The Nancy Cruzan Case: What It Changed for Families

Who was Nancy Cruzan?

Nancy Beth Cruzan was born on 20 July 1957. Her family lived in Carterville, a small town in southwest Missouri. Her parents were Lester "Joe" Cruzan and Joyce Cruzan.

Her family remembered a funny, outgoing and independent young woman. In high school she was co-captain of the twirling team. Her sister Christy said Nancy liked to give her "a hard time." Later, Nancy became "a second mother" to Christy's two daughters. Her father told the documentary series Frontline that she "enjoyed life as much as anybody I ever have been around."

On the night of 11 January 1983, Nancy was driving home from her job at a cheese factory. Her car left a country road and turned over. Paramedics restarted her heart. But her brain had gone without oxygen for about 15 minutes, The New York Times reported. She was 25.

She never woke up in any real sense. Doctors said she was in a "persistent vegetative state". This means a person can open their eyes and has sleep and wake cycles, but shows no sign of awareness. To keep her alive, surgeons placed a feeding tube into her stomach. Her father signed the consent form.

For four years, the family visited, talked to her and hoped. Joyce told Frontline that they would "hold hands and touch her and will strength into her body from ours." Nothing changed.

Why did the Cruzan family go to court?

By late 1986, Nancy's parents believed she would not recover. They also believed she would not want to live this way. In May 1987, they asked the state hospital to remove the feeding tube.

The hospital said no. It would not act without a court order. Missouri law had never dealt with a case like hers. New Jersey's courts had faced a similar question in 1976, in the Karen Ann Quinlan case.

The family had only one piece of direct evidence. When she was 25, Nancy had told a housemate that if she were sick or injured, she would not want to go on living unless she could live "at least halfway normally."

In July 1988, a local probate judge, Charles Teel, sided with the family. But the State of Missouri appealed. In November 1988, the Missouri Supreme Court reversed his decision by 4 votes to 3. It said nobody could refuse treatment for another person without a living will or "clear and convincing, inherently reliable evidence", and it found no such evidence here.

Joe Cruzan knew how heavy the decision was. He said on camera:

"If the decision's wrong, if we're playing God, then I'll have to live with that, and I'm willing to." — Joe Cruzan, Frontline, "The Death of Nancy Cruzan" (1992)

The family appealed to the US Supreme Court. It was the first "right to die" case the Court had ever heard.

What did the Supreme Court decide in Cruzan v. Director?

The Court heard arguments on 6 December 1989. It gave its decision on 25 June 1990. The case is Cruzan v. Director, Missouri Department of Health, 497 U.S. 261.

The ruling had two parts, and they point in different directions.

First, a right was recognised. Chief Justice William Rehnquist wrote that a competent person has a "constitutionally protected liberty interest in refusing unwanted medical treatment." The majority assumed this right covers food and water given by tube. Justice Sandra Day O'Connor said so directly.

Second, Missouri still won, 5 votes to 4. Nancy could no longer speak for herself. The Court said a state may demand "clear and convincing evidence" of what the patient wanted before life support is stopped. Missouri did not have to let her family decide on her behalf.

Why demand so much proof? Rehnquist explained that the two possible mistakes are not equal. If doctors wrongly continue treatment, the mistake might be fixed later. If they wrongly stop it, the mistake is final:

"An erroneous decision to withdraw life-sustaining treatment, however, is not susceptible of correction." — Chief Justice William Rehnquist, Cruzan v. Director (1990)

Think of a door that only opens one way. Once you walk through, you cannot come back. So the state may ask you to be very sure before you open it.

The Court also said it did not set one rule for the whole country. It left the details to each state, which it called the "laboratory" of the States.

The four judges who disagreed used strong words. Justice William Brennan wrote: "Nancy Cruzan is entitled to choose to die with dignity." In their view, Missouri had put its general interest in life above what Nancy herself would have wanted.

Is the Cruzan case about euthanasia?

No. The Cruzan case was about refusing or stopping medical treatment. It was not about a doctor acting to end a life.

In Cruzan, Justice Antonin Scalia argued that refusing life-saving treatment could be the same as suicide. The other judges did not join him. Seven years later, in Washington v. Glucksberg (1997), the Supreme Court ruled unanimously that the Constitution does not protect a right to assisted suicide.

So today in the US, the law separates three things:

• Refusing or stopping treatment: allowed in every state, under rules shaped by Cruzan.
• Medical aid in dying: legal only in some states, under strict state laws.
• Euthanasia, where a doctor acts directly: not legal anywhere in the US.

See where euthanasia is legal for other countries.

Our guide to euthanasia vs assisted suicide vs MAID explains these terms. For a wider view, see our list of famous euthanasia and right-to-die cases.

How did the Cruzan case end?

The Supreme Court ruling left one door open. If the family could find better evidence, a court could still agree with them.

After the case became national news, three of Nancy's former co-workers contacted the family. Their message, as the family lawyer Bill Colby told Frontline, was simple: "You do not know me, but I knew Nancy." At a new hearing in November 1990, they said she had told them she would never want to live "like a vegetable."

Missouri had already left the case in September 1990. Its law had been upheld, so it said it had no more role to play. On 14 December 1990, Judge Teel ruled that the evidence was now clear and convincing. He allowed the feeding tube to be removed.

Not everyone accepted this. Protesters went to court seven times to have the feeding restarted. The courts found they had no legal standing.

Nancy Cruzan died on 26 December 1990, aged 33, with her family beside her. Her parents said in a statement: "Knowing Nancy as only a family can, there remains no question that we made the choice she would want."

Her gravestone in Carterville tells the story in three lines: "Born July 20, 1957 / Departed January 11, 1983 / At Peace December 26, 1990."

What changed after the Cruzan case?

The case was a legal loss for the family. But it changed how Americans plan for the end of life.

• A rush for forms. In the month after the ruling, the Society for the Right to Die answered nearly 300,000 requests for advance directive forms.
• A new federal law. Congress passed the Patient Self-Determination Act in 1990. It took effect in December 1991. Today, under federal rules, hospitals, nursing homes, hospices and home health agencies paid by Medicare or Medicaid must give adult patients written information about their right to accept or refuse treatment and to make an advance directive.
• State laws. States wrote or updated laws on living wills and healthcare proxies. Nancy's sister Christy later said Nancy's legacy is the importance of telling loved ones your end-of-life choices, Missourinet reported.

So the next time a hospital asks you, "Do you have an advance directive?", that question is partly Nancy Cruzan's legacy. Our section on patient rights, advance directives and proxies explains these rights in more detail.

But planning is still the exception. A 2017 review of 150 US studies found that only 36.7% of adults had any advance directive. That is about one in three.

Why do people still disagree about the Cruzan case?

Supporters of the family see it as a case about personal freedom. They believe a person's wishes should not disappear when they lose the ability to speak. They point out that a family usually knows a person best. Christy Cruzan told Frontline that these "are decisions that I feel like families should make privately, with the help of their doctor." Many doctors also struggled with the idea that more treatment is always better. Dr. Davis, one of Nancy's doctors, said medicine aims "to prolong life and ease suffering," and that sometimes these two goals cannot both be met.

Religious voices raised a different concern. In a brief to the Supreme Court, the US Catholic Conference said the law should "establish a strong presumption in favor of" giving food and water by tube. It argued that food and water are basic needs for all people. The bishops accepted that patients may refuse treatment that is useless or too burdensome. But they warned against judging that a life itself is useless because a person has lost mental or physical abilities. Read more about how different religions view end-of-life decisions.

Disability-rights voices share part of that worry. They ask whether society too easily assumes that life with a severe brain injury is not worth living. Medicine has also learned more since 1990. In 2018, the American Academy of Neurology said the term "permanent vegetative state" should be replaced with "chronic" vegetative state, because some people do recover. An essay from Harvard Medical School's Center for Bioethics notes a misdiagnosis rate of about 40% for these conditions. These voices do not reject the right to refuse treatment. They ask for careful diagnosis and real care first.

Some nurses who cared for Nancy felt deep distress too. One told Frontline that "somebody's making some decisions that I don't feel should be in their hands."

Some lawyers question the legal test itself. Edward Grant, writing in 2015, argued that in practice the "clear and convincing" standard became a "legal fiction". Courts often pieced together a few old remarks and called it the patient's choice. The same questions returned in Florida in the Terri Schiavo case.

Our section on the ethics of euthanasia and end-of-life care explores these questions further. Ask yourself: if you could not speak, whose judgment would you trust more, your family's or the law's?

What does the Cruzan case mean for families today?

Nancy's family loved her and knew her well. Even so, they spent more than three years in court, because her wishes existed only in conversations. A few sentences to a housemate were not enough for the Missouri Supreme Court.

You can make your voice much easier to hear:

1. Write it down. An advance directive records the treatments you would or would not want. Think of it as a letter to doctors you have not met yet. See advance directives vs living wills and our living will guide.
2. Name one person to speak for you. A healthcare proxy is like a translator. When you cannot speak, they speak for you. See how to choose a healthcare proxy.
3. Be specific about feeding tubes and long-term unconsciousness. These were the exact questions in Cruzan. Check that your state's form covers them, and add a note if it does not.
4. Talk, and repeat. Tell your proxy, your family and your doctor. Our guide on how to talk to family about end-of-life wishes has opening lines you can use.
5. Share copies. A form nobody can find cannot help anyone.

Before you write anything, think about these questions:

• What would make life still worth living for you?
• Would you want a feeding tube if doctors were sure you would never wake up? What if they were not sure?
• Who knows you well enough to decide, and could they carry that weight?

What is the human cost of a case like this?

Behind the legal headlines was a family that never wanted to be famous. Reporters followed them for years. Joe Cruzan once compared himself to a fan in "the poorest seat in the house," watching strangers play "with my football."

In August 1996, nearly six years after Nancy died, Joe Cruzan died by suicide. He was 62. Grief after a long illness, a public fight and hard decisions can last for many years. No one should carry it alone.

Joe also left words about what mattered most to him. At the end of the Frontline film he said: "no one can ever take that 25 years from me."

Nancy Cruzan never chose to become a legal landmark. But her story still asks each of us a simple question: does anyone know what you would want?