Source: http://www.advocatesforpregnantwomen.org/articles/angela.htm
Timestamp: 2019-04-19 08:26:17+00:00

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Along the way, the Angela Carder case resulted in the only appellate decision in the country to address, on a fully developed legal record, a hospital's duty to its pregnant patients and the development of model hospital policies which protect the interests of both patient and institution alike. The life and death of Angela Carder focused national attention on the propriety of using courts to determine medical treatment for pregnant patients and inspired a chorus of diverse voices to condemn coercive medical treatment. In the end, GWUMC emerged from the shadows as a leader in protecting the autonomy of pregnant patients.
At age 13, Angela was diagnosed as suffering from a rare and fatal form of cancer. Despite the odds, she survived and was cured after years of aggressive and often experimental chemotherapy and radiation. Ten years later, however, she developed another form of cancer. She bravely fought for life again, returning to chemotherapy and radiation and resorting to multiple surgeries. Ultimately, she consented to a hemipelvectomy, the surgical removal of her left leg and hip. After more chemotherapy and radiation, there were no signs of cancer anywhere. In 1986, three years into remission and confident in her ability to rob the grim reaper, Angela married and became pregnant. Because of her disability, she was eventually referred to the High Risk Pregnancy Clinic at GWUMC, where she was enthusiastically accepted as a teaching case.
According to her clinic obstetrician, Angela emphasized two points about her health care: she wanted to be watched closely for any signs of recurrence of cancer and, having struggled so long to survive, she wanted to be sure her own health was not compromised because of her pregnancy.
Unfortunately, during the 25th week of gestation, Angela was admitted to GWUMC and eventually diagnosed as having a lung tumor. Again, fighting to live, she wanted everything possible done to prolong her life. Surgery was ruled out, leaving chemotherapy and radiation as the only means of prolonging her life. Angela was informed that her baby was too small to be born, meaning too premature to have a good chance to survive, 2 and that her doctors did not consider intervention on behalf of the fetus appropriate until 28 weeks.3 She was also informed of the added risks to the fetus from chemotherapy and radiation, but Angela still decided to institute aggressive treatment of her cancer. This course was so clearly understood that her attending obstetricians did not consider, much less attempt, intervention for the fetus later that night when Angela's condition rapidly deteriorated, depriving Angela and the fetus of substantial amounts of vital oxygen for many hours.
The next morning, events took an unexpected turn. The hospital's administrators (who were also its liability risk managers) learned of the decision not to attempt delivery of the fetus. The administrator questioned the right of anyone but a court to make decisions affecting a potentially viable fetus, particularly in light of the political controversy over fetal rights. Although the decision was supported by Angela's parents and husband and by the obstetrical department as a whole, as consistent with the wishes of their patient, and despite the advice of legal counsel that the doctors should exercise their best medical judgment under the circumstances (which was not to deliver the - extremely premature and highly compromised fetus), the hospital required a court to decide what should be done for the fetus. Technically, the hospital sought a declaratory judgment as to "what it should do in terms of the fetus, whether to intervene and save its life."
In response to the hospital's petition, a court hearing was hastily convened at the hospital, counsel was rounded up in the hallways of the courthouse and appointed to represent Angela, counsel for the fetus was also appointed, and hospital counsel appeared for GWUMC. The hospital summoned all the witnesses who would testify at the hearing. Angela's family was brought to the hearing just before the proceedings began, with only minutes to confer with Angela's counsel. Angela's long-term cancer specialist, who had been at GWUMC the day before to consult on her case, was not contacted at all.
At the hearing almost no attention was paid to what was clinically best for Angela or to what she would want since, according to the hospital, it was "the apparent desire of the patient and her family" that no intervention be done on behalf of the fetus. Instead, the hearing focused on whether to "rescue" the fetus. Balancing Angela Carder's life expectancy as a cancer-ridden patient against that of the fetus (based on the neonatologist's unduly optimistic guesswork), the court ordered the Caesarean. Despite the court's order, the obstetricians refused to carry it out. The hospital was then in the ironic position of being in contempt of an order that the hospital itself had sought. Reluctantly, a staff obstetrician agreed to perform the surgery.
Although assumed to be near death and unconscious, Angela was lucid and able to communicate when, after the court made its ruling, one of her obstetricians told her about the court's decision. When her doctor explained that she might die as a result of the ordered surgery and that he would not perform the surgery without her consent, she said repeatedly, "I don't want it done." However, this declaration did not sway the hospital to withdraw its petition or the court to amend its order. A three-judge appellate panel upheld the decision during an emergency telephone appeal. Minutes later, having just been told that she probably would not survive the surgery, the woman who had courageously cheated death for fourteen years was rolled into the operating room. The fetus died within two hours. Two days later, Angela Carder died, never having received the cancer treatment she requested.
At the same time, the ACLU, on behalf of Estate of Angela Carder, instituted an unprecedented civil action against the hospital for damages, claiming discriminatory treatment of her cancer and pregnancy, hospital negligence, medical malpractice, the lack of informed consent arising out of the treatment of Ms. Carder and the decision to require a court to determine the course of medical care (Stoners U. George Washington University Hospital, et al., Civil Action No. 88-0M33 (Sup. Ct. D.C.)).
On April 26, 1990 the D.C. Court of Appeals en banc in In Re A.C. vacated the court-ordered Caesarean and held that Angela Carder had the right to make health care decisions for herself and her fetus.5 Seven months later, but only days before the scheduled trial in the Stoner case, the hospital agreed to settle the claims in the civil action by the payment of an undisclosed sum of money to the Carder estate and the development and adoption of hospital policies which implement the Court of Appeals' decision protecting the rights of pregnant patients to make health care decisions.
A study conducted in 1987 reported that more than twenty-one hospitals in the last decade sought court direction on how to treat pregnant women who refuse medical recommendations to protect their fetuses.7 Fifteen court orders were sought in eleven states. All but two were granted.8 Except for In Re A.C., however, none were decided on a fully developed and carefully studied factual or legal record. Moreover, the only other case considered by an appellate court was decided on an emergency motion for a stay without benefit of a record or briefs from the parties.9 Because of extensive legal briefing and the participation of numerous amici, the decision in In Re A.C. is the only authoritative opinion on the subject of compelled treatment in pregnancy. Although technically it is controlling precedent only in the District of Columbia, it will be influential in courts across the country.
However, in the case of a pregnant woman refusing potentially beneficial medical treatment for the fetus, the principle has been too easily set aside, and for dubious reasons. In Angela Carder's case, GWUMC actually argued that its fears of liability justified its insistence on court-ordered medical care.13 The hospital also argued that, although a pregnant woman may have an interest in bodily integrity, there was an overriding state interest in potential fetal life which created a legal duty to subvert a woman's right to bodily integrity when it clashed with interests in the viable-fetus.14 Others rationalize that a women who "has chosen to lend her body to bring [a] child into the world" has an enhanced duty to assure the welfare of the fetus, sufficient even to require her to undergo Caesarean surgery.15 The District of Columbia Court of Appeals en bane decision in In Re A.C. rejected these rationales.
The court went on to hold that a pregnant woman who is unable to give an informed consent, like other patients, has the right to have her decision ascertained through the procedure known as substituted judgment and then carried out.17 In reaching its decision, the Court of Appeals expressly rejected the rationale that women may be compelled to undergo surgery simply because they chose to become pregnant, stating unequivocally that "a fetus cannot have rights in this respect superior to those of a person who has already been born."18 Neither the viability of the fetus nor the potential harm to it are factors that can be used to justify overiding the woman's wishes.
Thus, it is clear that neither the viability of the fetus nor the potential harm to it are factors that can be used to justify overriding the woman's wishes, nor is the fact that the intrusion on the woman might be deemed small given her health condition. Under the criteria in In Re A. C., none of the cases which found their way into court and resulted in court-ordered medical treatment would be legally justified or constitutionally permissible. As the court itself emphasized, "it would be an extraordinary case indeed in which a court might ever be justified in overriding the patient's wishes and authorizing a major surgical procedure such as a caesarean section."
The policies of the AMA and ACOG represent recommended standards for the delivery of health care to pregnant patients. Those standards do not condone compelled treatment in any of the situations which have found their way into court in the past, including cases where there is full placenta previa and a Caesarean section would benefit both the woman and the fetus.30 Although few women reject medical recommendations, the clinical situations which resulted in court-ordered treatment are both common and predictable and, in that sense, cannot be deemed truly extraordinary. In addition, court-ordered Caesareans, by virtue of their invasive nature and degree of risk to the woman alone, could never he reconciled with the above standards. Any physician or administrator who seeks court orders to override a patient's informed refusal of treatment must understand that those actions are now outside the recommended norms of clinical and ethical behavior.
To minimize the risk of error which necessarily inheres in hasty, poorly informed decision-making, hospitals which offer obstetrical services should adopt policies which reflect their ethical and legal obligations to their pregnant patients. The formulation of such policies will assure that an educated body exists within the hospital that is familiar with the legal and ethical limits on health care. Detailed policies will inform the decision-making process when an unusual or complex situation arises. Indeed, with the study of the legal and ethical issues involved in the Angela Carder case, GWUMC now recognizes that resort to courts is often detrimental to patient and institutional interests. In response, GWUMC has adopted policies which not only would have prevented the court petition in the Angela Carder case but will prevent unnecessary resort to the courts in the future.
A pregnant patient's refusal~~ of treatment should not pose any risk of liability for the physician.
Consistent with the ACOG guidelines, the policies adopted by GWUMC recognize that, as a corollary to its obligations to a pregnant patient, the physician is ethically obligated to consider the health of the fetus, as well as that of the pregnant patient, in assessing the range of medically reasonable treatment options.38 This is fully consistent with the longstanding doctrine of informed consent, which requires the physician to advise the patient of the risks and benefits of the full range of reasonable treatment options. However, once so informed, the policy explicitly emphasizes that treatment choices are left to the patient.
When a pregnant woman refuses recommended medical treatment, the feelings of frustration and perplexity by physicians are perhaps understandable. Nevertheless, those feelings, even by beneficient medical staff~ do not justify involving lawyers and courts to compel compliance with medical recommendations. Even less justifiable are hospital petitions to "test" the abstract acceptability of medical decisions. Recognizing the range of emotional responses to treatment decisions, GWUMC policies permit the treating physician or institution to withdraw from the doctor-patient relationship under certain limited, highly unusual circumstances, rather than to impose their views on the patient through court-compelled treatment. This possibility, if communicated early in the doctor-patient~ relationship, will encourage the physician and patient to discuss refusals of treatment before a medical emergency arises. It also provides an essential and important fact upon which a patient may decide whether to continue treatment with that physician or institution in light of her values and the willingness of health care providers to abide by them.
Adopting the recommended ACOG and In refusal A.C. standards, the policies emphasize that resort to the courts is virtually never justified, and decisions concerning health care should be resolved in the doctor-patient relationship. If the physician satisfies the obligation to provide adequate information relative to the treatment decision at hand, a pregnant patient's refusal of treatment should not pose any risk of liability for the physician. Although a hospital or physician could be liable for negligently informing or disregarding the medical decisions of a patient,41 there has never been a case subjecting either to liability for respecting an informed refusal of treatment by a pregnant patient. Thus, in pregnancy, as in other areas of health care, the doctrine of informed consent properly governs the decision-making process. Policies which expressly reaf~ the applicability of these principles for pregnant women will reassure medical and administrative staff that it is proper and desirable to respect informed refusals of treatment by pregnant patients and discourage unnecessary and detrimental use of the courts.
In their zeal to limit potential liability, some members of the health care community have resorted to defensive practices. Indeed, in the Angela Carder case, the hospital contended that its fear of liability justified the court proceeding in that case.42 Rejecting a patient's informed choice, however, poses an equally great risk of liability for the hospital. Patients have the right to make their own decisions about medical care, and hospitals and their medical staff have a commensurate duty to accede to those choices. Insistence on judicial decision-making that subordinates patient choice to institutional self-interest (such as the hospital's business interest in risk management) may constitute institutional negligence. where there is 110 responsible physician recommending contrary treatment, as in the Angela Carder case, the doctor-patient relationship which a patient relies upon in submitting to hospitalization is eviscerated.
Moreover, in situations where administrators take over the direction of treatment decisions, the mandatory responsibility of the medical staff for patient case which is reflected in the standards for accreditation is illusory. Such encroachments on the doctor-patient relationship could be viewed as vitiating the patient's initial consent to be admitted, as abandonment by the responsible physician and as a violation of the standards of care reflected in accreditation standards, hospital policies on informed consent, and patient bill of rights, to name only a few.
The doctor or hospital's failure to present full information at a judicial hearing presents other potential grounds for liability. A physician has a legal duty to the patient to advise her of all the risks and benefits of alternative treatment options which a reasonable patient might deem material.43 When a court is called upon to make the treatment decision for the patient, the duty to inform should necessarily be transferred to the substitute judicial decisionmaker.44 Thus, a treating physician or an institution which obtains a treatment decision from a court without providing it with all the medical and health information may well be found negligent.
Forced by the Angela Carder case to study law and ethics involved in compelled treatment, GWUMC adopted policies which implement the doctrine of informed consent for pregnant women as well as all other patients. While the adoption of such policies resulted in the settlement of civil litigation against the hospital, the policies were independently crafted and approved by its Ethics Committee, appropriate medical staff and advisors. These policies embrace the guidelines and recommendations of the AMA and ACOG, promote the quality of the decision-making process, and anchor the responsibility for treatment decisions within the doctor-patient relationship.
If, in June 1987, GWUMC had had its policies on decision-making with pregnant patients in place, it could have prevented the tragedy which unfolded in court and in the operating room that day. Guided by the recommendations of the AMA and ACOG, other hospitals should follow GWUMC and adopt policies which will prevent the detrimental and unnecessary use of court orders and return the decision to the bedside group-the patient in consultation with her loved ones and treating physicians.
Official Transcript of Proceedings Before District of Columbia Court of Appeals, Oral Argument In re Angela Carder No. 87-607 (Sept. 22, 1988) at 61-78; George Washington University Medical Center Memorandum of Points and Authorities in Support of Petition for Declaratory Relief 1, In Re AC. (served July 8, 1987); Brief of Appellee The George Washington University, filed in the Court of Appeals of the District of Columbia in In Re A. C., at 12-13, 19-20.
Affidavit of Jeffrey A. Moscow, M.D.; filed in In Re A. C., at 11.
Trial Transcript, Superior Court of the District of Columbia, Civil Division, Number 87.607, Tuesday, June 16, 1987 at 17.
In contrast, only two groups defended the court's order, Americans United for Life and the United States Catholic Conference.
In Re AC., 573 A.2d 1235 (D.C. App. 1990).
Statement read November 28, 1990 by Christine St.Andre, Administrator of GWLJMC, at Joint ACLU/GWUMC Press Conference.
Kolder, Gallagher, Parsons, Court-Ordered Obstetrical Interventions, 316 New Eng. J. Med. 1191(1987).
Id. Several other cases since then have also occurred: Shady Grove Adventist Hospital V. Walters, No.52658 (Cir.Ct. for Montgomery County, Md.) (order transfusing pregnant patient against will, Jan.12, 1990); Georgia V. Ellis, No.8912722-07 (Cobb Super. CL, Marietta, Ga April 28, 1989), referred to in Kirby, J., Judge Orders Caesarean Birth Despite Family Refusal, Marietta Daily Journal, Cobb County Superior Court, May 2, 1989, #IA; and In the Matter of the Unborn Child of Chao Lee, No. 90-JV-210 (County Cir. Ct., LaCrosse, Wisc. Jan. 2, 1990). (Caesarean ordered on Cambodian Hmong woman but was ultimately vacated before surgery was performed).
Jefferson V. Griffin Spalding County Hospital Authority, 247 Ga 86, 274 S.E.2d 457 (1981).
E.g. Schloendorft U. Society of New York Hospital 105 N.E. 92, 93 (N.Y. 1914); The V. Walter Reed Army Medical Hospital, 602 F.Supp. 1452 (D.D.C. 1985); In Re Farrell, 108 N.J. 355, 529 A.2d 404 (1987); Bartling V. Superior Court, 163 Cal.App.3d 186, 209 Cal. Rptr. 220 (1984); Superintendent of Belchertown State Sckool U. Saikewicz, 373 Mass. 728, 370 N.E.2d 417 (1977).
Cruzan V. Missouri Department of Health, 58 U.S.L.W. 4916 (1990).
President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research, Making Health Care Decisions, Vol.1 (1982); See also Canterbury U. Spence, 464 F.2d 772 (D.C. Cir. 1972) (adopting legal standard).
As the hospital's lawyer stated, "falnd of course, we admit the spectre of liability. We make no bones about it." Official Transcript, Supra, n.2 at 73; Brief of Appellee, supra, n.1 at 12-13, 19-20.
Robertson, Procreative Liberty and the Control of Contraception, Pregnancy and Childbirth, 69 V&L.Rev. 405, 456 (1983).
In Re AC., 573 ~2d 1235, 1237.
McFall v. Shimp,/i> 10 P~D.&C.&i 90 (C.P. 1978) (court refused to order a man to donate bone marrow to his cousin); In Re George, 630 S.W.2d 614 (Mo�t~App. 1982) (court refused to identify dying man's father as potential donor of bone marrow); In Re Unborn ~qI4 No.84-7-50006-0, Slip Op. at 5 (Wash. Super. C~ Benton/F~a~n Cos.Jur.Div. April 20, 1984) (court denied Caesarean, recognizing that the mother could not be compelled to donate an organ to one of her other children); In Re Pescinshi, 67 Wis.2d 4, 226 N.W.2d 180 (1975) (court refused to order man to donate kidney to sister in dire need).
In Re AC., 573 k~ at 1252.
Law and MedicineIBoard of Trustees Report, Legal Intervention During Pregnancy, 264 J.AnLMe~Assoc. 2663, 2670 (Nov.1990).
See Annas, Foreclosing the Use of Force: A.C. Reversed, Hastings Center Report, 27 (July 1 August 1990); E.g.Jefferson, 247 Ga. 86, 274 S.E.2d 457 (1981) (placenta previa); In Re Matter of Madyun Fetus, 114 Daily Wash. L. Rptr. 2233 (D.C. Super. Ct. July 26, 1986) (risk of infection due to failure to progress in labor).
Kolder, et al, Obstetrical Interventions, 316 New Eng. J Med 1192 (May 7, 1987).
In Re A.C., 573 A.2d at 1248-49.
Kolder, et al, Obstetrical Interventions, 316 New Eng.J Med 1192.
For example, in Jefferson, 279 S-E.2d 457 (1981), the physician predicted a 99 percent chance of fetal death and 50 percent chance of maternal death. However, Mrs. Jefferson delivered a healthy baby through natural labor. Nelson, Bugg & Weil, Forced Medical Treatment of Pregnant Women: "Compelling Each to Live as Seems Good to the Rest," 37 Hastings L-J. 703, 707 (1986); In Re Baby Jeffries, No.14004 (Jackson Co.Mich. May 24, 1982) (reported in Detroit Free Press, June 16, 1982 at 38, 7a) (woman who went into hiding to avoid forced surgery delivered vaginally without complications). See also, Gallagher, Prenatal Invasions and Intervention - What's Wrong with Fetal Rights, 10 Harv. Women's L.J. 9,48,51 n.215 (1987).
Collatti v. Franklin, 439 U.S. 379, 388 (1979).
In Re AC., 573 A.2d at 1237, 1252.
ACOG Committee on Ethics, Opinion No. 55.
Canterbury v. Spenee, 464 F.2d 772 (D.C.Cir. 1972); Pres. Commission for the Study of Ethical Problems, Making Health Care Decisions, Vol. 1 (1982).
Policy implements standard in In Re AC., 573 A.2d at 1237.
E.g. Holmes v. Silver Cross Hospital, 340 F.Supp. 125 (N.D.Ill 1972) (doctors and hospitals which seek court orders for medical treatment over a competent patient's refusal may be liable for violations of the patient's constitutional rights); Forced Medical Treatment of Pregnant Women, 37 Hastings L.J. 703, 724-25 (1986).
See supra n.1, 3, 13.
Canterbury v. Spence, supra, Pres. Commission, Making Health Care Decisions.
E.g. Hicks v. United States 357 F.Supp. 434 (D.D.C. 1973), aff'd 511 F.2d 407 (1975) (hospital held liable for failing to transmit information to court relative to order releasing patient).
This is particularly apparent in the case of court-ordered caesareans where 24 percent of the women did not speak English as their primary language. Kolder, supra n.. Appelbaum & Roth, Patients Who Refuse Treatment in Medical Hospitals, 250 J. Am. Med. Aasoc. 1296, 1298 (1983); Pres. Commission, Making Health Care Decisions at 69-70.
Nelson, et al, Forced Medical Treatment, 37 Hastings U. 703, 725 (1986).
Id.; In Re. Storar, 420 N.E.2d 264, 271 (N.Y.).

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