U.S. Supreme Court Upholds the Right to Refuse Medical Treatment

A milestone U.S. Supreme Court decision in 1990 established the constitutional right of terminally ill patients to refuse or discontinue medical interventions necessary to sustain their lives under conditions that were specified by the court. This ruling intensified debate concerning the “right to die.”

Summary of Event

The topic of “passive euthanasia,” allowing hopelessly afflicted patients to die by withdrawing life-support measures, was brought to the forefront of the public consciousness in 1976 when Karen Ann Quinlan’s family successfully petitioned the New Jersey Supreme Court for permission to turn off her respirator. Passive euthanasia
Euthanasia, passive Quinlan had been rendered comatose in 1975, with a total loss of brain function. She could not breathe properly without a respirator and received food and water through a tube. When Quinlan remained alive without a respirator, state courts refused the family’s requests to remove her feeding tube, and she lived for nine more years before dying in 1985. Right to die
Cruzan v. Director, Missouri Department of Health (1990)
Supreme Court, U.S.;physician-assisted suicide and right to die[physician assisted suicide and right to die]
[kw]U.S. Supreme Court Upholds the Right to Refuse Medical Treatment (June 25, 1990)
[kw]Supreme Court Upholds the Right to Refuse Medical Treatment, U.S. (June 25, 1990)
[kw]Court Upholds the Right to Refuse Medical Treatment, U.S. Supreme (June 25, 1990)
[kw]Right to Refuse Medical Treatment, U.S. Supreme Court Upholds the (June 25, 1990)
[kw]Medical Treatment, U.S. Supreme Court Upholds the Right to Refuse (June 25, 1990)
[kw]Treatment, U.S. Supreme Court Upholds the Right to Refuse Medical (June 25, 1990)
Right to die
Cruzan v. Director, Missouri Department of Health (1990)
Supreme Court, U.S.;physician-assisted suicide and right to die[physician assisted suicide and right to die]
[g]North America;June 25, 1990: U.S. Supreme Court Upholds the Right to Refuse Medical Treatment[07780]
[g]United States;June 25, 1990: U.S. Supreme Court Upholds the Right to Refuse Medical Treatment[07780]
[c]Health and medicine;June 25, 1990: U.S. Supreme Court Upholds the Right to Refuse Medical Treatment[07780]
[c]Laws, acts, and legal history;June 25, 1990: U.S. Supreme Court Upholds the Right to Refuse Medical Treatment[07780]
[c]Religion, theology, and ethics;June 25, 1990: U.S. Supreme Court Upholds the Right to Refuse Medical Treatment[07780]
[c]Social issues and reform;June 25, 1990: U.S. Supreme Court Upholds the Right to Refuse Medical Treatment[07780]
Cruzan, Nancy Beth
Colby, William H.
Webster, William L.
Starr, Kenneth
Rehnquist, William H.
Quinlan, Karen Ann

The distinction made by the New Jersey courts between the termination of breathing assistance and the allowance of death by starvation and dehydration in the Quinlan case proved to be extremely relevant to the case of Nancy Beth Cruzan. Cruzan also lapsed into an irreversible coma, termed a “persistent vegetative state,” in 1983, after she was thrown facedown, while unconscious, into a water-filled ditch during an automobile accident. She could breathe without assistance, and her family asked that she be fed through a tube to keep her alive. In 1987, doctors told Cruzan’s parents that she could live in a permanent comatose condition for years, but there was no hope of recovery. The parents requested that the feeding tube be removed and that their daughter be allowed to die, but the hospital insisted on a court order authorizing the removal. Thus began a three-year legal odyssey that resulted in the U.S. Supreme Court’s hearing its first “right to die” case.

A Missouri district court ruled in July, 1988, that Cruzan’s parents could act on her behalf and order that the feeding tube be removed. However, William L. Webster, the Missouri state attorney general, and Robert G. Harmon, director of the Missouri Department of Health, appealed the decision to the Missouri Supreme Court. The higher court said that for life support to be discontinued, state law required “clear and convincing evidence” that a person, before becoming comatose, had expressed a desire to be allowed to die. The higher court ruled that testimony by a former housemate of Cruzan, in which the housemate claimed that Cruzon had said that she would not want to live as a “vegetable,” did not constitute such definitive evidence and reversed the district court’s decision. The only legal recourse left to the parents at this juncture was to appeal to the U.S. Supreme Court.

By 1990, when the U.S. Supreme Court agreed to hear Cruzan v. Director, Missouri Department of Health, there had already been widespread media coverage of both the first two trials and the contentious debates and confrontations between “pro-life” groups and those supporting the “right to die.” The attorneys for Missouri included Webster and Kenneth Starr, U.S. solicitor general. They urged the Court to uphold the Missouri Supreme Court’s decisions that all human life must be preserved regardless of its quality and that removing a comatose patient’s feeding tube was murder.

The attorneys for Cruzan’s parents, headed by William H. Colby, argued that the suffering of Cruzan and her family showed that family members and health care professionals should be able to make decisions about withdrawing life support. Cruzan’s attorneys also argued that the Missouri Supreme Court’s decision was primarily influenced by concerns that an affirmation of the district court’s ruling would be used as precedent in cases involving suicide or abortion. This position was supported by the American Medical Association, the American Nurses Association, the Society for the Right to Die, and the American Academy of Neurology. Cruzan’s parents, and those who strongly held either of the polarized positions in the debate on the “right to die,” anxiously awaited the Court’s decision.

On June 25, 1990, in a five-to-four ruling, the U.S. Supreme Court upheld the Missouri Supreme Court’s decision, saying that the testimony did not constitute the “clear and convincing evidence” that the state required because there was no specific mention of withdrawing life support and, therefore, that Cruzan’s feeding tube could not be removed. This decision, delivered by Chief Justice William H. Rehnquist, established precedents that went far beyond Missouri’s ruling in the Cruzan case. The Court stated that a person who had made it known through an advance directive, like a “living will” or “clear and convincing” statements, that he or she did not wish to be kept alive with artificial life-support measures, did have the constitutional right to have life support, including nutrition and hydration, halted. The decision also said that states were allowed, but not required, to demand “clear and convincing evidence” before ordering life support terminated. Furthermore, the ruling stated that the U.S. Constitution’s guarantee of “liberty” was probably a more valid justification of a patient’s right to refuse medical treatment than the “right to privacy” often cited in state court cases.

Armed with the U.S. Supreme Court ruling, Cruzan’s parents filed suit in a probate court in Jasper County, Missouri. Three close friends of Cruzan testified that she had clearly stated to them that she would want life support, including the use of a feeding tube, halted rather than live in a permanently comatose condition. On December 14, 1990, the judge ruled that Cruzan’s feeding tube could be removed, which was done immediately following the decision at the request of Cruzan’s parents. After the feeding tube was removed, fifteen members of a pro-life group stormed the medical facility in an attempt to reinsert the tube, and all were arrested. Nancy Cruzan died on December 26, 1990.


About ten thousand people across the United States were living in a “persistent vegetative state” when the Cruzan case was heard by the Supreme Court in 1990. There was no nationwide legal precedent to answer the questions of whether a person had the right to chose in advance when life-sustaining medical interventions should be abandoned if the patient were rendered irreversibly comatose, or if third parties or a state had such a right. The media attention leading up to and following this Supreme Court decision stirred public and political interest in the importance of honoring written and oral advance directives.

On November 5, 1990, Congress passed the Patient Self-Determination Act. Patient Self-Determination Act (1990)[Patient Self Determination Act] This act required all health care facilities receiving Medicare or Medicaid funding (95 percent of all health care facilities in the nation) to advise patients of the facilities’ policies regarding the administration of artificial life-support measures and of each patient’s right to make an advance directive in the form of a living will or to appoint a proxy to state the patient’s wishes regarding the use, or withholding, of such measures. By the early years of the twenty-first century, every U.S. state had laws in place providing for living wills or proxies.

The legal precedents established in Cruzan v. Director, Missouri Department of Health, also intensified the debate over “active euthanasia,” or assisted suicide. Suicide;physician-assisted[physician assisted] Many advocates of the so-called right to die thought that it should be legal to end the suffering of terminally ill people, if requested by the individual, with lethal doses of drugs. This issue proved to be very controversial, with forty-four states declaring assisted suicide to be illegal. Oregon, on the other hand, passed a law in 1994 that made it legal for doctors to prescribe lethal drugs for terminally ill patients but forbade physicians to administer the drugs. Subsequent Supreme Court decisions have upheld the Oregon law but rejected the right to assisted suicide under the U.S. Constitution. Right to die
Cruzan v. Director, Missouri Department of Health (1990)
Supreme Court, U.S.;physician-assisted suicide and right to die[physician assisted suicide and right to die]

Further Reading

  • Colby, William. Long Goodbye: The Deaths of Nancy Cruzan. Carlsbad, Calif.: Hay House, 2002. Written by the attorney who represented the Cruzan family, this book chronicles the legal battles that culminated in the landmark 1990 Supreme Court decision.
  • Filene, Peter G. In the Arms of Others: A Cultural History of the Right-to-Die in America. Chicago: Ivan R. Dee, 1998. Discusses how the Cruzan case and others like it became centers of contention and the focus of religious, political, and philosophical debates regarding America’s changing attitudes toward dying.
  • Glick, Henry R. The Right to Die: Innovation and Its Consequences. New York: Columbia University Press, 1992. Focuses on policy changes that resulted in state laws that allowed the withholding or withdrawing of life support. Posits that the media attention on cases like Cruzan’s helped to sway public and political opinion in favor of right-to-die legislation.
  • Larson, Edward J., and Darrell W. Amundsen. A Differential Death: Euthanasia in the Christian Tradition. Downers Grove, Ill.: InterVarsity Press, 1998. Addresses some differences of opinion regarding the history of the Christian perspective on euthanasia, but mainly presents nontheological objections to the right-to-die movement.
  • Pence, Gregory E. Classical Cases in Medical Ethics. New York: McGraw Hill, 2004. Includes a chapter on the Karen Quinlan and Nancy Cruzan cases, and another on Oregon’s assisted suicide law. Examines the legal and ethical controversies surrounding the issue.

U.S. Supreme Court Expands Women’s Reproductive Rights

Presidential Advisory Commission Studies Medical and Research Ethics

United Nations Issues Principles of Medical Ethics

U.S. Supreme Court Upholds State Restrictions on Abortion

Oregon Voters Legalize Physician-Assisted Suicide