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decision because it clarifies several issues surrounding the termination of care for
incompetent patients. Although it does not resolve the dilemmas posed by
incompetent patients who have not properly formalized their wishes concerning
continued care, Cruzan may prove to be a wise compromise for a difficult problem.
The specific facts of the Cruzan case are compelling: a young woman, brain injured
in an automobile accident, was trapped in a persistent vegetative state for years.
Brain atrophy made recovery or rehabilitation hopeless, and her family requested that
her life support be terminated, but the state refused.
Cruzan is a hard case, and hard cases make bad law because they tempt judges and
juries to help the injured party rather than follow the law. Cruzan was litigated by a
Missouri attorney general seeking to gain support from antiabortion forces by
enforcing a statutory provision saying the state favored life in all circumstances.
Physicians are not strangers to hard cases. Every birth injury case tempts juries to
help the infant by disregarding the legal standard for proof of malpractice. The facts
in Cruzan call out to the court to ignore the traditional rule of patient autonomy and
allow the family to terminate a patient’s life support. This would be a good result in
Cruzan, but would it best serve the needs of future patients and their medical care
providers?
a) The Missouri Supreme Court Ruling
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
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