-convincing-evidence standard is used in civil cases when an individual’s liberty, rather than just money, is at issue. These situations include involuntary commitment for mental illness, deportation hearings, and proceedings to terminate parental rights. [ Addington v. Texas, 441 U.S. 418 (1979).] Courts choose the clear- and-convincing-evidence rather the preponderance-of-the- evidence standard as “a societal judgment about how the risk of error should be distributed between the litigants.” [ Santosky v. Kramer, 455 U.S. 745, 755 (1982).] The Cruzan court chose this standard because of the gravity of a decision to terminate life support.

Using this heightened standard of proof, the court then reviewed the evidence presented to the trial court. The court did not find that the testimony in the trial court’s record provided clear and convincing proof of Nancy Cruzan’s intentions. In particular, the court found that the reported conversations were only general reactions to other persons’ medical care and not an informed statement of her intention to refuse life support if she were in a persistent vegetative state.

The disqualification of Nancy Cruzan’s parents and the rejection of the evidence of her own desires forced the court to look for other sources of direction for determining whether it should authorize the termination of life support. The court’s decision to reverse the trial court’s order to terminate Nancy Cruzan’s life support was compelled by a Missouri statute passed as part of the state’s antiabortion laws: “At the beginning of life, Missouri adopts a strong predisposition in favor of preserving life. Section 188.010, RSMo 1986, announces the ‘intention of the General Assembly of Missouri to grant the right to life to all humans, born and unborn.…’” [ Cruzan v. Harmon, 760 S.W.2d 408 (Mo. 1988).] Although the legislators who passed this law had intended it to apply to abortions only, the court was compelled by its plain language to apply it to all human beings, including Nancy Cruzan. This decision was appealed to the U.S. Supreme Court.