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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
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