Source: http://austlii.community/foswiki/Books/CapacityAndTheLaw/Chapter11
Timestamp: 2019-04-22 23:58:29+00:00

Document:
Australia and the common law world generally are still formulating their approach to substitute consent to medical and dental treatment, advance directives, end of life decision-making and similar issues. Because of advances in public health, nutrition, standards of living and medical science, people can live for many years after losing decision-making capacity or lead a long life without ever having had decision-making capacity. With projected increases in dementia(1), there will be an increasing number of people who have lost capacity to make decisions about their own medical treatment. In addition to these advances, the late 19th century and the 20th century saw the growth of societal expectations of patient autonomy, informed decision-making and control over the dying process.
The issues that are thrown up by these developments require responses from the community, health care professionals, lawyers and ethicists. In Australia, all States and Territories have some legislation to deal with some of these issues. However, the common law applies where there is either no relevant legislation or gaps in that legislation. The common law has continued to develop in this field as applications are made to the courts and the judges deal with them, often as part of their parens patriae jurisdiction, which is sometimes described as inherent jurisdiction.
This has occurred particularly in the United States of America, but also in the United Kingdom and Canada. This chapter will refer to key aspects of the development of the common law in those countries. The relevant developments in the Australian common law and legislation, and in health policies and medical treatment practices, are addressed in the chapters that deal with substitute consent to medical and dental treatment, advance directives and care and decision-making at the end of life.
Under a free government, at least, the free citizen's first and greatest right … the right to inviolability of the person …necessarily forbids a physician or surgeon, no matter how skillful or eminent, … to violate, without permission, the bodily integrity of his patient….
Rich goes on to trace the development of the requirement of consent into a requirement of informed consent and of respect for patient autonomy into including respect for patient prospective autonomy in the form of advance directives.(4) While the courts were beginning to recognize advance directives and order that they be given effect to, they continued to support the right of competent people to refuse treatment, even without requiring them to give a reason for doing so.
The 2009 Australian cases confirming that the (Australian) common law recognises a competent adult's right to autonomy or self-determination are dealt with below at 11.4.
The claimed first use of a "formal" living will, which was subsequently upheld by the courts, was in Florida in 1981 when a terminally ill man was taken to the John F Kennedy Memorial Hospital in Florida.(9) Within two days of being admitted to the hospital, the man was unable to breathe on his own and doctors placed him on a ventilator. His doctor told his wife that he had no hope of recovery. She then handed over a paper entitled "Mercy Will and Last Testament" written out and signed by her husband in the presence of two witnesses six years before. As recently as two months before he entered the hospital, his wife had promised him that should he be hospitalised, she would make his "mercy will" part of his medical record. She was appointed his guardian by the probate court and immediately asked the hospital to turn off all life support systems. The hospital then sought a declaratory judgment as to its obligations in these circumstances. The man died but the court was willing to hear the case.
(i) There is a presumption that a patient has the mental capacity to make decisions whether to consent to or refuse medical or surgical treatment offered to him/her.
(ii) If mental capacity is not an issue and the patient, having been given the relevant information and offered available options, chooses to refuse treatment, that decision has to be respected by the doctors. Considerations that the best interests of the patient would indicate that the decision should be to consent to the treatment are irrelevant.
To summarise, these cases show the common law recognising the right of competent adults to refuse continuing treatment, including life maintaining treatment, without having to explain why, as well as their right to make advance directives in the form of verbal anticipatory refusals and for "blood cards" sometimes carried by Jehovah's Witnesses to be recognized and given effect to.
This issue was dealt with in an Australian case in 2009. See below at 11. 4.
The Quinlan Case did not go beyond the New Jersey Supreme Court; however the case of Nancy Cruzan did. When driving around midnight in the Missouri in January 1983, the recently divorced Nancy Cruzan lost control of her car and finished up face-down in a water-filled ditch. Her heart had stopped before she received assistance from the paramedics who restarted her heart. She was in a persistent vegetative state from that time until her death seven years later. Her existence was sustained by a feeding tube. Her parents wanted the feeding tube removed and permission was granted by the Missouri probate court. However, the Missouri Supreme Court held that before medical support could be withdrawn from an incompetent person there had to be clear and convincing evidence of their wish for this to happen. This is a higher standard of proof than the usual civil standard of the balance of probabilities (called in the US the preponderance of the evidence). As the Court held that the evidence in this case did not meet that higher standard, Ms Cruzan's feeding tube could not be removed.
After the false start in the Quinlan and Cruzan cases, the US courts have established and repeatedly restated that the right of a person to refuse medical treatment is not lost if they lose their capacity to give a valid consent to their own medical treatment and were thus considered incompetent to give or refuse consent to such treatment.(41) The assertion of that right, particularly when the treatment is life-sustaining, gives rise to a series of difficult questions that the US courts have dealt with. These include, who can give consent to the carrying out of or to the refusal of such treatment? Do the substitute decision-makers have to carry out the wishes of the person they are making the substitute decision for? If so, what degree of certainty do they have to have about the person's wishes before they can act? Can they make the decision in the person's best interests? If so what degree of certainty do they have to have about the person's best interests before they make the decision? Are there differences in the substitute's decision-making options arising from whether the person is comatose or in a persistent vegetative state or whether the person has some degree consciousness? A range of US cases deal with these and other related issues. The decisions made in these cases are not necessarily consistent with one another, nor do they reflect all relevant considerations as they result from court hearings in which non-legal perspectives on how to deal with the matters to be decided were given little account. Nevertheless, they raise issues and considerations that are relevant to any discussion of how the statute and judge-make law in Australia should continue to develop in this ethically difficult field.
In 1991 the Supreme Court of Michigan dealt with the case of a Mr Martin.(44) Mr Martin had a serious motor vehicle accident which left him unable to walk or talk. He had minimal cognition and essentially no ability to communicate. He had a colostomy bag for defecation and had to be fed through a PEG tube. Five years after his accident, when he was being treated for an obstructed bowel, his wife approached the hospital's bioethics committee. After consultation and consideration the committee reported that withdrawal of the PEG tube was both medically and ethically appropriate. Mrs Martin sought and obtained court authority to remove the tube but Mr Martin's mother and sister took the matter up.
This case represents perhaps the highest level of certainty about the evidence required under the clear and convincing evidence test. The fact that Mr Martin was not formally in a persistent vegetative state seems to have been relevant to the majority even though, as the dissenting judge pointed out, the bioethics committee had concluded that the persistence of Mr Martin's condition and his level of functioning was the equivalent of being in a persistent vegetative state for the purposes of considering removing nutrition support.(47) It was clear that Mr Martin was totally dependent on others for all activities of daily living and all other aspects of his life.
In 2001, the Supreme Court of California made a similar decision in similar circumstances and made use of the decision in In re Martin.(50) In that case Mr Wendland suffered brain injuries in a motor vehicle accident. Two years later his wife, who had been appointed his conservator, requested authority to withhold artificial nutrition and hydration. The evidence showed that Mr Wendland had "severe cognitive impairments, maladaptive behaviour characterised by agitation, aggressiveness and non-compliance, severe paralysis on the right and moderate paralysis on the left, severely impaired communication without compensatory augmentative communication system, severe swallowing dysfunction, dependent on enteric feeding for nutrition and hydration, incontinence of bowel and bladder, moderate spasticity, mild to moderate contractures, general dysphoria, recurrent medical illnesses, including pneumonia, bladder infections, sinusitis and some dental issues".
The facts upon which the case was decided were that in May 1989 LW was placed under the guardianship of a non-profit organization. He was a 79 year old man who had a long history of undifferentiated schizophrenia. He had been institutionalized since 1951. He had no close relatives or friends and had never indicated his wishes concerning life-sustaining medical treatment to anyone. The evidence indicated that he may never have been competent. Six days after being placed under guardianship, LW had a cardiac arrest in a nursing home and went to hospital. His treating doctors informed his guardian that LW was in a chronic, persistent vegetative state and advised that if LW did not improve in the following four weeks, they would ask the guardian to consent to the withdrawal of all life-sustaining medical treatment, including all artificial nutrition and hydration, thus occasion LW's death.(61) A week after LW's cardiac arrest, his guardian petitioned the circuit court for a declaratory judgment to determine whether the guardian or the court could consent to such withdrawal. The trial court held that a guardian has authority to consent to the withdrawal of all life-sustaining treatment, including artificial nutrition and hydration, without prior court order or approval, if the guardian determines that withdrawal is in the person's best interests. The matter was appealed to the Supreme Court of Wisconsin which upheld the trial court's decision, but added to it. LW died in February 1991 while the appeal was still pending.
The guardian determines in good faith that the withholding or withdrawal of treatment is in the ward's best interests, according to the objective factors outlined below.
A person's right to refuse medical treatment continues even when the person becomes incapable of exercising that right themselves. Others may exercise that right on their behalf, subject to them being satisfied as to certain matters by clear and convincing evidence.
that the incapable person, by making an advance directive or other formal declaration, or through informal statements has expressed views about how they would like to be treated in certain situations. If these expressions of view can be proved when one of those situations arises, then their views will be given effect to through the substituted judgment of others, including court appointed guardians. Life-sustaining treatment could be withheld or withdrawn in these circumstances.
the guardian determines in good faith that the withholding or withdrawal of treatment is in the person's best interests, according to the objective factors including the degree of humiliation, dependence and loss of dignity resulting from the condition and treatment; the various treatment options; and the risks, side effects, and benefits of each of these options.
In the US these principles may be applied without the need for a court order. It is assumed that they are regularly applied where family members, any significant others and treating doctors all agree that life-sustaining treatment be withdrawn. Where there are differences of view among family members, as a number of the cases show, the courts can be approached to hear the evidence and arguments, determine the facts and make appropriate orders arising from their findings.
Anthony Bland was 17 when he was seriously injured in the collapse of the stand at the Hillsborough soccer ground in April 1989. He went into a persistent vegetative state. Soon medical opinion was unanimous that there was no hope of any improvement in his condition or of recovery. Unsurprisingly, Anthony Bland had not indicated his wishes should he find himself in this condition. In 1992, with the support of Anthony Bland's family, the consultant in charge of his case and independent physicians, the Airedale NHS Trust applied to the High Court of Justice in England for a declaration that it was lawful to discontinue life-sustaining treatment to him.
The approval of the Family Division of the High Court has to be sought by way of an application for a declaration. This is because, in 1990, the House of Lords decided that the parens patriae jurisdiction of the High Court had been swept away by legislation and the revocation of the relevant royal warrant.(73) This is not a problem in Australia. As has been noted in Chapter 8.2 and elsewhere in Chapter 8, the parens patriae jurisdiction can be exercised by the State and Territory Supreme Courts in Australia to deal with matters relating to incompetent adults.
Nevertheless, as will be seen in this section and elsewhere in this chapter, cases involving those in a persistent vegetative state, still have to be, and other cases continue to be, brought to the courts for declarations.
A 2001 decision of the Family Division shows some of the difficulties arising from the House of Lords requiring applications being made to the Family Division for declarations allowing artificial nutrition and hydration to be withdrawn from an incapable person. This has effectively placed the responsibility for making such applications on the hospitals involved resulting in them being prepared to make such applications only in very clear cases, sometimes keeping people alive without hope of recovery for long periods. In NHS Trust A v H, Mrs H who was born in 1927 suffered a stroke aged 60 in 1987. In February 1993 she had further brain haemorrhages and became unconscious.(83) She had been unconscious ever since and had been fed through a PEG tube which had been replaced in both 1997 and 2000. Her condition remained unchanged for nearly eight years before an application was made to the court.
Since 1995, if not before, her son and daughter had thought it was not appropriate for her to have been kept alive through artificial means. In June 2000 a consultant neurologist formed the view that Mrs H was in a minimally conscious as different from a permanent vegetative state. This was based on his observation and on the observation of a nurse that she had a degree of visual tracking and a degree of response to menace.
In accordance with the Practice Note applications continue to be made to the Family Division. In October 2001 the court gave a declaration to allow the withdrawal of nutrition and hydration from a 45 year old woman, Mrs G, who had suffered extremely severe brain damage as a result of complications after minor surgery in September 2000 and who had no prospect of recovery.(90) Butler-Sloss P dealt with the fact that Mrs G had expressed a strong view during her life that "if she was found in this situation she should not be kept alive regardless" as a reason why Mrs G's family unanimously supported the order rather than as a reason in itself for granting the declaration.
One of latter kinds of case occurred in England in 2005.(92) An 86 year old man, Mr A, who was originally from Pakistan but who had settled in Scotland and who had already had a coronary bypass and a number of mini strokes fell seriously ill while visiting his home country. He had a heart attack, developed acute chronic renal failure, peripheral edema and total lack of urine production. He was flown back to England, but collapsed before he could return to Scotland and was admitted to hospital close to death. He had another cardiac arrest in hospital but was resuscitated. He could not be weaned off either respiratory or renal support. He was fed through a naso-gastric tube and had a number of invasive catheters inserted in him to so he could be monitored and provided with drugs. Within a short period the assessment of his treating doctors was that there was little likelihood of his recovery. They believed that the treatment he was receiving would not change the outcome of his illness and that, if it continued, it would subject him to both psychological and physical distress. They concluded that it was in his best interests to withdraw all but palliative care.
On the one hand, Mr A's family opposed the proposals to withdraw life-sustaining treatment They believed that there was some hope of recovery and that Mr A was not suffering any pain. They were all practicing Muslims and they had been advised by at least one Iman that to discontinue Mr A's treatment regime was contrary to the Islamic faith and belief system. On the other hand, because of the nature of the treatment and the need to insert new lines and naso-gastric tubes and replace those that Mr A pulled out, those treating him considered their treatment was an assault on him.
Lawyers became involved. Experts examined Mr A either directly or by more distant observation. All but one were of the view, particularly as time progressed, that the treatment was intrusive, put Mr A through considerable discomfort with the chances of it producing any reasonable quality of life being very low. They were of the view that that it was not in Mr A's best interests to be put through this considerable discomfort and that palliative care would allow him to die peacefully and with dignity. Within two months of Mr A's return to England, the Family Division had given a declaration that only palliative care need be given to Mr A and the Court of Appeal had upheld that decision.
Coleridge J of the Family Division took a similar view but put it more gently in The NHS Trust v Ms D.(97) In that case Ms D was 32 when she went into a vegetative state in 2005. She had the terminal condition mitochondrial cytopathy which attacked her brain and caused her to have continuous epileptic seizures. The medical evidence was that she probably had no awareness of any kind and that there was no hope of recovery. Her treating doctors took the view that it was not in her best interests to try and prolong her life if, for example, either her breathing failed or she suffered cardiac arrest or contracted a potentially life threatening infection which would normally be treated by antibiotics. The NHS Trust asked the court to declare that it is not in Ms D's interests to take these, and other invasive steps, given her current condition.
Ms D's parents, seven of her other relatives and her partner disagreed. They opposed the doctors doing or declining to do anything which might not prolong her life for as long as possible. They said that Ms D had some awareness and that on occasions she recognized them and communicated with them by blinking or the squeezing of her hand or similar signs. They said she was a fighter and that miracles do happen. The doctors' response was that the movements they saw were reflex actions and not true signs of awareness and that to intervene beyond providing the best possible nursing and palliative care is to do no more than prolong Ms D's dying process for Ms D for no discernible purpose and for probably no more than an extra six to twelve months.
From the family's point of view, of course, every extra day is worth fighting for and, given what they have had to face in the past few years, no one can have anything but the profoundest sympathy for them in their hope for the arrival of a miracle. But my focus must be on the patient's best interests and not on the family best interests.
The English courts have been clear that their view of what is in the patient's best interests can override the views of the patient's family. Their power to override the views of the patient has been more controversial, but was asserted in the Court of Appeal in 2005.(99) That power to override must however be exercised with great caution and only on the basis of well substantiated, but not necessarily uncontradicted evidence, from appropriately qualified and experienced doctors.
In 2005 Mr Burke was 45 years of age. He suffered from a congenital degenerative brain condition known as spino-cerebellar ataxia, which confined him to a wheelchair. His movements were uncoordinated. His condition affected his speech, but his mental ability was not impaired. Nevertheless, because of his condition there would come a time when he would be entirely dependent on others for his care and his very survival. In particular, he would lose the ability to swallow and would require artificial nutrition and hydration by tube to survive. The medical evidence was that he was likely to retain full cognitive faculties even during the end stage of his disease. He was unlikely to lose his capacity to make decisions for himself and was likely to be able to communicate his wishes until his death was imminent. He was likely to retain almost until the end insight and awareness of the pain, discomfort and extreme distress that would result from malnutrition and dehydration. If food and water were to be withheld he would die of dehydration after some two to three weeks. Mr Burke wanted to be fed and provided with appropriate hydration until he died of natural causes. He did not want artificial nutrition and hydration to be withdrawn. He did not want to die of thirst. He did not want a decision to be taken by the doctors that his life was no longer worth living. In order to ensure that his wishes would be given effect to, he sought judicial review of the guidance issued in 2002 by the General Medical Council "Withholding and Withdrawing Life Prolonging Treatments: Good Practice in Decision-making". Permission to proceed with this application was given and Munby J made a series of declarations. The Court of Appeal set aside these declarations, but made a number of statements about the law as it related to Mr Burke's circumstances and wishes.
Doctors, exercising their professional clinical judgment, decide what treatment options are clinically indicated (i.e. will provide overall clinical benefit) for their patients.
Doctors then offer those treatment options to all their patients in the course of which they explain to them the risks, benefits, side effects, etc. involved in each of the treatment options.
The patients then decide whether they wish to accept any of those treatment options and, if so, which one. In the vast majority of cases the patient will, of course, decide which treatment option they consider to be in their best interests and, in doing so, may take into account other, non-clinical factors. However, patients can if they wish decide to accept (or refuse) the treatment options recommended on the basis of reasons which are irrational or for no reasons at all.
If the patient chooses one of the treatment options offered to them, the doctor will then proceed to provide it.
11.2.7.5 Orders suppressing the identity of the patient, their family and the hospital in which they are being treated.
While there are different courts for England and Wales, Scotland and Northern Ireland the common law of the United Kingdom jurisdictions, particularly the recent developments in that law, tends to be the same. This is partly because the United Kingdom Supreme Court (previously known as the House of Lords) is the final court of appeal in civil matters in all United Kingdom jurisdictions and because of the convenience of having the same common law throughout the country. Also the parliament in Westminster makes the statute law that applies to England, Wales and Northern Ireland and sometimes Scotland. In this regard the common law is affected by fewer pieces of legislation than in the US where State legislation can affect the common law in many different ways in the different States. The US common law is also affected by the US constitution. While there is no written constitution in the UK, as has already been noted, the European Convention of Human Rights and Fundamental Freedoms 1950 has been incorporated into United Kingdom law as Schedule 1of the Human Rights Act I. It will have effects similar to the effects on US common law the "Bill of Rights" provisions of the US constitution have had in the last 50 years.
The best interests test is used in relation to both those in a persistent vegetative state and those with different conditions not involving unconsciousness but for whom treatment is intrusive, hazardous and unlikely to produce anything more than a very poor quality of life.
Court approval continues to be required in cases involving persistent vegetative state and the other conditions referred to in 1.
The views of the person do not have to be proved. Their views and those of their family can be taken into account, but it is for the court to decide what is in the person's best interests.
In the UK a judge has to be satisfied to a high degree of probability by the evidence before they can make a declaration allowing the withdrawal of life-sustaining treatment. This seems similar to the "clear and convincing evidence" test developed in the US.
The starting point is the maintenance of life. In the UK this is stated as a positive duty on hospitals to take such steps as are reasonable to keep a patient alive. While in both the US and the UK this duty is not absolute, substantial proof must be shown before life-sustaining treatment may be discontinued.
Courts have generally deferred to medical practitioner opinion about treatment decisions, even in the face of strong opposition from the patient's family.
The 2009 case that came before the Supreme Court of New South Wales involved a Mr A who had made an advance directive in an appointment of enduring guardianship. In it he directed his enduring guardian to refuse consent to dialysis. By July 2009 Mr A was being kept alive by mechanical ventilation and kidney dialysis.(111) The relevant Area Health Service sought a declaration that Mr A's treating doctors would be justified in complying with Mr A's wishes as set out in the advance directive.
the individual concerned may not have been competent in law to give or refuse that consent.
even if the individual were competent in law, the decision may have been obtained by undue influence or some other vitiating means.
He accepted that in circumstances where it was practicable for a doctor to obtain consent to treatment, that, for the consent to be valid, it must be based on full information, including information as to risks and benefits. But he then went on to deal with a question that is fundamental to the effectiveness of advance directives namely, whether an advance refusal of consent to certain specified forms of medical treatment equally needed to be supported by the provision of all adequate information.
[I]f there is any real doubt as to the sufficiency of an advance refusal of medical treatment, the court should undertake a careful analysis. But the analysis should start by respecting the proposition that a competent individual's right to self-determination prevails over the State's interest in the preservation of life even though the individual's exercise of that right may result in his or her death. An over-careful scrutiny of the material may well have the effect of undermining or even negating the exercise of that right.
If after the man had been given advice by an appropriately qualified medical practitioner as to the consequences which would flow from the cessation of the administration of nutrition and hydration, other than hydration associated with the provision of medication, he requested that his service providers cease administering such nutrition and hydration, then his service providers could not lawfully continue administering nutrition and hydration unless he revoked that direction. Further, his service providers would not be criminally responsible for any consequences to his life or health caused by ceasing to administer such nutrition and hydration to him.
The third 2009 case, Australian Capital Territory v JT, proceeded on the basis that JT could not be regarded as having refused available medical treatment because of his psychotic condition for which he was receiving the maximum tolerable dose of anti-psychotic medication.(126) JT had a psychiatric history going back many years, but following the death of Pope John Paul II in 2005, he became obsessed with fasting to bring him closer to God. His fasting amounted to starvation which was life threatening in itself; however, he had the irrational belief that God would not let him die.
Over a period of four years he was hospitalised and fed through a naso-gastric tube to avoid starvation. He resisted this treatment and had to be forcibly restrained. This forcible feeding caused distress to both JT and the people carrying out the treatment. Feeding through a PEG tube would require surgical insertion of the tube and was not a long-term solution of itself, leaving aside the question of JT seeking to remove the tube.
As early as 2005, consideration was given by JT's treating doctors to "a simple palliative approach" which Higgins CJ noted meant "avoiding euphemisms" would allow JT to starve to death while easing the associated suffering. In 2009 the Australian Capital Territory sought a declaration that it is lawful for doctors employed by it to desist from affording treatment other than palliative care to JT.
As was pointed out by the US Supreme Court in Washington v Glucksburg in 1997, an examination of history, legal traditions and practices shows that Anglo-American common law has punished or otherwise disapproved of assisting suicide for over 200 years.(133) Australian common law reflects the same tradition.
1 : Ferri CP, Prince M, Mrayne C., et al Global prevalence of dementia: a Delphi consensus study Lancet. (2005) 366 (9503): 2112-7.
2 : Rich, B A, Strange Bedfellows - How medical jurisprudence has influenced medical ethics and medical practice, New York, Kluwer Academic, 2001, 51-53; Mohr v Williams 104 N E 12, 14 and 14-15 (1905). See also Pratt v Davis 79 N E 563 (1906).
3 : 105 N.E. 93, 93 (1914).
4 : Rich op. cit. (footnote 2), Chs 4 and 5 generally. See also Salgo v Leland Stanford Jr University Board of Trustees 317 P.2d 170(1957) and Natanson v Kline 350 P.2d 1093 (1960).
5 : Rich op. cit. (footnote 2), Chs 4 and 5 generally. See also Salgo v Leland Stanford Jr University Board of Trustees 317 P.2d 170(1957) and Natanson v Kline 350 P.2d 1093 (1960).
6 : Urofsky, M I, Letting Go: Death, Dying and the Law, Norman, University of Oklahoma Press, 1994,132.
9 : Urofsky, op cit (footnote 5), 137.
16 : Malette v Shulman (1987) 47 DLR (4th) 18.
17 : Malette v Shulman (1990) 67 DLR (4th) 321, 333.
18 : Ibid 332 and 337.
19 : Re T  EWCA Civ 18;  Fam 95. See also Airedale NHS Trust v Bland  UKHL 5;  AC 789, 864; Re C  1 All ER 819 and R (Burke) v General Medical Council  EWCA Civ 1003,  EWCA Civ 1003; ,  QB 273.
20 : Re C  1 All ER 819, 824 and 825.
21 : B. R (on the application of) v General Medical Council  EWCA Civ 1003,  EWCA Civ 1003; ,  QB 273.
22 : T. Re  EWCA Civ 18 ;  EWCA Civ 18;  Fam 95.
23 : Ibid.  or page 116.
24 : Ibid.  or page 102.
25 : T. Re  EWCA Civ 18; Re T  EWCA Civ 18;  Fam 95, 102-103, 115-116 (Lord Donaldson) and the judgments of Butler-Sloss and Staughton LJJ.
26 : Ibid.  or page 113.
27 : Ibid.  or page 103.
29 : Nancy B v Hotel-Dieu de Quebec (1992) 86 DLR 4th 385.
30 : Re C  1 All ER 819.
31 : Re B (adult: refusal of medical treatment)  EWHC 429 (Fam);  2 All ER 449.
33 : In the matter of Quinlan 355 A.2d 647 (1976). See also Rich, B A, Strange Bedfellows - How medical jurisprudence has influenced medical ethics and medical practice, New York, Kluwer Academic, 2001), 68 and Pence, G, Classic Cases in Medical Ethics, Boston, McGaw -Hill, 3rd ed, 2000, ch. 2.
34 : Cruzan v Director, Missouri Department of Health  USSC 122; 497 US 261, 290 (1990).
37 : Pence, op cit (footnote 33), 41.
38 : Annas, G J, "Nancy Cruzan and the right to die" (1990) NEJM, Vol 323, no 10, 670, 672.
39 : 497 US 261, 290 (1990).
41 : See for example, In the matter of Conroy 486 A.2d 1209 (1985); In re Rosebush 491 N.W.2d 633 (1992); In re Martin 538 N.W.2d 399 (1995) and Conservatorship of Wendland 28 P.3d 151 (2001).
42 : John F Kennedy Memorial Hospital v Bludworth 452 So.2d 921, 926-927 (1984).
43 : In the estate of Browning 568 So.2d 4, 15 (1990).
44 : In re Martin 538 N.W.2d 399 (1995).
50 : Conservatorship of Wendland 28 P.3d 151 (2001).
52 : Ibid. 170 and 173.
55 : 568 So.2d 4 (1990).
57 : Gostin, J O, "Ethics, the Constitution and the Dying Process - the case of Theresa Marie Schiavo" (2005) JAMA Vol 293 No 19 2403.
58 : For a more detailed descriptions of the Schiavo matter see, Mendelson, D and Ashby, M "The medical provision of hydration and nutrition: Two very different outcomes in Victoria and Florida" (2004) 11 JML 282, 286-291 and Wllmott, L, White, B, Cooper, D, "The Schiavo decision: Emotional but legally controversial?" (2006) 18 Bond Law Review 132. See also Skene, L, "The Schiavo and Korp cases: Conceptualising end-of-life decision-making" (2005) 13 JML 223.
59 : In the matter of the Guardianship of L.W. 482 N.W.2d 60 (1992).
66 : Ibid. 71-72. For another account of the factors to be considered see, In re Conroy 486 A.2d 1209 (1985), 1230-33 and 1249-50 in particular.
67 : In the matter of the Guardianship of L.W. 482 N.W.2d 60, 76-79 (1992).
68 : Gostin, J O, op cit (footnote 57) 2403.
69 : This may explain why in 2002 in the Schiavo Case Mrs Schiavo's parents sought to show that she was in a minimally conscious state rather than in a persistent vegetative state. Greer J did not accept this new evidence. He was upheld on appeal. See In re Guardianship of Schiavo 2002 WL 31817960 (Fla. Cir. Ct.) and In re Guardianship of Schiavo 851 So.2d 182 (2003).
70 :  UKHL 5;  AC 789.
71 : Ibid. 871-872. For a New Zealand case which takes a similar approach but predates Bland see, Auckland Health Board v Attorney-General  1 NZLR 235.
72 : Law Hospital NHS Trust v Lord Advocate  ScotCS CSIH_2;  SC 301.
73 : In re F  UKHL 1;  2 AC 1, 57-58 and Airedale NHS Trust v Bland  UKHL 5;  AC 789, 862. For the procedure to follow see, Practice Note (Official Solicitor: Declaratory Proceedings: Medical and Welfare Decisions for Adults who lack Capacity)  2 FLR 158.
74 : R (Burke) v General Medical Council  EWCA Civ 1003,  EWCA Civ 1003; ,  QB 273. For the decision appealed from see, R (Burke) v General Medical Council  EWCA 1879 (Admin),  QB 424.
76 : Re T  EWCA Civ 18;  Fam 95.
77 : Airedale NHS Trust v Bland  UKHL 5;  AC 789, 862.
78 : Re D (Medical Treatment)  1 FLR 411. For another 1997 case involving a person in a condition which did not meet all the Royal College of Physicians' criteria for persistent vegetative state but in relation to whom a declaration was granted see, Re H (A Patient)  2 FLR 36.
79 : NHS Trust A v M; NHS Trust B v H  1 All ER 801.
81 : NHS Trust v D (unreported, Family Division, Johnson J, 10 November, 2000, 3. Mr D had a progressive, untreatable brain lesion, a posterior fossa arterio-venous malformation.
85 : Ibid. 506. For another case showing the cautious approach of UK hospitals see, NHS Trust v I  EWHC 2243 (Fam).
86 :  2 FLR 158.
90 : Re G (2001) 65 BMLR 6.
91 : Airedale NHS Trust v Bland  UKHL 5;  AC 789, 868.
92 : An NHS Trust v A  EWCA Civ 1145.
93 : Ibid. -. See also In re S  Fam 15, Butler-Sloss P at 27 and Thorpe LJ at 30.
94 : In re S  Fam 15, Butler-Sloss P at 28 and Thorpe LJ at 30; An NHS Trust v A  EWCA Civ 1145,  and .
95 : An NHS Trust v A  EWCA Civ 1145, ,  and ; In re J  2 WLR 140, 158.
96 : An NHS Trust v A  EWCA Civ 1145, .
97 :  EWHC 2439 (Fam).
99 : R (Burke) v General Medical Council  EWCA Civ 1003,  QB 273.
105 : Re G (2001) 65 BMLR 6. See also NHS Trust v I  EWHC 2243 (Fam),  and The NHS Trust v Ms D  EWHC 2439 (Fam).
106 : Willmott L., White B., Smith M., Wilkinson DJC (2014) Witholding and withdrawing life-sustaining treatment in a patient's best interests: Australian judicial deliberations Medical Journal of Australia 201 (9): 545-547.
107 : Faunce TA and Stewart C (2005) The Messiha and Schiavo Cases: third party ethical and legal interventions in futile care disputes Medical Journal Australia 183 (5): 261- 263.
108 : Hunter and New England Area Health Service v A  NSWSC 761 .
110 : Bridgewater Care Group v Rossiter  WASC 229 and Australian Capital Territory v JT  ACTSC 105.
111 : Hunter and New England Area Health Service v A  NSWSC 761.
116 : Rogers v Whitaker  HCA 58, (1992) 175 CLR 479, 489.
117 : Hunter and New England Area Health Service v A  NSWSC 761 .
119 : (1990) 67 DLR (4th) 321, 337.
120 : Hunter and New England Area Health Service v A  NSWSC 761 -.
123 : Bridgewater Care Group v Rossiter  WASC 229.
125 : Ibid. . Martin CJ gave his decision 14 August 2009. Mr Rossiter died 21 September 2009.
130 : Human Rights Act 2004 (ACT) s 10.
131 : Australian Capital Territory v JT  ACTSC 105 -.
133 : 521 US 702 (1997).
134 : Airedale NHS Trust v Bland  UKHL 5;  AC 789, 873.

References: EWCA 
 UKHL 
 EWCA 
 EWCA 
 EWCA 
 EWCA 
 EWCA 
 EWCA 
 EWCA 
 EWCA 
 UKHL 
 UKHL 
 UKHL 
 EWCA 
 EWCA 
 EWCA 
 EWCA 
 UKHL 
 UKHL 
 EWCA 
 EWCA 
 EWCA 
 EWCA 
 EWCA 
 UKHL